Category: MCKENZIE THERAPY

 

 

  1. Lumbar spinal stenois (LSS)…defined by any narrowing of the spinal canal and/or nerve root canals…In patients with severe LSS, a space reduction of 67% has been found in the spinal canal.”

 

Spinal stenosis is the narrowing of the holes of the spine. The spine has 3 holes in it in the lumbar region. Each hole carries a nerve. It could either be the nerve of the spinal cord down the middle, and larger, hole. It could be the nerve roots out of the holes on the side of the spine. Each hole needs to be big enough so that it doesn’t irritate the nerve that it allows to pass through the hole. Picture a water pipe. If you put too much stuff in the pipe it will clog up. Sometimes there are tissues that can make their way into the holes of the spine to clog the holes. When the hole is clogged, the nerves don’t have as much room to do their job (transmitting signals to and from the brain). Now take that same pipe and come back and look at it over decades. There will be sludge and stuff built up around the pipe. This is essentially creating a smaller diameter on the inside of the pipe. This smaller diameter due to sludge is also creating a smaller hole. This could happen in the spine with severe arthritis or degenerative disc issues in which the hole gets smaller. A visual is much better so maybe this will help. image for spinal stenosis

 

  1. “…estimated the incidence of LSS in Denmark to 272 per one million inhabitants per year”

 

In other words, it is not very common in Denmark.

 

  1. “…it is important to discriminate between LSS and disc generated pain since these conditions have different prognoses and the range of evidence based treatments are different, as well.”

 

The treatment between the two issues, discogenic back pain and stenotic back pain, is very different. A thorough evaluation can start to correlate symptoms with either discogenic pain or non-discogenic pain. Many patients believe that an MRI will be the answer to why they have pain, but unfortunately this isn’t so.

 

  1. “a valid and reliable clinical assessment protocol for identifying LSS would be valuable in terms of choosing relevant treatment and informing the patient about the prognosis as early as possible.”

 

This article was written in 2009. The medical profession has existed for eons. There is still not a valid way to assess a patient in order to determine spinal stenosis. There are biologically plausible ways, meaning that when I assess you, I can make an educated guess from some of the findings in the history and physical, but it is not a valid (proven) way of coming to a conclusion.

 

  1. “The high sensitivity and specificity of MRI suggests this is a good test for ruling in and out the disease.”

 

The MRI does a great job of telling us what is abnormal, but it doesn’t do a great job of telling us if the abnormal finding is causing symptoms. As seen in the link above, there are abnormal findings in a population without symptoms. We have to take the imaging findings and see if they make sense after performing a physical exam.

 

  1. “…history will provide strong clues to the presence of spinal stenosis…more than 65 years of age…prolonged history of low back pain and intermittent radiating symptoms having developed gradually…limited walking capacity…Movements or positions involving flexion e.g. sitting or stooping, will often abolish symptoms…total loss of lumbar extension range is usually found, while flexion most often is well preserved.”

 

The typical patient with lumbar spinal stenosis will notice that the ability to walk has gradually reduced over time and there is a need to sit due to back or leg pain. Sitting will typically turn down or off the symptoms rapidly. This patient will have limited motion into extension (think of looking over your head to see the stars or bending backwards while standing).

 

  1. “…stenosis from zygapophyseal joint hypertrophy, ligament thickening or other degenerative changes, it cannot be expected that physical exercise or manual treatment will create a lasting change in the degree of space reduction in the spinal canal or intervertebral foramina”

 

In the presence of physical changes to the bones, ligaments or loss of disc height, there is nothing that a PT can do to change these back to the way that they were previously. These have been described as wrinkles on the inside. If we look at your face we can start to see how much age you have based on the wrinkles in the face. This is also done on the inside in that some “degenerative” changes are normal. Wrinkles are normal; they are not symptoms of anything sinister. The same can be said for physical changes on the inside. They don’t have to be pain generators. It takes a physical exam to determine how your symptoms respond and whether or not this matches the images on an MRI or X-ray. Even then, we can’t say that movement won’t help, only that we won’t change the physical “inside wrinkles”.

 

  1. “The main purpose of this pilot study is to evaluate the validity and intertester reliability of an algorithm of physical examination tests, in relation to identifying symptomatic lumbar spinal stenosis.”

 

This is good. A pilot study is like a pilot for a t.v. show. This is done to see if additional episodes should be done. This study will conclude if additional studies on this topic should be done.   What it hopes to find is a reliable (consistent) way of determining validity (actually seeing what the test hopes to see) in testing for lumbar spinal stenosis. A test that is both reliable and valid should be able to test for spinal stenosis regardless of who is performing the test and who is measuring the test.

 

  1. “Two patients were classified as “LSS” and five patients “Not LSS”, meaning a 29% prevalence of “LSS” Intertester agreement for overall diagnostic conclusion was 100%”

 

There are so few patients that this study will likely not yield any results that are actionable. The interesting thing is that the examiners agreed 100% of the time. This is not common in the medical field to have 100% agreement on near anything.

 

  1. “…the algorithm in its present form can not be used as a screening test to rule out LSS, although it may be able to diagnose the condition.”

 

There were so few people in the study that it is hard for any clinician to put it to use in the clinic. It may be able to diagnose the condition in that it demonstrated a specificity of 1.0, which is really good.

 

 

Excerpts taken from:

 

Lengsoe L, Lyhne S, Melbye M. An algorithm for clinical identification of spinal stenosis-a pilot study of validity and intertester reliability. International J of MDT. 2009;4(2):21-28.

 

Can’t find the abstract to the study, but it is listed under the author’s CV http://pure.au.dk/portal/en/persons/martin-melbye(ed4ee688-2d9e-4c17-b0b1-44a5b4b59ada)/publications/an-algorithm-for-clinical-identification-of-spinal-stenosis–a-pilot-study-of-validity-and-intertester-reliability(6d714ee0-d910-11de-9e3b-000ea68e967b).html

 

 

 

 

Not all back pain is back pain

“Findings such as disk height loss and disc bulges are common in individuals without low back pain.”
Disc bulges, degenerative joint disease, spinal stenosis, can all be a result of living with gravity. We have gravity acting as a compression force on us almost 16 hours a day. Anytime that there is a problem, we want to blame something or somebody. Low back pain is an enigma at times. We can draw correlations, we can come up with risk factors, we can even tell you how to treat it sometimes, but what we can’t do is tell you is exactly what causes your back pain. 
“Surprisingly, disc protrusions were associated with a lower risk of subsequent back pain. Nerve root contact and central stenosis had the largest hazard ratios on baseline imaging findings, and they were associated with incident back pain in the expected direction but not statistically significant. Self identified depression was the strongest predictor of subsequent back pain, with a greeter hazard ratio than any imaging findings.”
What should be taken from the above statistics is that mental health plays a role in pain. There are a lot of new studies that are associating catastrophizing and external locus of control with increased pain levels. Work by Nadine Foster demonstrates a screen for patients who will have a difficult time improving with therapy alone. New were books, such as the one by Annie O’Connor and Melissa Kolski (two people with whom I’ve studied at our RIC study group), goes into great detail regarding pain science. Big picture, we can not neglect the patient’s emotional well-being when attempting to treat the patient’s physical complaints.
“Our results indicate that depression is a strong predictor of who will subsequently report low back pain than baseline imaging findings.Subjects with self reported depression at baseline were 2.3 times as likely to have back pain compared with those who do not report depression.” 
There is obviously a psychosocial component to low back pain. The question is… Chicken or the egg. Is a person more likely to be depressed because they have back pain that is not improving? Or is that person more likely to have back pain because they are depressed? I don’t think that there are cause and affect articles in the literature at this point, but there is definitely a high correlation between patients who are depressed and patient who continue to report low back pain.
“In our analysis of baseline data, we concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings related to prior low back pain. Our current analysis indicates that central stenosis, disc extrusion, and root contact may also be risk factors for future low back pain.”
In other words, if you have a major deformity you will probably have pain. This doesn’t mean that you will definitely have pain, it just increases your risk of experiencing symptoms.
The moral of the story is that we cannot deny the brain. The brain has the ability to see pain, and some patients are more susceptible to seeing this pain. Don’t get me wrong, a thorough mechanical evaluation should be performed when a patient has pain, but when this patient is not inclined to respond to mechanical therapy, the patient should be referred to someone that can better handle this patient’s pain.Sometimes, that person will be a behavioral therapist, a psychotherapist, or a clinical psychologist. Physical therapists are not always the go to in order to treat a patient’s pain.
Excerpts from:

Jarvik JG, Haegerty PJ, Boyko EJ. Three-Year Incidence of Low Back Pain in an Initially Asymptomatic Cohort. Spine. 2005;30(13):1541-1548.  

Outline to back pain presentation

žCentralization

žCentralization, although first described by McKenzie14, has been replicated in multiple research studies15,16,17.

žCentralization is the movement of symptoms from an area distal to the spine to a more proximal segment14,18.

žPeripherilization is the movement of symptoms, originating from the spine, from a more proximal and central location to a more distal location14.

žThe centralization phenomenon, when produced in patients, correlates with good outcome9,10,18,19.

žPatients presenting as non-centralizers are six times more likely to require surgical intervention19.

žCentralization is shown to highly correlate with a discogenic lesion20.

žOTHER CONSIDERATIONS

  • Spinal Stenosis= reduction of the surface area of the spinal canal or foramen

–No clinical feature or diagnostic test can confirm that stenosis is the cause of symptoms

–A literature review determined that “all studies favored decompressive surgery for improvement of pain, function and quality of life, as well as in terms of patient satisfaction” compared to conservative care24

  • The advantage of surgery was noted within 3-6 months and remained constant for up to 4 years.
  • Surgery is more cost-effective for this group of patients
  • Appropriate for patients that have not improved with 12 weeks of conservative care.

žEPIDURAL STEROID INJECTIONS

žThere are multiple systematic reviews demonstrating that ESI’s can be effective in the short term and long term for managing back pain for both discogenic pain and stenotic pain21,22

žFollowing an ESI, about 45% of patients then demonstrate centralization and report 90% satisfaction of results after 1 year23

žAny questions?

žreference

1.Garzillo MJD, Garzillo TAF. Review of the Literature: Does Obesity Cause Low Back Pain? JMPT 1994;17(9):601-604.

2.Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with the current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378:1560-1571.

3.Walker BF, Williamson OD. Mechanical or inflammatory low back pain. What are the potential signs and symptoms? Manual Therapy 2009;14:314-320.

4.Fritz JM, Cleland JA, Speckman M, et al. Physical Therapy for Acute Low Back Pain: Associations with Subsequent Healthcare Costs. Spine 2008;33(16):1800-1805.

5.Shin G, Mirka G. An in vivo assessment of the low back response to prolonged flexion: Interplay between active and passive tissues. Clin Biomech 2007;22:965-971.

6.Kelsey JL, Githens PB, White AA, et al. An Epidemiologic Study of Lifting and Twisting on the Job and Risk for Acute Prolapsed Lumbar Intervertebral disc. J Orthop Research 1984;2:61-66.

7.Pople IK, Griffith HB. Prediction of an Extruded Fragment in Lumbar Disc Patients from Clinical Presentations. Spine 1994;19(2):156-158.

8.Natural history of lumbar disc hernia with radicular leg pain: Spontaneous MRI changes of the herniated mass and correlation with clinical outcome. J orthopedic surg 2001;9(1):1-7.

9.Long A, Donelson R, Fung T. Does it Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain. Spine 2004. 29(23):2593-2602.

10.Long A, May S, Fung T. Specific Directional Exercises for Patients with Low Back Pain: A Case Series. Physiotherapy Canada 2008;60:307-317.

ž

  1. Kovacs FM, Urrutia G, Alarcon JD. Surgery Versus Conservative Treatment for Symptomatic Lumbar Spinal Stenosis: A Systematic Review of Randomized Controlled Trials. Spine 2011;36(20):1334-1351.
  2. Urquhart DM, Bell R, Cicuttini FM, et al. Low back pain and disability in community-based women: prevalence and associated factors. Menopause 2009;16(1):24-29.
  3. Konstantinou K, Dunn K. Sciatica: Review of Epidemiological Studies and Prevalence Estimates. Spine 2008;33(22):2464-2472.
  4. McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis and Therapy. 2nd ed. Waikanae, New Zealand: Spinal Publication Ltd;2003.

15.Delitto A, Cibulka MT, Erhard RE, et al. Evidence for an extension-mobilization category in acute low back syndrome: A prescriptive validation pilot study. Phys Ther 1993;73:216-228.

16.Donelson R, Silva G, Murphy K. The centralizaiotn phenomenon: Its usefulness in evaluationg and treating referred pain. Spine 1990;15:211-215.

17.Donelson R, Grant W, Kamps C, Medcalf R. Pain response to sagittal end-range spinal motion: A multi-centered, prospective randomized trial. Spine 1991;16:S206-212.

  1. Werneke MW, Hart DL, Cutrone G, et al. Association Between Directional Preference and Centralization in Patients with Low Back Pain. JOSPT 2011;41(1): 22-31.
  2. Skytte L, May S, Peterson P. Centralization: its prognostic value in patients with referred symptoms and sciatica. Spine 2005;30(11):293-299
  3. Laslett M, Oberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal 2005;5:370-380.

ž

  1. Manchikanti L, Kaye AD, Manchikanti K, et al. Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med. 2015;5(1):e23139.
  2. ManchikantiL, Buenaventura RM, Manchikanti K, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3):E199-245.
  3. van Helvoirt H, Apeldoorn AT, Ostelo RW, et al. Transforaminal Epidural Steroid Injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. Pain Med. 2014;15(7):1100-1108.

ž

Directional preference compared to “evidenced based practice”

The Audrey Long article is commonly cited as one of the landmark articles for those of us that treat spines utilizing directional preference and centralization.  As well it should be! The results are unbelievable.  This researcher…I take that back…clinician performing research in the clinic published an article that, up until this time, was only speculation.  How could patients not get better using evidence based practice?  For a long time, the evidence was based on expert opinion and not really research.  I enjoy reading the publications on spine and it is interesting to read the changes in the Clinical Practice Guidelines for Low Back, published in JOSPT over the years.  Prior to the most recent publication, flexion based exercises were the rage and directional preference was only moderately supported.  Thanks to clinicians such as Audrey Long, this type of treatment has gained more support in the practice guidelines.  When I was in PT school (I sound like an old man, and year to year this is true, but not yet) this was a very small talking point in our curriculum.  Students now come out of school with a better awareness, though not a true understanding, of the concept of directional preference.

 

A Critical Appraisal of Directional Preference Exercises Compared to Two Other Exercise Paradigms

 

P: For patients with low back pain, with or without leg pain, demonstrating a directional preference

I: is treatment with a directional preference

C: as compared to treatment in the opposite direction of the directional preference or an evidence based approach

O: more beneficial when compared with subjective outcome measures

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Pedro.org with the keyword terms “directional preference and low back pain”. Nine results were found and the article with the highest score was chosen.

 

Date of Search: February 15,2014

 

Citation:

Long A, Donelson R, Fung T. Does it Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain. Spine 2004;29(23):2593-2602.

 

Summary:

 

Eleven clinics, from five separate countries, participated in the study. Consecutive patients presenting for treatment of LBP, with or without leg pain, were asked to participate in the study. The inclusion criteria is as follows: consecutive patients with low back pain, with or without one neurological sign, age 18-65 years and demonstrating a directional preference. The exclusion criteria is as follows: cauda equina, two or more neurological signs, spinal fractures, post surgical, off work for one year or more due to low back pain, medical causes, uncontrolled medical conditions, pregnancy, inability to read English (except for those from Germany), patients with prior knowledge of, or specific physician referral for, the Mckenzie method, or no directional preference (DP) elicited.

Therapists credentialed or diplomaed in the McKenzie method performed the assessments. The directional preference was noted as either extension, flexion or lateral, but the subjects were shielded from the significance of directional preference. The subjects were then randomized to one of three groups: matched directional preference exercises, opposite directional preference (ODP) exercises, or evidence-based care (EBC). There were no baseline differences among the groups regarding demographics

The subjects attended at least three and no more than six sessions over the course of two weeks. Those in the DP group received exercises that matched the DP and were instructed to avoid all activities that increase intensity or radiation of symptoms. Those in the ODP group received exercises that were opposite to the DP, and the EBC group performed mid-range exerices and stretches for the hips and thighs. The final two groups also were instructed to return to remain active.

 

The outcome measures utilized in the study are as follows: back and leg pain intensity ratings using an 11 point visual analogue scale, the Roland Morris Disability Questionnaire (RMDQ), and medication use.

 

Five hundred three subjects were assessed and 230 demonstrated a DP as follows: 83% extension, 7% flexion and 10% lateral. Twenty-nine dropped out of the study at two weeks, and the remaining 201 were eligible for analysis. There were 36 withdrawals, which indicated that the subjects worsened or had no change in symptoms and were transitioned to alternative care. None of the DP group withdrew, but 16 in the ODP and 20 in the EBC withdrew. All outcome measures improved in the three groups over the course of two weeks, with the DP group demonstrating significant improvement compared to the ODP and EBC.

 

Appraisal:

The authors satisfied eight of the ten questions regarding the Quality Appraisal Checklist. The subjects’ group design was not blinded to those enrolling the subjects and this was a comparison study of varying interventions, which indicates that a true control group was absent.

 

This study will have a direct impact for clinical therapists. Because this study compared three different interventions, opposed to identifying the efficacy of a single intervention compared to a control group, it mimicked clinical practice. The authors compared evidence based care with a directional preference treatment paradigm, which would be similar to a question asked in clinical practice.

 

Conclusion:

Directional preference exercises are superior to performing exercises opposite to the directional preference or “evidence based care”. Patients that demonstrate a directional preference and are treated accordingly perform significantly better in outcomes measured in this study. There appears to be no harm in treating a patient with directional preference exercises, but the same does not hold true for performing exercises opposite of the directional preference or “evidence based care”.

The following is breakdown of the systems involved in “assessing” research articles.

 

  1. Were the subjects randomly assigned into groups?

Yes. The subjects were randomly assigned to one of three groups.

 

  1. Was each subject’s group assignment concealed from the people enrolling individuals in the study?

No. Because the study is a multi-centered study in outpatient practice, it was not acceptable to the authors to have patients drop out of the study due to changing therapists.

 

  1. Did groups have similar characteristics at the start of the study?

Yes. The authors note that there were “no differences among the three treatment groups in any baseline demographic characteristics or outcome measures.”

 

  1. Were subjects masked or blinded to their group assignment?

Yes. Although subjects couldn’t be blinded to the treatment, they were unaware of the specific grouping (i.e. matched vs unmatched vs EBP)

 

  1. Were clinicians and/or outcome assessors blinded to the subjects group assignment?

No and yes. Although the clinicians were not blinded, which is common in practice, the assessors of the outcome measures were blinded. The outcome measures were subjective measurements in order to minimize therapist bias.

 

  1. Did the investigators manage all of the groups in the same way except for the experimental investigation?

No. Because this is an intervention study in patient’s seeking treatment, it was impossible to withhold treatment to establish a true control group. The types of treatment for the opposite direction and EBP groups were vaguely described.

 

  1. Did the investigators apply the study protocol and collect follow-up data on all subjects over a time frame long enough for the outcomes of interest to occur?

No. There was a 12% dropout rate, which was anticipated by the authors when determining the number of patients needed to maintain a power of .90. Thirty-eight patients withdrew from the study, as opposed to dropped out, due to no improvement or worsening of symptoms in the EBP and unmatched group. Two weeks was long enough in order to assess change.

 

  1. Did subject attrition occur over the course of the study?

Yes. Twenty-nine subjects dropped out of the study, with 12 of the 29 dropping out due to no change or worsening of symptoms. Although these participants did not “drop out”, indicating that follow-up information was unattainable, 36 subjects withdrew early due to no change or worsening of symptoms. No subjects from the matched group withdrew. Those that withdrew completed the outcome measures prior to 2 weeks in order to seek alternative care.

You are not your MRI..at least not for long

did-you-know-your-mri-can-be-misleadingYou are not your MRI…at least not for long.

 

MORAL OF THE STORY: Stop your whining over your herniated disc, bulging disc or exploding disc. You are probably not the outlier. If your pain is lasting longer than six months, your disc is probably healed, but you still move like crap. Start to move better and take better care of yourself and the improvements will follow. In general, this means that you are most likely the problem…not your back.

Also, I will be taking a couple of weeks off from reading and writing to travel with the family.  Taking some time to breathe.  If you enjoy the blog, please add a topic that you would like to see covered at a later date.

 

  1. “Lumbar disc hernia (LDH) is a common cause of low back pain and radicular leg pain…majority of LDH patients recover spontaneously…Purpose of the present study was to investigate the natural history of the morphologic changes of LDH on MRI and to assess correlations with the type of LDH and the clinical outcome”

 

First, disc herniations are a common cause of pain. I believe this to be true and the research consistently reports this fact. The part that doesn’t get reported is the second part of the statement being that spontaneous recovery is normal.

 

When people come into the clinic, they have this seemingly rehearsed story of how they had an MRI and was told that they have a bulging/herniated/exploding (maybe a little overboard) disc. The doctors never tell them that this can recover on its own and patients then wear the herniated disc patch for the rest of their lives.

 

As you will see, you no longer need to wear that patch if your were told that you have an exploding disc.

 

  1. “…42 patients…mean age of 42…unilateral leg pain and low back pain…symptomatic level was L2-3 in 8 cases, L3-4 in 6 cases, L4-5 in 15 cases and L5-S1 in 13 cases”

 

Let’s start here. l_spine

 

The lumbar spine is labeled as L1-5 and the sacral spine then starts. The intersection between the lumbar spine and the sacrum is L5-S1. The segments are named by the upper segment first-lower segment second.

 

Some interesting notes regarding this study:

 

  1. 66% of the patients have symptoms coming from the lower lumbar segments, those being L4-S1. This is inconsistent with published research reporting that up to 95% of symptoms come from these lower segments.
  2. Therefore, 34% of symptoms are coming from the upper segments. Again, previous research notes that only 5% of symptoms come from these segments.

 

Unilateral leg pain simply means that only one leg is affected. For those that may have experienced sciatica in the past, you will remember that it was only one leg that experienced symptoms. If you have symptoms in both legs, then it may not be sciatica.

 

  1. “All patients underwent MRI examinations every three months for a period of 3-24 months”

 

This is not affordable for most and won’t be approved by any insurance that I have encountered. The reason for the frequent MRI’s is to see how things change over time.

 

  1. “LDH was classified into three types: protrusion (n=7), extrusion (n=17 and sequestration (n=18)”

 

Here comes the jelly donut theory. If you have heard it, then you can pass this paragraph up. Think of the disc as a jelly donut (I know that this is an oversimplification, but this model makes the most sense…even if it is not the most accurate).

 

A protrusion means that the outer portion of the donut (the actual donut itself) has been deformed. If you plug the hole of the jelly donut so that the jelly can’t come out of the hole, you will be able to follow along with the rest of the idea. I personally don’t like jelly donuts. I much prefer custard or cream. Speaking of that, Tim Hortons has the best filled donuts that I have ever had. This reminds me of a trip to Canada with my best buddy Carl. If I have the time later, some stories from this road trip may come out. Back to business; if you squeeze the donut on an edge lightly, you will start to squeeze the jelly away from the area that you are squeezing. If you squeeze a little harder, you will see the donut “bulge” just prior to the jelly coming out. This is a protrusion.

 

An extrusion means that the jelly has escaped! Oh no! Now what? No big deal. You will see later that this may actually be a better situation for you than the protrusion.

 

A sequestration means that not only has the jelly escaped, but a piece has broken off and hit the floor. If enough nuclear material (the jelly inside the disc) breaks through the annulus (the donut in the example), then it may break off and be free floating in the spinal canal (near the nerves of the spine). This again may not be as bad as it sounds.

 

  1. Correlation between the clinical outcome and spontaneous changes of the herniated mass on MRI (6 months)

 

MRI change Excellent Good Poor Total%
Disappearance 6 2 0 19
More than 50% reduction 11 18 0 69
Little or no reduction 0 1 4 12
Total 40 50 10 100

 

What this means is that in 19% of patients, the herniation seen on the MRI disappeared over the course of time. Better yet, about 88% improved significantly over the course of time. You are not your MRI… at least not for long.

 

6.

Type of herniation Case Duration of symptoms
Protrusion 3 cases in total 3-14 weeks with 8 weeks average
Extrusion 17 cases 4-8 weeks with 4.8 weeks average
Sequestration 18 cases 1-5 weeks with 3.2 weeks average

 

What does this chart mean? Those that have a “more serious” appearing herniation on MRI actually respond faster than those with a smaller herniation. You are not your MRI…at least not for long

 

Excerpts taken from:

 

Takada E, Takahashi M. Natural history of lumbar disc hernia with radicular leg pain: Spontaneous MRI changes of the herniated mass and correlation with clinical outcome. Journal of Orthopaedic Surgery. 2001;9(1):1-7.

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.

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.

 

If it hurts it must be bad, or good, or whatever. Vincent Gutierrez, PT, cert. MDT

Louw A, Puentedura EJ, Zimney K, Schmidt S. Know Pain, Know Gain? A perspective on Pain Neuroscience Education in Physical Therapy. J Orthop Sports Phys Ther. 2016;46(3):131-134.

 

  1. “Pain is a normal human experience and essential to survival”

This portion is rarely spoken of in PT school and we spend our time in school learning how to shut down the pain, either in an ideal way of dealing with a mechanical problem or in a way in which we “trick” the brain of not seeing the pain for a short period of time. When working with patients, I often describe the gate control theory as the “Three Stooges” way of treating pain. For instance, if you have a headache and I hit your foot with a hammer, what happened to your headache. I stole the example from my dad, because this is how he would always respond if I told him my arm was sore after baseball practice. This was way back in the 1980’s and he was a laborer by trade. The gate control theory makes sense to most people, but we can also see the example and understand that it is probably not the best way to fix a problem, as we end up with a broken foot from the hammer.

 

  1. “The pain neuromatrix explained our knowledge and understanding of the functional and structural changes in the brains of people suffering from chronic pain”

To simplify, we have pain because our brains tell us that something is painful. This could be due to past experiences, actual painful stimuli eliciting Nociception, super excited nerves , so on and so forth.

 

  1. “biomedical models may induce fear and anxiety, which may further fuel fear avoidance and pain catastrophization”

It is very common for a patient to come into the clinic and say that he/she is avoiding a particular activity because of a history of a herniated disc. There is research that shows that a herniated disc can become “unherniated” (for a lack of a more layman’s term) over the course of 6 months. The patients are never educated regarding this point. Once a herniation, always a herniation is just not true. This biomedical or pathoanatomical (patho=bad and anatomical = body parts) model of health care is outdated and simply is not as useful to use with the general public because research demonstrates that the patient may become “sick listed” and from there stop participating in previously enjoyable activities.

 

  1. “a plethora of papers have been dedicated to a mere 20-millisecond delay of abdominal muscle contraction, yet despite the enormous amount of time, money and energy spent on this science, clinically it has yet to provide results superior to those of any other form of exercise for low back pain”

Doing the vacuum pose while lying down is no better than doing a general squat or learning how to utilize your diaphragm during breathing mechanics. As the layperson, there are many people that want to take your money in the health care industry. (I hate to say it like this, but healthcare is a huge business and the public needs to see it as so.) When the new fad comes out to solve back pain, don’t buy into the infomercial and as a matter of fact, turn off the t.v. and go get a book from the local library. You will spend hundreds of dollars less than what is proposed on the infomercial and be better off after having read the book. Nothing beats knowledge and the smarter you are at taking care of yourself, the better armed you are when you actually get in front of a health care practitioner. Remember, it is a business and we all want your money if you will give it to us. A better use of your time is to come educated so that I don’t have to teach you the basics of posture for 30 minutes, but can instead can teach you how to perform more high level movement patterns instead of sitting properly to reduce your pain. Oh wait, pain is normal. I’d lose my job if I sold this to all of my patients, but instead the patients need to be educated between hurt and harm.

 

  1. “In all health care education, be it smoking cessation, weight loss, or breaking addiction, the ultimate goal is behavior change.”

Speaking as a physical therapist, I can’t stress to the patients enough how the therapy experience is a team. Smart people call it therapeutic alliance, but I’ll settle for team. My part is to educate the patient and attempt to solve the puzzle of the patient’s pain, but it is the patient’s job to take the information that they have gained during the session and go home and apply it to their daily lives. For a patient to do nothing at home, AKA make no changes in behavior, and come to the following session thinking that the pain will go away is similar to :

 

https://spencergarnold.files.wordpress.com/2013/01/snatch-miracle.jpg

 

Patients may come hoping for a miracle, but it is not to be. The patient and therapist have to work together to attempt to solve the pain problem. If one side of the team is not doing their part, then the PT has to be willing to discharge the patient or the patient has to be willing to fire the PT.

 

  1. “…when PNE (Pain Nueroscience Education [pain is a normal human response]) is paired combined with either exercise or manual therapy, it is far superior in reducing pain compared to education alone”

From this I take that teaching the patient and then moving the patient is better than just teaching the patient. We can all agree that low level exercise is good for people. If we don’t agree with this, then we are saying that it is safer long term to live like a slug then to get up and walk around the living room. It just isn’t so. People will refuse to get up and walk around the living room when they start experiencing low back tightness, leg fatigue, or the dreaded “Fran cough” (look it up and btw I am an advocate professionally speaking). We as a society have to start moving more and learn about how our body is supposed to work. This can not be done from infomercials that have pictures of pulsating backs or frowning stomach fat.

And this is my two cents for the night.
If you are in need of physical therapy or would like to sign up for a complementary discovery session (a conversation to determine if therapy is right for you), contact me. 

Functional Therapy and Rehabilitation 

(Now part of the Goodlife family)

903 N 129th Infantry Dr. 

Joliet Il 60435

815-483-2440

Rehab post TKA

Piva SR, Gil AB, Almeida GJM, et al. A Balance Exercise Program Appears to Improve Function for Patients With Total Knee Arthroplasty: A Randomized Clinical Trial. Phys Ther. 2010;90:880-894.

Intro: 37% of TKA’s still have functional limitations p one year. Diminished walking speed, difficulty ascending/descending stairs, inability to return to sport are chief functional complaints. During TKA surgery several tendons, capsule, and remaining ligaments are retightened to restore the joint spaces deteriorated by the arthritis. Some of the knee ligaments are removed or released, which may affect mechanoreceptors/balance.

PURPOSE:

  1. To determine the feasibility of applying a balance exercise program in patients with TKA
  2. To investigate whether an F (functional) T (training) program supplemented with a balance exercise program (FT+B) could improve function compared to FT program alone
  3. To test the method and calculate a sample size for a future RCT with a larger sample size

METHOD: Double-blind pilot RCT (very strong evidence)

Inclusion: TKA in the previous 2-6 months (meaning not eligible for study if the TKA was before 2 months previous)

Exclusion: 2 or more falls in the previous year. Unable to ambulate 100 feet with an AD or rest period, acute illness or cardiac issues, uncontrolled HTN, severe visual impairment, LE amputation, progressive neurological disorder or pregnant (interesting exclusion criteria).

All went through a quadriceps muscle-sparing incision (cuts through the fascia of the patella instead of the quadriceps) this may be a factor in reducing rehab stay.

See the appendix for the protocol (6 weeks).

Testing measures:

  1. Self-selected gait speed (interesting, but probably not feasible for our clinic)
  2. Timed chair rise test (5 repetitions): easily added to our testing.
  3. single leg stance time: easily added in
  4. LEFS
  5. WOMAC

RESULTS:

  1. Adherence for both groups is 100% and the HEP adherence was similar (filled out logs)
  2. walking speed continued to improve over the course of 6 months for the FT+B group and was 25% better than the FT only group.
  3. The interesting fact is that improvement continued up to 6 months, when previous literature describes 3 months and done.
  4. Single leg stance: FT+B improved (as expected due to SAID), but the FT group either maintained or worsened on speed and balance.

DISCUSSION: FT+B demonstrates clinically important differences in walking speed, SLS, stiffness and pain, without adverse events. Subjects in the FT+B could balance on average 4 seconds longer than baseline. This may be important for weight bearing during the stance phase of walking. Performance-based measures should be used in place of subjective measures.

TAKE HOME: Patients will benefit from the addition of balance exercises post-surgically. It may be prudent to discuss with the surgeons of increasing the length of stay in therapy and decreasing the number of visits per week, as progress continues to occur past the 3 months initially surmised. Each patient should be tested with one or more of the following:

  1. SLS
  2. Chair rise test
  3. Gait speed: important indicator of function/independence/death
  4. Balance test (excluding Tinetti due to possible ceiling affect when the patient no longer needs an AD).

If you need therapy after a total knee replacement, you can contact me at the following location.
Dr. Vince Gutierrez, PT, cert. MDT

Functional Therapy and Rehabilitation (Now part of the Goodlife family)

903 N Infantry Dr.

suite 500

Joliet, IL

60435

815-483-2440