I see patterns

I see patterns, quick flashback to the Sixth Sense.

 

“Nonspecific LBP accounts for the great majority of cases of LBP and is defined as LBP for which there is no identifiable cause (e.g, injury or disease). As a result, treatment recommendations commonly involve a one-size-fits-all approach.”

This is reality. When someone has back pain, it is a guess and a poor one at that as to what is the cause of the back pain. Herniated discs? Sure. Arthritis? Sure, why not. Spinal stenosis? Must be. Cancer? Naw, this one we could rule in or out with imaging. The sinister (read really bad) stuff can be picked up through imaging and is assumed to be the cause of pain. What else is out there? Lumbago…WTF is this about? My favorite is back pain. For real, this is how it works. The patient goes to the doctor with a complaint of back pain and after the end of the session, the doctor says…You have back pain. Here’s your script for back pain. See me in a few weeks.

The problem when we can’t identify different causes of back pain, then all back pain is treated via a “shake and bake” or cookie cutter approach. Is Suzy’s back pain the same as Johnny’s, probably not since the symptoms aren’t even in the same location, but it is still coming from the back so it must be treated the same way. There’s a reason that we as the industry of healthcare have failed in treating back pain…we can’t even define it.

 

“The current treatment classification system (ie, a small group [5%-10%] of patients with identified specific pathology versus the large group [90% -95%] with nonspecific LBP) is clearly not working well.”

Have you seen the numbers?! Not working well is an understatement. Here are some scary stats. The 5-10% that physicians can diagnose are those sinister (read really bad) problems.

“Subgrouping patients in LBP does not need to be complex or difficult”

Everyone subgroups patients. Tony Delitto has stated in an article (It’s late and I don’t want to go find it so trust me…I’m a professional) that everyone classifies patients, but the classifcation system may be very rudimentary. For instance, if someone comes in with a history of back pain and has failed at therapy elsewhere, we would say that this person may fail again. This is a way of classifying, albeit not a good one, but one way. There are methods of classifying back pain (don’t see this as diagnosing) based on signs and symptoms and response to movement or other interventions. This is a slightly more sophisticated way. There are methods that have withstood the rigor of research and demonstrate moderate reliability in the assessment of back pain.

 

“A good example in the LBP field is the STarT Back trial that used a simple prognostic tool (9 questions only) to match patients to treatment packages appropriate for them.”

I was fortunate enough to hear Nadine Foster, one of the authors of the original study, speak at a spine conference in 2013. The questionnaire can help clinicians, especially the primary care coordinator (Physician Assistant, Primary care physician, orthopedist, Advance Nurse Practitioner) determine if the patient may improve without treatment or if PT could be beneficial. The final category that a patient could be classified into is the inclusion of physical therapy with the addition of a psychosocial approach to pain.

 

“Clinicians are usually favorable to the idea of individualized treatments for nonspecific LBP.”

If all back pain were created equal, then I’d be in favor for all treatments being equal. When a patient comes in looking crooked with 9/10 pain, then that patient should not receive the same treatment as someone that has 1/10 pain and is looking to return to sports. Different presentations call for different solutions. There is an excellent book out there for patients and insurance companies called: Rapidly Reversible Low Back Pain by an orthopedic surgeon. He follows the thought and ideas of Robin McKenzie.

“Put simply, if there is a subgroup that does well, it must be balanced by a subgroup that does poorly.”

This research is out there, but because it doesn’t meet the stringent standards of most research studies, it is frowned upon. The problem with the study is that the authors of the study aren’t blinded to the treatments and patient classification. This means that the authors could be biased in one way or another. Aside from this, the study is a legitimate study assessing varying treatment for low back pain. There was one group that did very well and one group that did poorly. One group was in the middle of the two, but leaned more towards poor than well. Check out the study from Audrey Long

“Two aspects of human nature that could explain this situation (treatment effect) are that we tend to see patterns where none exist (patternicity) and that we presume we have more control over events than we truly do (illusion of control).”

This is great stuff. I actually printed off the articles so that I could read them later. I’d love to believe that this isn’t me…but wouldn’t everyone. I’d love to believe that I actually see dead people…I mean patterns and no, not the patterns that people create when they see a shadow and believe it’s a ghost. It does intrigue me though to learn more about pattern recognition.

“…we must conclude that in general, the current research initiatives and achievement in this field are far from optimal and not yet ready to be implemented in clinical practice.”

I wish I could agree with this, but then we are treating all patients the same. If we can’t give individualized instruction to each patient, then it doesn’t matter who the patient sees for their problem. It doesn’t matter that one person’s back pain started 2 years ago and hasn’t subsided or that another’s started this week and is expected to improve with time. Both patient’s would get the same treatment approach if we can’t classify.

 

 

Do your neighbors know what you do?

Do your neighbors know what you do?

 

“Many of our potential customers can’t tell the difference in therapists from one clinic to another”. This is an age old argument. Pepsi or Coke? Both colas and both had a strong following in the previous decades. I’d like to believe that the brands are losing strength in the days of paleo, crossfit and the resurgence of health and fitness. Not as much as I’d like to see, but it’s a start.

 

Let’s touch on this for a second. Why would Joe Shmoe believe that one therapist is any better than another? To start the argument, the APTA has stated that it would prefer that all PT’s place their licensed initials after the therapists name and then place all of the other qualifications after this. This means that my name is Vincent Gutierrez, PT, DPT, cert MDT, CFT. We get accused of alphabet soup, meaning that we have way too many letters after our names. We could easily cut that down by having the therapists establish themselves based on credentials and not on simply passing the licensure exam. For instance, if I wrote Vincent Gutierrez, DPT this would enable our customers to see that there must be a difference between BSPT, MPT and DPT. I’m not going into the turf war of whether or not one is better than the other, but we could allow clinicians to educate patients on why or why not the clinician chose to pursue one degree over the other. The public has a right to know what we do and how we are educated. This is a start. We make the assumption that a medical doctor went through 4 years of undergraduate schooling, 4 years of medical school and a few years to specialize prior to us going to the medical doctor. Us placing our initials after our names is the starting point to differentiation.

 

Past credentials, another way for Mr. Shmoe to understand the difference between therapists or companies is to soft market ourselves. When I say this, I don’t mean go for the sell, but instead educate the person in front of us while they are there so that the person that is in front of us can make a better choice of which provider to see for their problem when said problem arises. Otherwise, Dr. Superstar is no better than Dr. Squirrely in their eyes.   Every person that we encounter is a potential patient either for me or for one of my colleagues. I at least want to make sure that the potential patient has the information to arm themselves with confidence in making that decision.

 

Your “brand” is how people think of you or your company when the company’s name is mentioned.

 

Coke = Polar bears

Apple = easy enough for a toddler to use

Honda = 200K miles

Marianos = high end grocery shopping

TJ Max = bargain shopping

 

What words do you think of when I say your company’s name?

 

You can see that there are only two companies that my first though was positive for me. I want to exceed expectations for my patients so that when they think of my name they think of excellence and exceeding expectations.

 

Testimonials were previously against the law in our state. This changed recently and I recently learned of this. Testimonials seem to be the most powerful use of marketing for a service based profession. We are behind the times in healthcare. Let’s look at one brand and how testimonials are used. Crossfit has made significant gains in terms of business growth. How’d they do this? A simple Google search for “Crossfit testimonials” has yielded over 28,000 hits. This is how you brand a business. The same type of search for “physical therapy testimonials” yields about 4X that amount. Wow! That’s a lot of testimonials. What’s the problem with these numbers? PT has been around for almost 100 years and crossfit has been around for about 10. There are over 200,000 PT’s and only about 7,000 crossfit gyms. We need to do a better job of educating the public about the importance of PT using real people. Those that have experienced the joy of becoming pain-free, living life with improved function or simply receiving a consultation that assisted in a life-saving diagnosis. This is what we do! We need to make sure that our neighbors and their neighbors understand our value.

 

Theme from:

Barron B. Is Your Brand an Experience? The Importance of the “HOW” in branding for physical therapy private practice. IMPACT. January 2017:56-70.

Wait…PT’s perform manipulations?!

Wait…PT’s perform manipulations?!

 

“Without the ability to match patients to specific interventions, clinicians are left without evidence or guidance for their decision-making”

 

This couldn’t be truer. If we believe that all patients with back pain are the same, then we will give all patients the same treatment. If not all patients respond to the same treatment, then we can say that not all back pain is the same. We have to be able to classify which patients are most likely to respond to a specific treatment; otherwise we are just throwing spaghetti at a wall and hoping that some sticks. When a patient walks into the clinic, I am forming hypotheses as soon as I see the patient get out of the chair in the waiting room. By watching a patient move from the chair to walking and from walking to sitting, we can start to assess pain response (facial expressions) and movement quality (upright versus bent forward or sideways in addition to stride length of the legs and how much rotation is happening with arm swing). We can also have a short chat with the patient to determine how the patient describes their symptoms. Some patients are okay with waiting until we get to the private area before telling their story and others just want to start unloading their story before I have pen to paper to write things down. These are all of the actions that I take into consideration before we even get to the room to assess the patient.

 

“Identifying methods for classifying patients with LBP has been identified as an important research priority”

 

Why do most things matter…MONEY! We as a country lose almost $100 billion per year on back pain. This is a lot of money. If we were to put in a dollar every second to pay for this, it would take 31 years to equal $1 billion! As you can see, LBP is an ailment that we have to figure out in order to keep healthcare solvent.

 

“The purpose of this study was to develop a clinical prediction rule for identifying patients with LBP likely to respond favorably to a specific manipulation technique.”

 

This is a derivation study, the first step of trying to come up with a clinical prediction rule. One must understand CPR’s prior to reading and implementing the research. Here is a quick link that has to do with the types of CPR (clinical prediction rules). Also, there is much controversy surrounding CPR’s from people such as Dr. Chad Cook, who I highly respect. I don’t know if I would go as far as he does in saying that Clinical Prediction Rules are dead, but they do have to be read thoroughly and criticized. They also have to be validated and placed into an environment in which they can be utilized in order to have an environmental impact. This has been done with diagnostic CPR’s such as the ankle or knee rules.

 

Me personally, I don’t believe that we should give up on a quest to determine which intervention works best for a specific set of the population. We can provide value to our customers by providing the best evidence based treatments that we have available. To kill off a method of prescribing treatment limits a therapist’s ability to confidently provide treatment.

“…patients with LBP at two outpatient facilities: Brooke Army Medical Center and Wilford Hall Air Force Medical Center…between the ages of 18 and 60 years…baseline Oswestry disability score had to be at least 30%”

 

This study is highly specific to a military crowd, with an average age of younger than 40. Now if this is not the patient that is being treated in my clinic, it is difficult for me to make the correlation from one population to another. The only thing that we can say for certain about the results of this study is that is pertains to the population that was involved in the study. The baseline Oswestry disability score (for more on the Oswestry see this link.

 

“After the manipulation, the therapist noted whether a cavitation was heard or felt by the therapist or patient.”

 

The cavitation is the audible pop that people think of when getting a fast manipulation. This is similar to popping your knuckles. This pop is not needed for a manipulation to occur, as the movement and speed instead of by the noise that occurs define the manipulation.

 

“A maximum of two attempts per side was permitted.”

 

This doesn’t make sense to me to perform multiple manipulations directed at the same region. The authors noted that if no cavitation was produced that another manipulation would be performed up to four maximum manipulations. We just covered that an audible pop is not needed, so I am unsure why two were allowed for the patient. Let’s just assume that a patient gets better from the manipulation, was it one manipulation or two manipulations that improved the patient? Is it possible that a patient could get better with one, but then get worse with the second…even though a cavitation is heard? There are too many variables that start to play into this study.   This is the landmark study for giving the prediction recommendations for spinal manipulation in PT. Which brings us to the next point.

 

“Two additional treatment components were included: 1) instruction in a supine pelvic tilt range of motion exercise…and 2)instruction to maintain usual activity level within the limits of pain.”
Now we have 3 possible variables introduced into this science experiment. Any scientist would look at this and say that there are too many independent variables, which can affect the outcome. The first is obviously the manipulation. The second is the pelvic tilt. The third is time.

 

“The mean OSW (Oswestry Disability Index) score at baseline was 42.4+/-11.7, and at study conclusion was 25.1 +/- 13.9.”

 

This means that the scores initially ranged from 31-53 and the final scores ranged from 11-39. A change of 10 can be considered significant, so there was a significant change overall for the better.

 

“Thirty-two patients (45%) were classified as treatment successes, and 39 (55%) were nonsuccesses”

 

A majority of patients didn’t respond to the intervention(s), but it was close to a coin flip. This indicates that if we manipulated everyone that came through the door, we would have a success (about 50% improvement in ability) in about half of the patients. This isn’t a bad ratio if it is only done in one visit.

 

“…duration of symptoms < 16 days, at least one hip with >35 degrees of internal rotation, hypomobility with lumbar spring testing, FABQ work subscale score <19, and no symptoms distal to the knee…were used to form the clinical prediction rule.”

 

Here it is! All students are expected to memorize this by the time that they graduate from PT school. All PT’s (at least those that work on backs) are expected to know these criteria for manipulation. There are of course some that will state that CPR’s aren’t very effective in practice, but this rule seems to have stood the test of time over many studies.

 

“…a subject with four or more variables present at baseline increases his or her probability of success with manipulation from 45% to 95%. If the criteria were changed to three of more variables present, the probability of success was only increased to 68%”

 

WHAAAT!? If someone has 4 of the 5 guidelines from above, the success was 95%! This is yuge. I’ll take those odds of success to the tables any day of the week. Now with this said, I have manipulated very few patients. Those that I have manipulated had immediate positive results and the pain was abolished…didn’t return upon follow-up over the course of 2 weeks. I may not be manipulating as many patients as I could, but I also give the patient the opportunity to independently manage and abolish before attempting to perform a manipulation. It’s a theory from another spine management system.

 

“In the present study, only one manipulation technique was used, and it is unknown whether other techniques would provide similar results.”

 

This is also very important to state. There was little research regarding manipulations in the physical therapy research. It must be said that not all manipulations are created equal and that performing a different technique may not have the same result. It may be better or worse. We can only extrapolate this study’s results to those that would match the type of patient treated in this study and the manipulation performed in this study.

 

 

 

 

EXCERPT FROM:

Flynn T, Fritz J, Whitman J et al. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement With Spinal Manipulation. Spine. 2002;27(24):2835-2843.

Why we do what we do

I’ve been writing blogs now for about a year.  Soon will be the 100th blog post.  I don’t make anything for this.  I don’t get any recognition for this.  Big picture, there is no incentive for me to do this blog. So why do it?

I owe it to the profession that has given me the capabilities to treat patients, make a living, and pay my bills.  My job is not that hard.  I don’t have to dig ditches (what my dad did for a living working in water and sewer), I don’t have to drive a forklift (which is what I did prior to going into PT school), I don’t have to teach kids in high school (which is what I initially intended to do).  This job of a Doctor of PT is not that bad.

Looking at it realistically, writing this blog actually makes me a worse clinician.  I spend a lot of time reading.  Instead of spending 30-40 minutes typing a blog weekly, I could be reading to enhance my own knowledge of the profession.  I could be reading to improve my skills.  I could be spending extra time with my family.  There are a lot of things that I could be doing instead of writing the blog.  This isn’t a rant, but why do I do it?

I have students that come through me as a clinical instructor.  It is my responsibility to pass off the knowledge that I obtained over my years in the profession.  It is my responsibility to coach up others around me and those in the profession that may not have the want to actually do the research themselves.  There is a saying on a t-shirt that I read in a Crossfit arena that says something to the effect: the only knowledge wasted is the knowledge not shared.  This really hit home for me.  I spent a lot of time acquiring knowledge through reading books, research articles, spending time in the gym, watching youtube videos and so on and so forth.  I have a lot of hours put into increasing my knowledge and now that I think of it…it would all be for a waste if I don’t attempt to share it.

I owe a big thank you to Dr. Ben Fung for inspiring this blog.  I owe a thank you toDr. Mickey Shah  for his years of mentorship through my growing process.

 

If any of you have a topic that you would like to see covered on this blog in the future, please send me the topic and I will do the work of reading and writing about the research.

Thanks for reading.

What do pigs and humans have in common?

“The majority of in vitro research has examined repeated axial loading with the spine in a neutral position from which observed herniations are extremely rare.”

 

This means that loading much weight onto your shoulders doesn’t appear to affect the disc negatively, aside from compressing it. Picture the people doing strongman, powerlifting, Olympic weightlifting or Crossfit. All of these sports are safe regardless of how much weight is being used, as long as technique remains good, while under the weight.

 

“The most consistent development of disc herniation with repeated loading conditions was achieved by Gordon et al. In vitro human lumbar motion segments were flexed from a neutral posture to 7 degrees of flexion with a small axial twist motion. All 14 of the motion segments examined failed with herniations of the Intervertebral disc (either nuclear protrusion or extrusion) with an average of 40,000 loading cycles to failure. It appears that load, motion, degenerative condition, and repetition require further investigation as prerequisites to disc herniation.”

 

Stu is one of the great gurus of back pain. He states in his papers that he does not endorse a specific number of flexion cycles to create a herniation. This is individual for each person. Also of note is that the above experiment is not done on a live person, but on a cadaver. This means that there is little compensatory motion that can occur, which may occur in real life. For example, there is one paper (don’t have it currently, but I will find it for later) that postulates that the posterior longitudinal ligament (a strong ligament on the back of the spine) may be a protective mechanism for back pain, which would then work to prevent a disc herniation by absorbing some of the flexion load. It’s just an idea though and is no more right or wrong than the number of loading cycles found in the above quote.

 

“The cervical spines of 26 porcine specimens were obtained immediately following death. Pig cervical spines have been shown to be the section closest to human lumbar spines for anatomical and biomechanical characteristics.”

 

The authors make is sound so humane that they waited until the pigs died, but then went on to say that the mean age was 6 months. They died for science. What is most important though is that this study was performed on pig spines! The results can be correlated to humans, but again this will not be precise because the subjects aren’t real live humans.

 

“The remains of any soft tissue and discs were dissected from the cranial and caudal endplates.”

 

The muscles were removed. The muscles, tendons and ligaments provide active and passive support to the joint. Without this support, we are only looking at how the spine joint moves in a vacuum. This again makes it hard to take the results of this study and apply them to humans. We can though take the idea of the study and generalize it to another spine.

“Herniation occurred with modest levels of compression and flexion/extension movements but with a high number of motion cycles. Specimens tested in the lowest compressive force group had nuclei that were intact after 86,400 flexion cycles…All herniations that were created during testing occurred in the posterior or posterior-lateral areas of the annulus.”

 

The first thing to take from this is that the spinal segment is strong. It can withstand over 80,000 cycles of flexion/extension, without resting, and some were able to withstand the force without significant anatomical changes. All herniations were posterior or posterior lateral. This is consistent with what we see in the clinic. Very rarely is there an anterior herniation, but in real life there is also a very strong ligament on the anterior portion of the spine, which would impede a herniation in this direction.

 

“…highly repetitive flexion/extension motions and modest flexion/extension moments, even with relatively low magnitude compression joint forces, consistently resulted in Intervertebral disc herniations. Larger axial compressive force resulted in more frequent and more severe disc injuries…there is no doubt that disc herniation is a cumulative process that can result with modest forces if sufficient flexion/extension cycles are applied.”

 

This is a mouthful. Let’s start by saying that if you spend a lot of time in a flexed (slouched posture position), this may lead to a posterior disc herniation. It’s kind of like the straw that broke the camel’s back. It may not happen the first time, but the more often one spends in flexion the more that the nucleus (the pudding substance inside the disc) will travel towards the border of the disc (annulus). This article doesn’t state what happens to the disc when we rest and stop spending time in a flexed position. For instance, what is not stated is that if we flexion for an entire day, but then move in the opposite direction (extension), do we then counteract the effects of flexion? This article doesn’t say this, but one would have to infer if we could create a herniation that we can reduce a herniation with movement. More to come in future posts.

 

“While there may be a tendency to identify an event that ‘caused’ an intervertebral disc herniation, this work together with our other experiments have led us to form the opinion that this is only a culminating event and that the real cause had already occurred.”

 

This quote says it best and I will leave it at that.

 

Thanks for reading. If you would like to learn more about a topic, feel free to ask a question on here or at my Facebook page @movementthinker. I love reading research and if I can read something that may help you specifically then it is more functional than just reading stuff that I enjoy.

 

Callaghan JP, McGill SM. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compression force. Clinical Biomechanics. 2001;16:28-37.

 

link to article

Post 79: Movement Impairment System and hip pain

Post 79: Hip pain
“Hip pain is a common complaint for which people are referred to physical therapy. The prevalence of hip pain in adults over the age of 60 ranges from 9.7% to 19.2%”

Hip pain…think of a pain that is around the groin region that radiates down to the knee (but on the front/inner part of the thigh). Sometimes pain in the buttock could come from the hip, but other areas that could cause buttock pain should be ruled out first. For instance, the SI joint can also cause buttock pain, but if the person is elderly it is probably not the cause. The spine could also cause buttock pain, and in a majority of “pains in the asses” that I see are coming from a spinal referral.

Hip pain is not the most common ailment that I see in the clinic, but it is not rare either. There are a lot of structures surrounding the hip that are innervated (have a nerve source), which means that there are a lot of structures surrounding the hip that could cause pain. I don’t think that our job as therapists is to find the exact tissue that is causing pain (although there are some patients that just need to know), but our job is to classify the symptoms and place the symptoms into a puzzle that makes sense for us. We do this mostly by pattern recognition (at least for therapists that have seen patterns over his/her careers), but we may also have to do this by using the HOAC method (smart way of saying: “give it a shot and see if it works”).

“Abnormal or excessive loading of the hip has recently been recognized as a potential cause of anterior hip pain and subtle hip instability”
I partly agree with this. For those that don’t know me well, I am certified in Mechanical Diagnosis and Therapy, which was proposed by Robin McKenzie in the 1960’s. He proposed a syndrome called the postural syndrome, in which healthy tissue, abnormally loaded, will create pain with the possibility of becoming a dysfunctional tissue over time. In short, I agree with the above statement.

“Femoracetabular impingement is present in 10% to 15% of the population…symptoms are commonly manifested as insidious groin pain.”

I had to look up the three different types of FAI (the long words from above). This means that the ball and socket portion of the hip is not working appropriately. When thinking of a hip, think of a golf ball and tee. The ball is the ball portion at the top of the thigh. When it is round like a ball, it can spin on the tee without falling off. Now imagine that your tee is a little deeper and larger and can encompass the ball. This portion that would encompass the ball is the acetabulum. It is a piece of cartilage that makes the tee deeper so that the ball can sit in without falling off the tee (think dislocated hip if the ball falls off of the tee). So one type of impingement is if the ball is no longer round, but shaped in a different fashion that makes the ball a little bigger on one side. This would cause the ball to pinch on the acetabulum with certain movements (more on this later).

Another type of impingement is when the tee is malformed. This could cause the tee to pinch on the ball, also causing pain.

Either way, groin pain is the chief complaint typically seen in the clinic.

“Combined hip flexion, adduction, and internal rotation movements (FADIR) along with maximal hip flexion most commonly replicates the pain…catching, clicking and feeling of ‘giving way’.”

Picture a little kid doing the “W” sit. This is what the above sentence describes as FADIR. I know…you’re thinking I can’t do that any more…GOOD! That’s not good for you anyway. Now close your eyes and imagine yourself going up stairs. When you go up stairs, do your knees collapse inwards? Don’t answer yet! Imagine yourself slowly sitting down onto a soft couch (you know what I mean…the ones that you sink down into). Did your knees cave in? DON’T ANSWER YET!! Finally, imagine that you are getting up off of the toilet. Do you have to lean far forward or better yet, rock forward and backwards a couple of times in order to get up off of the toilet? Now you can answer. Did you answer yes to any of these? If you don’t know, that’s alright, my imagination sucks also. Go try it. If you have these things happening, YOU HAVE A PROBLEM!

The first step is simply admitting that you have a problem. Unless you admit that you have a problem, you’ll never get to asking for forgiveness from your hips and knees. I thought that the analogy was good.

Anyway, when the knees cave in, this is a poor position for the knee and the hip when in a hip flexed (knee closer to chest) position.

“Hip joint forces are altered by hip joint positions and changes in muscle force contribution”

“I love it when a plan comes together” Hannibal Smith from the A-TEAM.

This describes another of MDT’s syndromes: the derangement syndrome. This is simply a change in the normal resting position of a joint. It may cause muscle inhibition. This a lay term for “shutting down”. On a side note, there has been major debate on Facebook for the terms used to educate society. For instance, in Supple Leopard, Dr. Kelly Starrett describes a muscle as turning off (he means that it is not working to its fullest potential), but some therapists have a hard time with this phrase. This is why I used the phrase “shutting down”. Maybe they won’t have a as hard of a time with this terminology. I don’t know, but if you don’t get the point…please ask.

When a joint’s position is changed then the muscles that act on the joint will change also. Quick example: my dad used to take me out to plant trees in the forest every year. We would tie the tree down using 3 stakes in order to ensure that the tree grew straight. Now imagine if we used the same 3 stakes, but before driving them in, we placed the tree at a 45 degree angle to the ground. (Think leaning tower of Pisa/Pizza). If we pull on the strings in each scenario, there will be a different outcome on the tree. In one, it will be stabilized and in the other it will fall over even further. This is what happens when a joint is altered in its position. When the muscles contract (the strings are pulled), the joints movement will be altered from normal.

“The 2014 clinical practice guideline on nonarthritic hip joint pain recommends interventions such as patient education, manual therapy, therapeutic exercise, and neuromuscular education, but the strength of the evidence for all of the recommended interventions are at the level of expert opinion”
This is important for all of the PT students that may read this blog. We have entered a world with buzzwords such as evidenced based practice/medicine. We are supposed to be using the highest form of evidence or using “best practice” when treating patients. For this ailment, nonarthritic hip pain, the best we got is a bunch of people coming together to give us an opinion. Granted, the people are really smart, but for a profession that is trying to sell itself as “movement specialists”, we should have more than opinions to sell to patients.

“However, Byrd and Jones report that FAI is not necessarily a cause of hip pain; it is simply a morphological variant…”

Wait… You mean to tell me that having a problem on an image, such as an x-ray or MRI does not correlate to having symptoms?! Obviously I jest. An image alone does not indicate a problem for most musculoskeletal problems. The image must be correlated with clinical signs and symptoms. A person without signs and symptoms is healthy, as some problems noted on an image are correlated with age related deformities. Think of this as a wrinkle. For instance, as we age our muscles go from the texture of filet to the texture of beef jerky. Things start wearing down. We are the ultimate machine, but we have yet to figure out how to keep the machine from breaking down.

“While physical therapists can not change the morphology of the hip joint, they can address movement impairments, muscle strength deficits, and certain aspects of joint range of motion to decrease stresses on the anterior hip joint”

I will not make your bones longer or shorter. I will not change the depth of your joint capsule. I will not make you into something that you’re not. But what we can do is address the issues that you have at that point in time, that aren’t structurally unchangeable. Here’s an experiment I want you do: squeeze yourself into the smallest suitcase that you have and I want you to hang out there for 5 hours and then try to get out. It doesn’t feel so good. I didn’t change any of your structures, but I probably created symptoms. Not all symptoms are related to the structural change, and not all structural changes related to symptoms.

“…movement system impairment syndromes described by Shirley Sahrmann,PT, PhD. The movement system impairment approach places less emphasis on identifying the source of the symptoms and more on identifying the pathomechanical cause.”

I’m always reminded of an old research study, I don’t remember the author, when we give you a diagnosis based on pathoanatomy, we (medical professionals) are right 10% of the time. I can’t specifically tell you which structure is causing your symptoms. What I can tell you is you have symptoms when you move. Maybe if we move a different way your symptoms all go away. It’s my job as a therapist to understand the different ways that movements may affect your symptoms.

“27-year old female…left anterior hip pain July 2014 after doing Miri-directional lunges…continued despite pain…after one week discontinued the multi-directional lunge but continued with deadlifts, squats to 90 degrees…sprinting/walking interval training prior to her injury…discontinued in August due to pain. Before July…she was pain-free…did have clicking, snapping and pinching in both hips…main goal was to return to lifting weights while doing squatting and lunging movements without pain.”
The biggest thing to take from the above is that the patient is active. She is not a couch potato.. This patient is the perfect patient to come into the clinic. I love trying to help these patients get back to their active lifestyles. This is the patient that I am going to go over and above in order to return them back to the gym. I AM A MEATHEAD. I see that as a term of endearment.

“…stood with swayback posture and displayed increased hip medial rotation on the left compared to the right… Had increased pronation bilaterally as well as a positive “too many toes” sign… Range of motion of the lumbar spine was normal and pain-free… Adequate hip flexion range of motion during forward bending but the majority of the motion came from the thoracic and lumbar spine… positive Trendelenburg sign bilaterally.”

 Essentially, description is that of a person with poor usage of the hip muscles and a lazy stance. Could indicate some tightness and she stands with the swayback, but it also may mean that she needs better motor control and a better understanding of what appropriate standing posture actually is. Just from the above description, she seems like many of the females that I see in practice.

“During single leg stance, the patient displayed contralateral hip drop during single leg stance bilaterally, increased hip medial rotation on the left, and decreased balance on the left… Able to squat just passed 90° of hip flexion, but displayed increased forward trunk flexion and reported pain at and range. Hip flexion range of motion at her and range squad was 104° in the flexion range of motion was 92°.”

What this is describing is a partial squat. She is unable to go to full depth because of pain. She also has significant weakness in her hip muscles as noted during single leg stance. If you stand on 1 foot, and you notice your opposite pocket falls significantly compared to when you’re standing on both feet, then you probably have a problem in your hip ability to generate force. Sometimes we’ll see this when a person, specifically female, is walking away from us. This looks like that infamous hip wiggle. Not that I’ve ever watched! I love you babe.

“patient displayed overall hypermobility throughout the exam and had 8/9 Bieghton score for increased ligamentous laxity.”
This is otherwise known as the contortionist scale. If you could dislocate your joints at will, they probably aren’t very stable.

The intervention was actually pretty good. The authors describe meso and microcycles for endurance and strength training. This takes me back to my days as a personal trainer through the International Sports Science Association. I have yet to hear physical therapists discuss mesocycles, until this article. Essentially, they placed the patient on a progressive 2 week cycle that built upon itself over the course of 6 weeks emphasizing core stability, endurance exercises, and the addition of plyometrics.

“At the end of 6 weeks, a second reassessment was conducted. The patient stated she was now able to perform a full squat.”

Nuff said!

This is a good article because it describes that patients can improve rather quickly from functional limitations and pain when issued the appropriate interventions. One thing to note from the article is that although it took 6 weeks to improve, the patient was not treated frequently due to her schedule. The idea that a patient needs to be seen three times per week for four weeks is a tradition that needs to be questioned. As a therapist, I must place my patient’s values and health above my own needs. This is one of the core values of our profession. When I start treating you like a dollar sign, then I no longer am treating the patient according to their needs. Don’t get me wrong, some patients may need to be seen 3 times in a week, but these are few and far between in our clinic.

If you have an questions, comments, concerns or good jokes please feel free to let them fly. I can be reached through comments on this blog, @movementthinker on Facebook or at my personal page on Facebook.

Vince Gutierrez, PT, DPT, cert. MDT

Excerpts taken from:

Smith A, Brewer W. Management of Anterior Hip Pain Using a Movement System Impairment Approach: A Case Report. Orthopaedic Physical Therapy Practice. 2016;28(4):226-235.

 

If the shoe fits

  • SHODDY FOOTWEAR

Understanding the difference among shoes with regards to function

Vincent Gutierrez, PT, MPT, cert. MDT

  • OBJECTIVES

1.To briefly relate the history of the modern athletic shoe

2.To explain the differences regarding functionality among dress shoes, classic footwear, minimalist footwear and barefoot.

3.To provide general recommendations of footwear for varying populations.

  • The Shoe
  • The worlds oldest shoe is roughly 6,000 years old and was meant for foot protection. Prior to this it is theorized that all activities took place barefoot1.
  • Through the years
  • First athletic shoes
  • Keds Champions: unchanged since 19172,3
  • Modern (Classic) Shoe
  • Designed with the foot anatomy in mind (i.e. motion control)3,4,5
  • Minimalist shoes
  • In the recent years these shoes have noted increased sales and are advertised to mimic barefoot activities.
  • These shoes offer no support and increase the intrinsic/extrinsic strength of the foot musculature
  • WALKING
  • When compared to barefoot, wearing standard walking shoes increases stride length by 6%14.
  • Heel strike is more pronounced with larger stride length and varum stresses at the knee were found (9%).
  • Impact on medial compartment OA.
  • For every 1% increase in stress, there is 6x greater risk of knee OA
  • “Flat flexible footwear are associated with significant reductions in dynamic knee loads during ambulation, compared to supportive, stable shoes with less flexible soles.”15
  • Running
  • (1980) It was advised to buy a shoe with built in support mechanisms for the arch and cushioned heel7
  • The authors make this recommendation based on the gait cycle and apply the same gait cycle to running.
  • Recent running analysis challenges this basis of running as fast walking
  • To understand this lets talk GFR
  • http://links.lww.com/CSMR/A3
  • By incorporating arch supports, there is a reduction in elastic recoil of the spring ligament and posterior tibialis, thereby reducing force output at the foot intrinsic/extrinsic3
  • Running
  • Minimalist shoes are more economical compared to classic running shoes in that the the runner utilizes less energy to run9
  • The weight of the shoe was controlled for by using ankle weights.
  • Neuropathic foot8
  • Most ulcers occur in forefoot
  • Study compares barefoot walking in patients with DM neuropathy and those without neuropathy
  • Results
  • Pt with neuropathy place more stress on the forefoot when barefoot (2x more) than controls
  • Possibly due to hammer toe formation and a lack of distribution among toes
  • Unable to feel increased stresses at the forefoot resulting in injury under met. Heads.
  • Balance
  • 100 older women (mean=82 y/a) examining usual footwear vs. barefoot on balance6
  • 68% required AD
  • 42% wore walking shoes, 17% sandals, 11% moccasin
  • Subjects with poorest balance (BBS) benefitted most from usual footwear
  • Post CVA subjects demonstrate increased gait speeds when using a classic shoe compared to barefoot or slippers11
  • Wearing dress shoes (>.5 inch heel) resulted in 15% worsening of balance testing compared to barefoot and a 12% worsening when changing from standard shoe to dress shoe. The TUG improved in standard shoes compared to barefoot12.
  • Healthy older adults demonstrate increased postural sway when wearing traditional walking shoes compared to barefoot13
  • Authors postulate due to sensory deprivation due to footwear
  • Pediatric population
  • “Influence of footwear on the prevalence of flat foot”
  • Study of 2300 children between 4 and 13 y/a
  • 1555 used footwear and 745 never wore shoes
  • 9% of shodded children presented with flat foot and only 3% of children without footwear presented with flat foot.
  • Closed toed shoes appeared to inhibit arch formation moreso than sandals/slippers.
  • The authors suggest that children should play barefoot or in sandals/slippers.
  • Recommendations
  • Running:
  • Classic Running shoes influence a RFS, which increases impact loading into the LE and runners sustain 2.5x more injuries (LBP, LE pain) when running with a RFS3,9
  • Barefoot running fosters a FFS, which strengthens the muscles of the foot3,10
  • Balance:
  • Those with poor balance are advised to wear shoes6 and avoid higher heeled shoes12
  • Healthy individuals are advised to wear minimalist shoes for static balance
  • Neuropathic foot
  • Therapeutic shoes to reduce plantar pressure at the metatarsal heads
  • Walking
  • s/p CVA should wear classic shoes for improved gait speed.
  • Healthy individuals are advised to wear minimalist/barefoot shoes to decrease risk of knee OA
  • Kids
  • barefoot or minimalist shoes
  • QUESTIONS:
  • What’s the difference between running barefoot and running in standard/classic shoes?
  • What are two benefits and limitations of classic shoes?
  • Did this presentation add to your knowledge base and is there a change in your confidence level when recommending shoes for patients/friends?
  • References

1.Ravilious, K. National Geographic News. June 2010. Available at: http://news.nationalgeographic.com/news/2010/06/100609-worlds-oldest-leather-shoe-armenia-science/. Accessed on July 10, 2013.

2.Keds Shoes Official Site. July 2013. Available at: http://www.keds.com/store/SiteController/keds/ourstorypage. Accessed on July 10, 2013.

3.Altman AR, Davis IS. Barefoot Running: Biomechanics and Implications for Running Injuries. Curr Sports Med Reports. 2012;11(5): 244-250.

4.Griffith I. Choosing Running Shoes: The Evidence Behind the Recommendations. February 2011. Available at: http://sportspodiatryinfo.wordpress.com/2011/02/02/choosing-running-shoes-the-evidence-behind-the-recommendations/. Accessed on July 10, 2013.

5.McPoil TG. Footwear. Phys Ther. 1988;68: 1857-1865.

6.Hrogan NF, Crehan F, Bartlett E, et al. The effects of usual footwear on balance amonsgst elderly women attending a day hospital. Age and Ageing. 2009;38:62-67.

7.Heckman B. Selection of a Running Shoe: If the Shoe Fits-Run. JOSPT. 1980;2(2):65-68.

  1. Mueller MJ, Zou D, Bohnert KL, et al. Plantar Stresses on the Neuropathic Foot During Barefoot Walking. Phys Ther. 2008;88:1375-1384.
  2. Perl DP, Daoud AI, Lieberman DE. Effects of Footwear and Strike Type on Running Economy. Med Sci Sports Exer. 2012;44(7):1335-1343.
  3. Lieberman DE. What We can Learn About Running from Barefoot Running: An Evolutionary Medical Perspective. Exerc Sport Sci Rev. 2012;40(2):63-72.
  4. Ng H, McGinley JL, Jolley D, et al. Effects of footwear on gait and balance in people recovering from stroke. http://ageing.oxfordjournals.org/. Accessed on July 6, 2013.
  5. Arnadottir SA, Mercer VS. Effects of footwear on Measurements of Balance and Gait in Women Between the Ages of 65 and 93 Years. Phys Ther. 2000;80:17-27.
  6. Brenton-Rule A, Bassett S, Walsh A, Rome K. The evaluation of walking footwear on postural stability in healthy older adults: An exploratory study. Clinical Biomechanics. 2011;26:885-887.
  7. Keenan GS, Franz JR, Dicharry J, et al. Lower limb joint kinetics in walking: The role of industry recommended footwear. Gait and Posture. 2011;33:350-355.
  8. Shakoor N, Sengupta M, Foucher K, et al. The effects of Common Footwear on Joint Loading in Osteoarthritis of the knee. Arthritis Care Res. 2010;62(7):917-923.