Sciatica of the Arm?

01-branch-615SCIATICA OF THE ARM

 

The great chameleon; the spine. It can mimick any symptom that you are feeling, or believe to be feeling. I can remember my first year in practice treating a patient with an amputation from WWII. He would tell me about his pain in the foot (which was no longer there). This is well before the mirror box studies became popular and the whole Graded Motor Imagery style of treatment. At the time I only knew directional preference and mechanical assessment procedures. Luckily for me, he fit the paradigm. This patient complaining of leg pain, without a leg, responded rapidly to repeated extension in lying.

 

Many patients will experience neck pain, which also radiates into the shoulder blade, chest, arm or hand region. I know, because I am also one of the 70% that will experience these symptoms in his/her lifetime. It was so bad that I had to go to the ER because I thought I was having a heart attack at the time. It doesn’t matter how much information may be known, chest pain is still no joke. After ruling out a heart attack, I was able to rapidly fix the chest pain through a few sets of cervical exercises.

 

When a person is experiencing symptoms that radiate into the arm, with associated neurological signs, such as weakness, numbness, or reflex loss, this is called cervical radiculopathy. There is a clinical prediction rule that is very strong for classifying patients with cervical radiculopathy, prior to the patient receiving any type of test, such as an EMG or NCV, while in the clinic.

 

We as therapists will do well to know the evidence. Whether we fall on the side of Chad Cook regarding CPR’s having little utility until they have been verified or we fall on the side of believing everything that is written, we at least have to respect the information and know it…more knowledge can’t be harmful when we have more options with which to treat patients.

 

Facts from the following:

 

Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability and Diagnostic Accuracy of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy. Spine. 2003;28:52-62.

 

Introduction

  1. No universally accepted criteria for dx of CS radic have been est (2ndary)
  2. Useful to establish accurate clinical examination findings for a diagnosis of cervical radiculopathy
  3. Purpose of theis study was twofold: to assess the reliability and accuracy of

selected clinical examination findings for the dx of c/s radic using an electophysiologic reference criterion, and to identify and assess the accuracy of an optimum cluster of clinical examination findings for the dx of C/s radic.

 

METHODS

  1. 82 patients
  2. eligibility
  3. consecutive patients from 18-70
  4. suspected of CS radic or CTS
  5. Exclusion
  6. systemic disease that causes peripheral neuropathy
  7. primary report of bilateral radiating arm pain
  8. h/o condition affecting the UE interfering with function
  9. no work >=6 m 2nd to symptoms
  10. h/o surgical procedures for pathologies giving rise to neck pain or CTS
  11. Previous EMG and NCS testing for CR and/or CTS
  12. workman’s comp or litigation

 

patient self report items

  1. VAS
  2. NDI

 

Standardized Electrophyologic examination procedure

  1. Needle EMG and NCS served as reference criterion for radic

 

Standardized clinical examination procedure

  1. 34 items performed by examiner one after EMG and NCS
  2. same by examiner two after 10 minute rest to determine reliability
  3. blinded to EMG/NCS/PT 1 results

 

History:

  1. 6 questions thought to be diagnostic for CR

 

Conventional Neurologic Examination and Provocative Tests

  1. MMT of C5-T1
  2. Reflex of biceps, brachioradialis, Triceps
  3. absent/reduced, normal, increased
  4. Pin-prick sensation C5-C8

 

Provocative testing

  1. Spurling test A+B
  2. Shoulder abduction test
  3. Valsalva maneuver
  4. Neck Distraction
  5. ULTT A+B

 

Cervical ROM

  1. All inclinometer for saggital and frontal and goni for rotation

 

RESULTS:

  1. Prevalence of CR and CTS was 23% and 35%
  2. CPR
  3. ULTTA + (+LR 1.3)
  4. involved cervical rotation < 60 degrees (+ LR 1.8)
  5. distraction test (+LR 4.4)
  6. Spurling A (+LR 3.5)
  7. Two positive: +LR 0.88 PTP: 21%
  8. Three positive: +LR: 6.1 PTP: 65%
  9. All positive: +LR: 30.3 PTP: 90%

 

Clinical Utility: Three + tests increase the liklihood from 23% to 65%, which makes this cutoff worth looking at clinically. The fact that the PTP with all 4 is 90% is very clinically useful. With experience, I see that there are neurologists and orthopedic spine surgeons utilizing a version of this CPR . I am not aware if the study was read by these clinicians.

CPR…not that kind

In the PT world, those of us that follow the research like to quiz students on Clinical Prediction Rules, because these have become all of the rage in the Evidenced Based Practice world.  Unfortunately, few CPR’s have been validated through repeated testing and those that have are still being assessed in order to determine if the CPR actually changes the way that PT’s practice.  In my opinion the answer is no to this basic question. When we look at the clinical practice guidelines, it clearly states that manipulations are a tool to be used for patients with low back pain.

It would be great if all PT’s, in the outpatient setting were familiar and comfortable with performing grade V mobilizations (otherwise known as manipulations in the research).  This is an entirely different subject to begin with, but we should also go there.

Each profession owns certain terminology, and this varies by state.  For example, in the state of Illinois, chiropractors own the term manipulation, but therapists can use the term grade V thrust mobilization.  The end outcome is the same procedure, but we can get in trouble for performing interventions outside of our practice act if we call it by the wrong name.

Moving on to a gripe with the American Physical Therapy Association.  Many PTA’s are taught that they are not allowed to manipulate a patient.  The rationale for this is that when PT’s (Doctors of Physical Therapy) graduate from an accredited program, that the newly graduated PT is now considered an expert at performing the manipulations;whereas the PTA, because the topic wasn’t taught in school, is not an expert and therefore should not be performing the maneuver.  The problem with this rationale is that the APTA is greatly overestimating students’ ability upon graduating from a PT program.  Working closely with many students over the years, I have only had up to 3 students that were able to walk into the clinic on day one and perform manipulations without any cues.  This is up to 3 of 50 in total.  This is not a high percentage of students that are “experts”.  I would have to teach a PTA student in the same fashion that I teach a DPT student.  The maneuver didn’t change because the person’s title is different.  No where does it legally state that a PTA is not allowed to perform a manipulation.  I have worked with PTA’s that quickly grasp the concept and the mechanics of a grade V thrust mobilization and on the same note I have worked with many DPT’s that I wouldn’t want to perform this maneuver on a cadaver because the newly graduated DPT may get hurt.  That’s my axe to grind for the night.

Here’s my article for the night.  Not as exciting as above.

Beneciuk JM, Bishop MD, George SZ. Clinical Prediction Rules for Physical Therapy Interventions: A systematic review. Phys Ther. 2009;89:114-124.

 

INTRODUCTION:

  1. The purpose of the review was to determine the quality of CPR’s developled for interventions used by PT’s.
  2. included if the explicit purpose was to develop a CPR related to a specific

intervention approach for conditions commonly treated in PT.

  1. excluded if already validated (VG: This brings up a point: would the

previously validated CPR (manip LS) be approved based on the

criteria established in this article (topic for a later debate seeing that

the authors ask readers to examine the Type IV CPR prior to

attempting utilization).

 

METHODS:

  1. 18 criteria used to assess quality in the SR covering 8 qualities
  2. study population
  3. response information
  4. follow-up
  5. intervention
  6. outcome
  7. masking
  8. prognostic factors
  9. data presentation
  10. high score of 18/18 correlates with high quality
  11. taken from average of 3 reviewers per article.
  12. high quality is >60%
  13. 8 studies remained after the initial compilation of 25

 

methodological criteria

  1. items rated
  2. inception cohort
  3. inclusion/exclusion criteria
  4. Study Population
  5. Nonresponders vs. responders
  6. Prospective data collection
  7. Follow-up at >= 6 months
  8. Dropouts/loss to follow-up of <20%
  9. Inforation on subjects completing study vs. loss to follow-up/dropouts
  10. Intervention fully described/standardized
  11. Standardized assessment of relevant outcome criteria
  12. Masking of outcome assessor and treating clinician
  13. Standardized assessment of subject characteristics and potential clinical

prognostic factors.

  1. Standardized assessment of position psychosocial prognostic factors
  2. Frequencies of most important outcome measures
  3. Frequencieis of most improtan outcome measures
  4. Appropriate analysis techniques
  5. Prognostic model presented
  6. Sufficient numbers of subjects
  7. Five studies >60% (good quality), 4 rated 50-60%, 1 rated <50%

 

DISCUSSION

  1. Quality of derivation studies has never been assessed.
  2. Only 40% of the studies had adequate sample size.

 

CONCLUSION:

  1. Follow-up validation studies are needed.

OREO COOKIE FRACTURES

ht_oreo_cookie_jef_120301_wmainOREO COOKIE FRACTURES

 

Osteoporosis is a common malady to see in the clinic. Most patients diagnosed with the bone weakening disease don’t know much about the disease. I would think that if a patient was diagnosed with cancer, then they would want to know how to beat it…I don’t tend to get that same sense of urgency from my patients initially. Like the old commercial…”the more you know…” and the patients seem to want to know everything once they hear the basics.

 

  1. “Osteoporetic fractures, including vertebral compression fractures are associated with significant mortality, morbidity, and low quality of life”

 

Osteoporosis is the gradual demineralization of bone, typically seen in elderly women. Fractures due to this condition are called osteoporetic fractures. The most common areas of fracture are thoracic spine, hip and wrist. When the bones are so weak, they start to crumble due to the weight that they have to hold.

 

Think of a compression fracture as an Oreo cookie. The cream filling is the disc and the cookie is the bone of the spine, known as vertebra. If you squeeze the cookie together just to the outside of the filling (because we all know that the little circular filling is never the same size as the cookie) the cookie breaks. This is the same type of predicament that happens to patients with osteoporosis. Their cookie breaks. Mmmm…cookie.

 

  1. “…physical therapy-related treatment that emphasize exercises to reduce fall risk, back strengthening exercises, and proprioceptive postural training”

 

If your bones are weak and you fall, to cite Robbie O’Shea, “bummer for you”. You are looking for a fracture and the ground will help you find it. Weak bones don’t like to be jostled. If we can prevent a fall, we can at least prevent a fracture caused by a fall.

 

Why do we want to give back strengthening exercises? Think hunchback of Notre Dame. That’s what many patients with osteoporosis look like over time. The thoracic spine develops so many fractures that the patient is now looking at the floor for money all day long. The spine loses it’s “normal” curve and now the patient is unable to look at the stars or reach into high cabinets. No good.

 

  1. “Up to 67% of OVCF’s (osteoporetic vertebral compression fractures) are asymptomatic and the associative pain pattern in patients with symptomatic conditions is often inconsistent”

 

In a previous post, I noted that problem with imaging. The image can only tell you what the abnormal issue is, but can not tell you what is causing your pain. I had a patient once that had multiple compression fractures…some old and some new…but prior to this new fracture had never experienced pain. Not all fractures cause pain. This is an interesting concept to me because if something is so far off that it breaks, I expect pain to be present. This is another case in which what we believe to be true…isn’t.

 

  1. “Clinical findings or clusters of findings may improve the manual physical therapist’s ability to indentify OVCF before treatment and when imaging is unavailable”

 

In therapy, we want to know when it is safe for us to treat you. If you have a history of osteoporosis, we are traditionally taught to stay hands-off of the patient. We run a risk of actually causing additional fractures. Of course, there is evidence to counter this, but traditionally speaking we are taught to treat you like you have the plague. If we can predict which patients may have osteoporosis, we can make a more informed decision as to whether we should touch you.

 

  1. “The most diagnostic combination included a cluster of: (1) age > 52 years; (2) no presence of leg pain; (3) body mass index </= 22; (4) does not exercise regularly; (5) female gender…a finding of two of the five positive tests demonstrated the lowest LR-, providing value to rule out an osteoporosis compression fracture or wedge deformity. A combination of four of five tests yielded a LR+ of 9.6…Five of five was always associated with a fracture.”

 

If the patient does not meet at least 2 of the 5 scenarios, then the patient likely (Likelihood Ratio negative) does not have a compression fracture. If the patient has 4 of 5 of the scenarios, then the odds of the patient having a compression fracture increase from 2.4% to 20%. This number is still small, but applying the above scenarios allows the therapist or patient to have a better idea of the chances of a vertebral fracture.

 

EXCERPTS TAKEN FROM:

 

Roman M, Brown C, Richardson W, et al. The development of a clinical decision making algorithm for detection of osteoporotic vertebral compression fracture or wedge deformity. JMMT.2010;18(1):44-49.

THAT JUST CHAPS MY ARSE!

101_1749THAT JUST CHAPS MY ARSE!

 

MORAL: We know a little more than we did 10 years ago, but we didn’t know much then either. We now know that we have been calling trochanteric bursitis by the wrong name. WHOOPEE! We think we know how to treat hip pain (isometrics progressing to loaded movement), but we aren’t completely sure yet. Don’t you love evidence-based medicine? I know I do. I feel smarter after reading this article (shaking my head no at the same time).

 

  1. “Gluteal tendinopathy is though to be the primary cause of lateral hip pain”

 

Gluteal, otherwise known as buttock, tendinopathy (a dysfunction of the tendon) is a major cause of lateral hip pain. Of course before we go here, the therapist or physician should rule out the spine as a cause of your symptoms. If he/she does not know how to do this, go to find a MDT therapist.

A long time ago (couple of years ago actually) there was this common diagnosis that we would get as a referral…trochanteric bursitis. It would make patients feel so smart that they remembered this term for their entire lives, because at some point a doctor may have told them that this is what is causing their pain. In 2 out of 10 patients with hip pain (outer border of the thigh), this diagnosis may be correct. If so…you are such a smarty pants. For the other 8 of 10, this article will apply to you (see below).

 

  1. “While this condition has traditionally been referred to as trochanteric bursitis, gluteus medius and/or minimus tendinopathy is now accepted as the most prevalent pathology in those with pain and tenderness over the greater trochanter…of 75 individuals…only 8 had bursal involvement”

 

This to me is awesome! Think about it…the medical profession has been around as long as prostitution and yet we still don’t know what we are selling. At least the other profession knows its product.

 

The research on this diagnosis is relatively new…the past 15 years, but I didn’t hear about this while going to PT school. I’ll tell you what I did learn about though…trochanteric bursitis. It’s a shame that the research is not making it into the school system. If your doctor/therapist/chiropractor/naturopath/neighbor calls it trochanteric bursitis it means one of two things, or both: 1. They don’t read current research 2. They graduated from a school that doesn’t teach current research. I know that it is semantics, a rose is but a rose and all, but a name is important. If we are treating trochanteric bursitis, we are assuming from the name that it is an inflammatory issue of the trochanteric bursa (fluid filled sack that hurts like heck when irritated). If we are treating gluteal tendinopathy, then we are treating a muscle tendon dysfunction. These are treated totally different based on tradition and current research; so the name matters.

 

  1. “While a number of risk factors for the development of gluteal tendinopathy have been proposed, few have been validated”

 

In other words, we think we know what places you at risk, but we can’t be sure. Modern science is awesome. Everyone wants information, but also needs to understand that we don’t have crystal balls. This whole evidence based practice thing is fairly new…considering the overall length of time that medicine has been practiced. It will take a long time in order to obtain answers. All we can give you at this point in time is our best guess.

 

  1. “…the prevalence of lateral hip pain (likely gluteal tendinopathy) in people with low back pain has been reported to be as high as 35%…Importantly, treating the tendon-related pain has been shown to improve the function of those with low back pain, suggesting an interaction if not a causal relationship”

 

Okay…the authors of this journal article just made some big boy claims. First, to say that the lateral hip pain is likely tendinopathy is biased and absurd. We can not say this until the spine has been ruled out as a cause of lateral hip pain. Lateral hip pain is just that…pain in the outside portion of the hip. Until we rule out the spine as a cause of the pain, we can’t even say that the pain is coming from the hip. To make a claim this bold is arrogant. KNOW THIS: MULTIPLE JOINTS CAN REFER PAIN TO THE LATERAL HIP. If there is a problem in the back, it can show up at the lateral hip, which as the authors say is very common to have both back pain and hip pain simultaneously. If the SI joint is causing you problems, it could also show up at the lateral hip (not as common, but at least we can test for this). Finally, if the hip joint is causing problems, this can also show up as pain at the lateral hip. This is all before even talking about the gluteal tendons! The above statement is arrogant.

 

The second statement that is a stretch is to say that gluteal tendinopathy is the cause of low back pain. If you truly believe that, then you should buy this bridge I’m selling. It overlooks the bay in San Fran. Treating the hip tendons (also knows as core stabilization) is shown to be helpful in a small category of patients with back pain. To say that the hip caused the back pain is just as absurd as making a broad statement as the back caused the hip pain. Neither can be said until the patient is evaluated by someone unbiased.

 

  1. “Many orthopedic hip tests can be used for diagnostic purposes for more than 1 condition”

 

This is like saying there are many tests that can be used to measure water pressure, but none of the tests can tell you where exactly the problem is coming from. The tests only tell us that you hurt when we do these tests. There is a good article by Jeremy Lewis, PhD called something along the lines of “Special tests aren’t that special”. This means that as much as we would like to hinge our decision making process on special tests…they don’t tell us much.

 

  1. “…signs of local soft tissue pathology at the greater trochanter are common in imaging of those without lateral hip pain; thus, diagnosis should not rely solely on imaging studies”

 

Holy mouthful Batman! I think that the authors just said that imaging doesn’t tell the whole picture. Healthy people…without pain healthy people…can have the same exact picture as you, only they have no pain! IMAGINE THAT! We know so much more now than 10 years ago, but some of our new knowledge just works to muddy the picture of the pathoanatomical model (saying that we know which tissue is the problem).

 

  1. “In studies of patients with clinical symptoms of lateral hip pain…atrophic changes in the gluteus minims and medius in 40% of the hips”

 

If your hip hurts, you may not use it as well (otherwise known as limping), which may cause a further problem with the muscles. This is just speculation, but the authors already speculated that hip pain causes back pain…so I feel justified.

 

  1. “The authors of a recent article have demonstrated that five 45-second isometric quadriceps contractions held at 70% of a maximum contraction provided almost complete relief of patellar tendon pain, immediately and for at least 45 minutes”

 

I find this study fascinating because based on MDT principles, maybe it wasn’t the force or the prolonged hold, but simply straightening out a knee that is typically bent. I’ll have to find the study and see if the authors of that study actually tried to classify the patients before giving the treatment.

 

  1. “Increases in night pain may indicate that the load has been too high and needs to be adjusted. Once each level of tensile load is well tolerated, the load should be slowly increased and the response monitored to maximize structural change in the musculotendinous unit, while avoiding or minimizing pain exacerbation. “

 

DON’T BE A MEATHEAD! Hi…my name is Vince and I am a meathead. I say this with love. If you do too much, you will create a chemical response in your body called INFLAMMATION (read it with the menacing voice like in the commercial for heinous diseases…like erectile dysfunction). If you do too much, you will hurt. The funny thing is that you won’t know you’ve done too much until you’ve actually done it. It’s like a new graduate not getting a job because they need 3 years of experience. The only way to get there is to get there.

 

EXCERPTS TAKEN FROM:

 

Grimaldi A, Fearon A. Gluteal Tendinopathy: Integrating Pathomechanics and clinical Features in Its Management. J Orthop Sorts Phys Ther. 2015;45(11):910-922.

GHOST RIDER

Ghost rider

This article will apply mostly to medical researchers. It is boring to read, but this is the type of stuff that I had to write while in the Doctorate program. I can sound smart at times. Enjoy or use it for toilet paper.

 

Alexander LL. Ghostbusting. AMWA Journal. 2008;23(2):54-55

  1. “’Biomedical communicators who contribute substantially to the writing or editing of a manuscript should be acknowledged with their permission and with disclosure of any pertinent professional or financial relationships’”

This quote still doesn’t denote that ghostwriting is a horrible topic. For instance, a person can ghostwrite by not giving permission to be acknowledged, based on the above quote.

  1. “There are two types of ghostwriting. Writing a paper for which you receive no author credit (but for which you get paid) and authoring a paper to which you contribute no work. The first type of ghostwriting is not illegal and is hardly unethical…the second type of ghostwriting is more troublesome’” This touches on the topic of payment. One of the other articles that we were to read also discusses payment and stated to the effect that being paid for services does not take the place of authorship.

 

Yoshikawa TT, Ouslander JG. Integrity in Publishing: Update on Policies and Statements on Authorship, Duplicate Publications, and Conflicts of Interest. JAGS. 2007; 55(2):155-157.

 

  1. “The principles of this document, including those related to overlapping (duplicate) publications, authorship, and disclosure of potential COI, apply equally to manuscripts for consideration in this Journal or in a separate supplement.”

I appreciate the straightforwardness of the above statement. There is no ambiguity in the statement and it simply states that these rules apply only to this journal.

  1. “authorship credit should be based on substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data, drafting the article or revising it critically for important intellectual content; and final approval of the version to be published. Authors should meet all three conditions.”

The statement of “substantial contributions” has not been defined. This is left to interpretation in multiple studies. The use of the word “or” is powerful in that the author can partake in one of the three listed activities in the first sentence, but doesn’t have to partake in all activities. The author would have to be active in the drafting of the article and the final approval of the article for publication.

  1. “Within the Acknowledgments section and under the subheading ‘Authors’ Contributions,’ all authors’ specific areas of contributions should be listed”

I have read a lot of research articles over the years and do not recall reading this in any of the sections.

 

Wen Q, Gao, Y. Viewpoint: Dual Publication and Academic Inequality. Int J Applied Linguistics. 2007;17(2):221-225.

  1. “Some of our colleagues believe that submission of the same research findings in different languages is a violation of academic ethics: such a practice constitutes self-plagiarism”.

The authors are starting to make their case that they do not believe that submission in a separate language is plagiarism.

  1. ”We are among those who believe otherwise. In our view, this practice has little to do with self-plagiarism and does not violate intellectual ethics.”

I would disagree with this statement, as the authors are not performing anything new in the study, but simply translating a study from its original language. This should be listed in the article that the study is a translation and not an original work.

  1. “for the above reasons, we strongly propose a relaxation in the rule that international journals only publish “original” papers that have not been published anywhere before, taking into consideration the disadvantaged position of …”

I personally have an issue with this statement, as it is asking for a “relaxation of rules”. We discussed this semester how some ethical issues come to the forefront. It is persons like this, whom are able to rationalize plagiarism that ethics in action always has to remain at the forefront.

 

Geelhoed RJ, Phillips JC, Fischer AF, et al. Authorship Decision Making: An Empirical Investigation. Ethics & Behavior. 207;17(2): 95-115.

  1. “Both the 1992 and 2002 versions of the code state that ‘authors take responsibility and credit, including authorship credit, only for work they have actually performed or to which they have contributed’, with the 2002 version also qualifying the last word with the adjective substantially.

Again the word substantially is included, but is left open to interpretation.

  1. “Significant differences between groups regarding authorship decisions were noted when faculty assigned significantly more credit to students than did student participants and students assigned significantly more credit to the advisor than did faculty.”

I find this statement interesting. The faculty may be trying to assist the students with authorship publication, but this may set a poor

precedent, which continues to proliferate. For example, many of us have stated that faculty should serve as mentors, but would we agree that it isn’t appropriate to give first authorship to someone that did not perform all of the prerequisite work required to have the first authorship position.

  1. “38% of author positions were misplaced relative to their contribution…seven authors in the sample were given authorship credit when they had made no contributions to the study.”

This is a good example of how authorship may be misunderstood or confusing for some.

  1. “discussing authorship in the planning stage of a project while allowing for changes”

This is an excellent point that the discussion regarding authorship should start at the initiation of the planning phase for the study in order to reduce confusion or dissension

  1. “untenured faculty were more likely to report ath both power diffentials and a sense of loyalty or obligation influenced the decision-making process…untenured faculty more frequently reported that unwarranted authorship had been granted than did tenured faculty”

This demonstrates that a person’s place in the “pecking order” may dictate authorship.

 

Louis KS, Holdsworth JM, Anderson MS, Campbell EG. Everyday Ethics in Research: Translating Authorship Guidelines into Practice in the Bench Sciences. J Higher Education. 2008;79(1):88-112.

  1. “Issues related to authorship extend beyond disciplinary boundaries and relate to intellectual ownership and the competitive nature of the academic enterprise…academic researchers are awarded funding, prestige, prizes, promotions and tenure based almost exclusively on their publication history”

This may be the first issue with research. There is a “prize” at the end of the tunnel. We discussed in previous weeks regarding conflicts of interest. The fact that the “teachers” stand to profit from the research should be stated in the publication of the research.

  1. “most scientists are reluctant to exclude people from authorhip”

This is interesting. In our class, we discuss how the authorship should earned based on the requirements of publication, but scientists see no harm with assisting with the advancement of others, although they may have not performed the requisite work for authorship.

  1. high-impact compared to major journals

This is the first that I have seen a comparison such as this. I like how they defined each.

  1. Fairness “Authorship credit should be based only on (1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation…”

This is how we all seem to interpret the research based on the answers submitted for publication. Based on this alone, there should only be one author of the publication.

  1. “My rule of thumb that is somebody who would read the paper and be able to defend it, or defend their part of it”

This is an interesting part, in that some scientists don’t believe that all three must be met. An author only has to be able to defend the part in which he/she participated. This goes against the initial rule that an author must have had a say in the publication of the article, as this is not stated in the scientists opinion.

  1. “(Adding authors) has no negative effect on my reputation as a scientist if there are four names rather than three names (on a paper), but it can make a huge difference to a student or even a technician”

I agree with this statement. If someone performed work on the paper and the work was deemed substantial to the group, then the person should be added. This needs to be discussed prior to starting the study though.

  1. “Scientists have little, if any, motive to deny authorship”

This comment is comical. In PT, it is not uncommon to read 7-8 names in a study. This may be due to that fact that little is lost from including additional authors.

  1. Based on this article, all of the authors listed in the assignment may be entitled to authorship credit.

 

Washburn JJ. Encouraging Research Collaboration Through Ethical and Fair Authorship: A Model Policy. Ethics and Behavior. 2008;18(1):44-58.

  1. “It may be possible to avoid problems with authorship credit by explicitly discussing authorship credit and order, preferably at the outset of research collaborations.”

This point continues to be emphasized in articles. It appears that basic communication may be lacking in research.

  1. “they propose that for the same level of authorship credit, a greater contribution should be expected fro contributors with greater competence and less of a contribution should be expected from contributors with less competence”

This brings the issue of fair vs. equal. I don’t understand how this type of statement can be made. How can one grade fairness in terms of the sliding scale of competency?

  1. “…the policy proposes that contributions be weighted such that contributors with greater competence must make greater contributions for the same authorship position than those with less competence”

I completely disagree with this type of authorship. Someone with little input could be placed as the lead author because, although they provided little in terms of the actual publication, they have little experience, which would balance out the production performed. It doesn’t seem appropriate.

Feelings…Nothing more than feelings

Feelings…Nothing more than, feelings

 

This weeks article speaks to the importance of choosing your provider. Writings may be few and far between, as I am getting married the afternoon of this writing. Because we will be taking our honeymoon soon, there will be a pause in publishing more articles. FEAR NOT! I will return.  Thanks for reading

 

  1. non-specific “LBP (low back pain) where it is not possible to diagnose a specific cause”

 

This accounts for about 90% of back pain issues as stated in previous research. When a doctor tells you “you have a herniated disc”, “you have arthritis”, “you have spondylolisthesis” (sorry, I wanted to sound smart), they are simply telling you what another doctor saw on an image. What does this mean? It means that you have lived a life on this Earth and are no different than a majority of the population…okay the spondylolisthesis is not that common. Aside from telling you that you are normal compared to most people, they are telling you that your picture on an image (x-ray, MRI, CT scan) is not the ideal that is in the textbooks. The picture alone can not tell you with certainty that this is what is causing your pain. In other words, your pain is not specifically coming from anywhere, but it may be coming from any structure that senses pain and refers pain to that area.

 

Think of a heart attack. I picture George Costanza (Cant standja) from Seinfield. His imagined heart attack was complete with left arm pain and chest tightness. This is what we mean by referred. The heart, when upset, can send pain signals to other portions of the body…even though there is nothing wrong with the left arm or jaw or any other location that the heart tells the brain.

 

  1. “…experts have questioned whether the current paradigm is flawed”

 

We are right about what structure is causing your pain in about 10% of the cases..do you think that there is a flaw in the system somewhere? The first flaw is that the structure causing the pain actually matters. I know…I know, you want to know why you feel a knife slicing your spine in half or ants crawling on your skin, but in the end, if we turn off the pain…Does it matter?

I think the primary flaw is trying turn non-specific low back pain into something specific. There is plenty of research that demonstrates this: once you have an “answer” to the cause of your pain, you are quite willing to start blaming all of your problems on your disc or stenosis or arthritis or spondylolisthesis. “Sorry honey, can’t do the dishes…my disc bulge is acting up.” Actually…I may need to use this later. I RECANT ALL I JUST SAID. Joking of course…don’t take anything I write seriously.

 

  1. “Guidelines for the rehabilitation of patients with persistent NSLBP (that non-specific low back pain thingy from above) highlight the importance of practitioners encouraging patients to remain at work and stay as active as possible, with a key focus on self-managing their condition”

 

I of course will tell you that back pain will not kill you. It could in a very small percentage of the population be something so serious that it will kill you, but in reality it’s probably not you. (again, I am not a medical doctor, but a doctor of physical therapy, so if you think your back pain will kill you…go see your medical doctor). I can understand that some people just want a break from work. If this gives you good reason to take a break from work…Shhh…I won’t tell. Aside from the mental health days that you may want to take, don’t let back pain keep you from working. You are highly unlikely to make it any worse, or better for that manner, by working. Back pains due to disc herniations (bulges) are not the result of one massive injury, but the result of multiple small injuries over time. It’s like the old saying, “the straw that broke the camel’s back” (HAHAHA…it literally fits).

 

  1. “It is not known why physical therapists do not follow guideline advice”

 

This is my complete opinion here, but the patient’s don’t know any better. If the patient’s can’t tell the difference between good therapy and bad therapy, and if we then let the cat out of the bag and say that bad therapy pays more than good therapy, why don’t YOU think that the guidelines aren’t followed? There are some therapists that know the guidelines like the back of there hands, such as myself. You can see a previous blog in which I summarize the guidelines for low back pain, but there are other therapists altogether that don’t know that these guidelines don’t exist. I make this statement in a general sense and I extrapolate it from previous research that states that older therapists don’t have either the time or expertise to find a research article. If they can’t find it, then like the tree in the forest…it didn’t happen.

On an aside, I have to keep touching on the bad therapy pays more than good therapy situation. Our profession has historically been paid for what we do to you. Meaning if we give you an ultrasound…cha ching$$$. If we give you e-stim…cha ching$$$. If we give you a rub down…cha ching$$$. If we have you do exercise (whether we are watching you [the ethical thing] or a high school graduate aide is watching you [the pay is the same]…cha ching$$$. If we do all of the above and add traction…$$$. You get the point. We are finally starting to move to a system that if you have a knee replacement, then we will get paid a specific amount, regardless of what we do to you in that process. You will slowly start seeing all of the above disappearing over time because the effect is questionable and we would then be getting paid less per treatment approach that we use. ITS ALL ABOUT THE BENJAMINS BABY!

 

  1. “Practitioners’ attitudes and beliefs about LBP have been shown to influence their advice and treatment recommendations”

 

What this tells me is that we are treating based on tradition instead of the current evidence. Again, if you go to multiple doctors, you will get multiple opinions. The same thing holds true for PT’s. If you see a myofascial specialist…then you have a myofascial problem. If you see a manipulator…then you have a facet (back joint problem). If you see a MDT specialist…then you have a disc problem. We as practitioners have to know more than one system, but we better be good using at least one of the systems; otherwise we will just start mixing and matching systems.

 

  1. “Results have shown that practitioners’ professional group and practice setting appear to be associated with their attitudes, beliefs, and advice”

 

$$$$$$$$$!

If the practice setting values money over results, then the people working in that setting will have to reflect the values of their employers. It’s rough out there in this profession because it is hard to figure out which employer you are walking into until it is too late. There is such a huge pressure financially to make a living and pay off the hundreds of thousands in student loan debt, that the new graduate doesn’t know the difference between an awesome environment and one of financial manipulation.

 

  1. “ I would probably explain to her that it was most likely postural strain…there could be an underlying facet joint degenerative problem evident”

 

How confident are you in this practitioner’s opinion of your problem. It could be this or it could be that? I don’t really have a good reason for either, but “Hey, it’s usually this or that…so why not now?”

 

  1. “They believed that patients who exercises and kept active were more likely to avoid future episodes of NSLBP”

 

For future reference, please read Audrey Long’s article about the right exercise.

What if I told you that your therapist could be making you worse? If we don’t keep up with the research…it is possible. Not all exercise is good exercise. More on this in another blog.

 

  1. “Empowerment through education and pain control were clear subthemes…”

 

People…IT’S YOUR BODY! TAKE CONTROL. We can hold your hand, coach you, be compassionate towards you, but WE CAN NOT FIX YOU! You have to play a role. We can give you the tools to fix yourself, but if you don’t use the tools then WE failed TOGETHER. I didn’t fail, you didn’t fail…BUT WE FAILED!

 

  1. “’passive attitudes’…Therapists found working with these patients demanding, as from their perspective, patients with these attitudes were difficult to communicate with and, therefore difficult to educate and empower”

 

Please see # 9.

 

Excerpts taken from:

Jeffrey JE. Foster NE. A Qualitative Investigation of Physical Therapists’ Experiences and Feelings of Managing Patients with Nonspecific Low Back Pain. Phys her. 2012;92:266-278.

 

As an aside, I just saw that Nadine Foster is one of the authors. I absolutely adore this lady. I had to opportunity to hear her talk at the MDT conference in Austin. I really adore smart people, and she was impressive.

 

Medicine’s dirty little secrets

This is another paper from my previous doctorate program.  This is long and can be complex at times, just know that medicine and health care is a business.  In this business, the end goal is to take your money, otherwise known as making a profit.  Everyone can see that the shady car salesman is trying to take the money from your pocket and place it into his.  For some reason, we have trouble seeing the shady little scientists doing the same thing.  Picture Pinky and the Brain.  Pinky and the Brain…Pinky and the Brain…One is a genius, the other’s insane.  Welcome to the healthcare.

 

Couglin SS, Barker A, Dawson A. Ethics and Scientific Integrity in Public Health, Epidemiological and Clinical Research. Public Health Reviews. 2012;34:1-13.

 

“It can be intrinsically unethical because it may involve activities held to be wrong in themselves such as deception, misrepresentation and falsification. It can also be extrinsically unethical because such actions can cause direct harm to individuals and populations where such research is relied upon, negatively impact public trust in and support for research and result in wasted research resources.”

I appreciate the first quote as it discusses the basic ethical principles, as we have already discussed these in the course. There has been little discussion thus far as to how these discussions could affect future research trial that attempt to replicate the original research.

 

“narrow…way. On this model we might think of integrity as abiding by the relevant research ethics rules or regulations”

This is a very narrow way of looking at integrity. There may be many practicing, which according to the narrow way, do not practice with integrity. Some of the written rules do not account for the “internalistic account”. For example, some insurances only pay for up to ten sessions of traction, whereas there is a sub classification of traction, which will typically only respond well to traction initially, for LBP. For this group, it go against my internal integrity to not provide the treatment in which the research reports the best results.

 

“…rather than it being quickly concluded that a piece of research is unethical because it does not meet a presumed requirement, such as the need for informed consent.”

This is an excellent statement. It is up to the reader to be able to critically analyze research and come to his/her own conclusions regarding the ethics of the research. If a written informed consent is not applied, but a verbal is implied, is this unethical? We all practice with verbal consent (when we educate and then proceed) and sometimes we practice with an implied consent (when we apply what seems to be a benign treatment such as postural correction).

 

“…integrity need not always be about following the rules, as much as being able to see that different kinds of moral considerations are important, often conflict, and that sometimes difficult decisions have to be made about priorities.”

This article is excellent in that it places the autonomy of decision in the practitioner’s/researcher’s hands.

 

“Honest error or scientific differences in the design and conduct or research or interpretation of study findings do not constitute scientific misconduct”

This is a great statement, although I don’t necessarily agree. As professionals, we should attain for the least amount of error. When a grievance is performed, it would be hard to prove that it was performed intentionally.

 

“When properly executed, study protocols ensure the integrity of the process used to answer a single research question or a series of questions. However, when not adhered to, negative consequences, such as the inability to reproduce a study in order to verify its validity or the loss of confidence in research findings, can ensue”.

I wonder how often studies reproduced, and published, in the field of physical therapy? Rarely is a study reproduced in my readings, but studies typically utilize protocols performed in previous studies. This is discussed at length with clinical prediction rules for the spine. These studies are created utilizing characteristics that are the most common for treating/classifying patients, but follow-up studies to reproduce (confirm) the original study is rarely performed.

 

Sax JK. Protecting Scientific Integrity: The Commercial Speech Doctrine Applied to Industry Publications. American Journal of Law & Medicine. 2011;37:203-224.

 

“…companies will publish positive results of their clinical trials. They tend not, however, to disclose negative results of clinical trials in scientific publication, or they down-play the negative results…No regulation requires that industry publish negative results…”

The article is staring with an obvious bias against pharmaceutical companies. At no point in my career have I heard about other industries such as physical therapy being reprimanded for not publishing negative results. Beyond the fact that negative results are not submitted for publication, it is possible that a negative result would not be published in a peer reviewed journal to begin with, as this has been previously documented and is also covered later in the article. “Previous studies demonstrate that industry publications have a bias in that they tend to report positive results of clinical trials.” This initial paragraph sets the tone of attacking the establishment of “big pharm”.

 

“…(s)tudies funded by pharmaceutical companies were nearly 8 times less likely to reach unfavorable qualitative conclusions than nonprofit-funded studies and 1.4 times more likely to reach favorable qualitative conclusions.”

The author states this as if we, as the readers, should be surprised. As a class, we have already discussed COI, and when those that stand to profit from the results fund the study, we should not be surprised by the favorable results.

 

“Instead of subjecting themselves to peer review, some members of industry will skirt around this system by creating their own publications, such as symposium issues, which allows them to promote their products without having the academic and scientific community review the research prior to publication”

Although I find this to be unethical, I must say that it is an ingenious way to get around the establishment in order to make a profit. Unfortunately, that profit may be the result of harm. Although I wouldn’t make the same decisions, the decisions are understandable in a profit driven society.

 

“The tobacco industry also wrote review articles, citing their own work. Policymakers often rely on review articles because they are supposed to provide a summary of the most up-to-date data. Another tactic utilized included suppressing or criticizing research that did not support the tobacco industry’s position”

Again, these statements demonstrate the articles purpose of demonizing portions of the pharmaceutical companies practices. To compare pharmaceutical companies with the tobacco industry, the author is essentially comparing a company that the reader may not have a strong feeling towards to a company that most in America can rally against.

 

“…the FACT Act did not become law.”

This is shameful. There were good ideas implemented in the FACT Act, that would have allowed the reader to make individual conclusions, instead of taking the authors word regarding the conclusion.

 

“If the expected value of noncompliance is positive, then the rational pharmaceutical company will ignore the regulation and violate the law because the incentives create a regime where it is cheaper for them to ignore the law”

Although this makes sense, applying a larger financial penalty in order to obtain results does not historically work. For instance, the price of cigarettes continues to rise, but there are still smokers. Obviously there is more than finances at stake with this example, but the authors opened the door by introducing tobacco companies in the argument. The tobacco industry is the reason why this rationale does not work.

 

“[u]ntruthful speech, commercial or otherwise, has never been protected for its own sake…a state may regulate commercial speech that is provably false, deceptive, or misleading.”

This forces the burden of proof on the state that the company was knowingly being deceptive and misleading. These cases that are proven are the landmark cases, such as the teenage antidepressant case presented in the study. There are few landmark cases presented in the article. On a side note, the teenage antidepressant study was so influential that an episode of Law and Order was created similar to the case.

 

Rohr JR, McCoy KA. Preserving environmental health and scientific credibility: a practical guide to reducing conflicts of interest. Conservation Letters. 2010;3:143-150.

I had little vested interest in this article, so there are fewer quotes that I found to comment.

 

“Perhaps the most commonly used strategy to avert undesired environmental and public health decisions is to manufacture uncertainty”

This is not necessarily an evil concept in my opinion. If the evidence is lacking, then “manufacturing uncertainty” is easy. If the evidence is overwhelmingly in support of a specific action, such as the earth circles the sun, then manufacturing uncertainty is impossible. I find the burden for this to be on those in support of those attempting to preserve the environment. For instance, in 2007 the Illinois chiropractors were trying to take mobilizations away from physical therapists. We had ample evidence to demonstrate that we not only owned the technique (thanks to Mary McMillan), but also owned the wording. Because of the evidence cited over the previous century, we were able to prevent this loss.

 

“…delay regulations that might be necessary to protect environmental health.”

This is an opinion of the author and seeing as how this paper is meant to be a persuasion based paper, it should be omitted or cited if there is evidence to support this.

 

“Some authors have even argued that conservation science, with its mission of advancing the sience and practice of conserving the Earth’s biological diversity, is normative and biased and thus can be perceived as having a conflict of interest.”

I can appreciate the authors providing this statement and research in the article, because while reading the article I can only think of the conflict of interest that has been established by those attempting to preserve the environment. If one has a vested interest in the outcome of the research, I find it hard to believe that the research is performed without bias.