Category: PTs

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

To hear the audio post, click Here

You 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.

 

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.

Complex case study

This is a great article for the “n” of one crowd. Not every article has to be a randomized control trial and sometimes we can learn much more from a case report than from a systematic review. This is one case report that taught me to be a little more exhaustive than I typically am when treating a patient. When a patient presents to the clinic with facial pain, the “jump to conclusion” idea is that the patient has larger issues that need to be addressed, as this is a sign of a cranial nerve (think direct to the brain nerve) dysfunction. I forgot some details of the nervous system, or a better way of saying it is that I didn’t have a complete understanding of this coming out of PT school that this review is more of a clinical application of the anatomy in order for it to make more sense. My ego is not too big to say that I am still learning daily. This article makes me a better therapist tomorrow than I was yesterday. Thank you J. Lincoln.

 

Big picture, the patient improved. We can’t draw cause and effect conclusions from a single case, but we can take the information provided and use it on a later patient in which stronger research-based interventions have failed the patient.

 

  1. “female…with symptoms of unilateral right sided head,face,ear, neck, shoulder and arm pain, as well as subjective sensation of swelling in the right side of the face and anterior triangle of the neck”

 

Yeah…we don’t particularly like seeing these types of patients. Especially not on a Friday after noon at 4PM. These symptoms are going to be difficult to try to figure out. Many therapists (myself included when I was a young buck) would just write this patient off as one of two things:

  1. psychosomatic: look it up. You will find that the psycho plays a role in the pain presentation. By psycho, I don’t always mean the patient, but the patient’s perception of the pain.
  2. secondary gain: This patient was either in a car accident looking for litigation, is trying to score some time off of work, or is trying to get money without working for it.

 

Needless to say, I don’t tend to lump patients into these categories as quickly as I did in the past ( I still do, as this is also a part of classifying patients), but I will at least take a crack at helping the patient before jumping to one of the above conclusions. On a side note: if you are faking/exaggerating or seeking some sort of financial gain, please don’t seek me out. I take pride in thoroughly assessing you and if I find inconsistencies in your presentation, it will not look good for your case.

 

  1. “referred for neck pain…complained of a constant ache in the right shoulder and neck extending down the entire anterior aspect of the right arm…intermittent pain in the right side of the face, ear and head as well as a constant sensation of swelling in the right side of the face and anterior triangle of the neck…waking at night with right arm pain…intermittent pins and needles in the right fingertips…aggravating activites included reaching or lifting with the right arm, ironing or wringing out clothes. Cold weather or having influenza generally made all symptoms worse…blowing her nose or sneezing specifically increased her facial pain.”

 

Get ready to swim because we are going into the deep end.

 

  1. Neck pain radiating down the arm. This is a very common symptom and can be coming from any structure that radiates symptoms down the arm (such as disc, nerve, facet) or from the brain’s heightened state of response to threat. This is a common symptom and I always think that there is a mechanical problem and force the patient’s symptoms to make me change my mind.

When assessing all patients, it is like one big chess game. Every movement and question that I ask of you provides me with your first move. I always let the patient start, except for very rare cases. Once the patient starts with their history or the first movements, the chess game begins. Every move the patient makes leads me to my next move. It is really like one complex dance. I will follow your lead and then take the lead when your body has given me my checkmate. Once I know how to win, I completely take the lead.

  1. intermittent pain in the face, ear and head leads most therapists to start thinking cranial nerves. These nerves are interesting because they don’t go through the spine. Think of it this way, why should the nerves go down into the spine only to come back up into the face. There is a much shorter distance from the brain to the face. When the face starts experiencing symptoms, we think brain first (and always keep this in the back of our minds if there is no change in the patient’s symptoms with movement, as nerves from the brain to the face won’t change much with neck movements). Secondly, the upper portion of the neck can refer into the head and face. Neck movement’s can affect these symptoms. This is why it is important to have a thorough evaluation.
  2. waking up at night with arm pain can be considered a red flag (think red light as our stop sign) and the therapist may start thinking of things such as cancer, but again the mechanical evaluation will help to start weeding out the white board (House MD reference).
  3. cold weather or influenza: This could also signal a systemic issue having a role in the patient’s systems.

 

Overall, the white board just got very confusing.

 

  1. “insidious onset of pain over a 12 month period, which had gradually worsened…no past history of shoulder or cervical spine injury…medical history included …diabetes, angina (chest pain), dizziness associated with postural changes and blurred vision bilaterally (both eyes)”

 

Big picture, this patient has a lot of stuff going on! I would call the doctor to ensure that he/she is aware of the atypical symptoms of blurred vision (possibly brain issue), dizziness (could be brain issue, neck issue, eye issue or ear issue) and chest pain (could be neck issue or heart issue). The fact that the patient is worsening over time is also a red flag that would also need to be alerted to the physician.

 

Many would think that the physician should already know all of this, but as a former teacher “Master John Luby” once said: “Never should on yourself” (say it fast and it will make sense). Most all of us have been to the doctor. I hear stories frequently from patients that they only see the physician for 5-10 minutes (if they ever see the physician at all). The therapist gets anywhere from 30 minutes to 1 hour with the patient and more information can be garnered in this time period (if the therapist cares enough to ask).

 

  1. “protracted cervical spine with forward head”

 

This is unfortunately more and more common. I can count on one finger how many patients enter the clinic with good posture. If your posture is crappy, then your movement will also be crappy. If you can’t stand still with good form, what makes you think that you can walk, run, jump, squat, or lift with good form.

 

  1. “an increase in the shoulder and neck pain at the end of range for left rotation and left lateral flexion”

 

This would indicate that opening up the facet joints would provoke symptoms. The spine has 3 holes in it…don’t worry, they are supposed to be there. When you move in a direction you can only do 1 of 2 thing to the hole: open or close. When you move to the left (either side bend like holding a phone to your ear or rotating in such a way to look over the left shoulder) you close down the left holes of the neck and open up the right holes of the neck. Opening up the right hole provokes symptoms.

 

  1. “Cervical spine extension produced central thoracic pain. Flexion, right rotation and right lateral flexion were asymptomatic”

 

looking up was no good, but looking right and leaning right were great. Looking down was okay. This creates a complicating factor because when you look down, you open the right hole and when you look up, you close the right hole. This patient will not be as simple as which holes are opening and closing.

 

  1. “arm,shoulder and neck pain was increased with flexion from 90 degrees through end range, abduction initially at 100 degrees through end range, and at the end of range with the hand behind the back movement”

 

White board: shoulder problem, neck problem, nerve problem.

 

Raising the arm can place tension on a nerve (they don’t like tension). Placing the arm behind the back doesn’t place tension on the same nerve, so this would start to rule out nerve tension as the major source of problems.

 

Neck problems can mimick all of the above symptoms, so not ruled out yet.

 

Shoulder problems can mimic the shoulder pain with the movement, but doesn’t typically cause neck pain with the movements.

 

Based on the pain presentation, we should probably start by looking at the neck.

  1. “Position assessment of the axis vertebra via palpation revealed the right transverse process to be prominent posteriorly as well as tender. This possibly suggested some rotation of this vertebra”

 

I understand what the author is saying, but I am so far removed from assessing each individual segment that I find it hard to believe that this is still a major component of performing a cervical evaluation.

 

  1. “patient was given a modified…neural mobilization exercise for home”

 

This doesn’t make sense to me when the author initially thought that there was a neck problem based on palpation. If I thought that you had a lug nut loose, I wouldn’t recommend putting air in the tire as a fix.

 

  1. “reported an initial increase in symptoms for 2 days and then large decrease for subsequent 4 days…active cervical spine movements reproduced right shoulder and neck pain at the end range or right rotation and right lateral flexion…it was decided to test for upper cervical spine stability…symptoms had virtually disappeared to a minor sensation…directly after treatment (headache snag).

 

Again, there are some topics here that seem like illogical jumps. The symptoms in the neck shifted sided from left to right. This is common, so I can understand that the symptoms shifted sides, but I can’t understand how the therapist made the jump to test for cervical instability after already having done all of the cervical movements. When a spine is unstable, it is like balancing a golf ball on a golf tee. If everything is aligned, the golf ball will stay on the tee, but if there is a slight change in alignment, off the tee it falls. Guess what your head resembles?! If there is a suspicion of cervical instability, this is a major clinical sign that needs to be assessed.

 

  1. “Infections in the tonsils, middle ear, teeth and nose may drain into the cervical spine region and the subsequent inflammation may lead to loosening of the transverse ligament attachments”

 

First, I didn’t know this. Second, this is a guess at best to state that this is the reason for the “loosening” of the ligaments of the spine.

 

  1. “It is therefore possible that this patient’s increased mobility was due to chronic loosening of the transverse ligament over time.”

 

This is a stretch and I would say long shot. First, we don’t know how mobile or hypermobile this patient was prior to the incident. The “increased mobility” may be the patient’s norm. We all know some people that can touch the floor and others that can’t even touch their knees. This may be the person’s norm.

 

Also, if the infections are causing the ligament loosening, then the exercises will not have a long-term effect on someone that continues to experience infections. If this is the case, then the best way to treat the facial symptoms is to treat the infection and wait to see if the ligament tightens up and the symptoms disappear.

 

  1. “This patient presented with pain at rest, suggesting the spine’s inability to maintain a sufficient neutral zone to prevent abnormal stresses on upper cervical spine…the development of a clinical instability situation”

 

If something has increased mobility from what is expected as normal, it doesn’t make sense to mobilize the segment. I don’t understand the author’s rationale for mobilizing a hypermobile segment. This may just be my ignorance though.

The patient improved over a short number of sessions.  This is obviously the goal of therapy.  If this patient’s symptoms were unchanged or worsened over the course of 6 visits, then it would be appropriate to communicate with a physician that either referred the patient or that the patient would like to see.  This is why it is important to shop around for therapists.  We have to demonstrate functional improvement.  Sometimes that function may just be reducing and eliminating pain so that you can continue to watch Game of Thrones or play the latest game on FB.

Can back surgery be predicted?

800px-flickr_-_official_u-s-_navy_imagery_-_a_doctor_performs_surgeryDo you want to have back surgery? A therapist highly trained in treating back pain can tell you the odds that you will end up on a surgical table. This is a great study for patients that are debating surgical intervention. If you are already scheduled for surgery, ask your physician for a second opinion from a specially trained PT. What do you have to lose? Not all PT’s are trained the same and if your PT didn’t do a thorough assessment, go see a PT certified or Diplomaed in Mechanical Diagnosis and Therapy. I would be able to give you an honest assessment of whether therapy will be able to help you. Seek out someone trained in MDT.

MORAL OF THE STORY:

With patients that present to the clinic sub-acutely, with complaints of lower extremity pain referred from the spine, a MDT evaluation in order to assess for CP would be beneficial to predict non-response to conservative care. Patients that do not demonstrate the CP are greater than six times more likely to require surgery than patients that demonstrate CP.

 

A Critical Appraisal of Centralization and its Ability to Predict Surgical Outcome

 

P: For patients with back and leg pain

I: can patients that do not demonstrate the centralization phenomenon (CP)

C: as compared to patients that demonstrate the CP

O: be utilized to predict a surgical outcome

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Ovidsp with keyword terms “centralization and prognosis”. The results were limited to full text.   58 citations were found with no limit to year published.

 

Date of Search: February 2,2014

Re-evaluation date: February 9, 2014

 

Citation:

Skytte L, May S, Petersen P. Centralization: Its Prognostic Value in Patients with Referred Symptoms and Sciatica. Spine 2005;30(11):E293-E299.

 

Summary:

 

The purpose of this study is to evaluate the CP prognostic value in determining conservative or surgical treatment. This is a prospective cohort study of patients with unremitting back and leg pain, between 18 and 60 years of age. One hundred fourteen consecutive patients meeting these criteria were initially entered in the study and 54 patients were excluded based on the exclusion criteria. The exclusion criteria consisted of the following: previous lumbar spinal operation, pregnancy, serious spinal pathology, other serious pathology, Danish not the patient’s first language, symptoms present greater than 14 weeks and lack of consent.

 

Baseline data including the Nottingham Health Profile (NHP), Low Back Pain Rating Scale (LBPRS), demographic data and the Quebec Task Force (QTF) category of symptom referral. The examining therapist was blinded to the baseline data and performed a Mechanical Diagnosis and Therapy (MDT) evaluation in order to classify the subject as “centralizer” (CG), indicating that the most distal symptom was abolished and remained abolished upon returning to a neutral position, or “noncentralizer” (NCG), indicating no change during the MDT evaluation or the symptoms changed to a more distal location. Twenty-five patients were allocated to the CG and 35 patients to the NCG.

 

The treatment was the same for both the CG and NCG, consisting of “watchful waiting”. This included bed rest for those with neurological deficit and “light mobilization” for those without neurological deficit. Follow-up data was obtained at 1,2,3,6, and 12 months. Three patients from the CG and 16 from the NCG underwent surgery by the one-year follow-up. All patients were accounted for in the results.

Appraisal:

The authors satisfied six of the nine questions regarding the Quality Appraisal Checklist. A follow-up study, to establish the reliability of the results was not performed, and patients entered the study with varying acuity of symptoms. The examiner was blinded from the data collection, and the treating therapists were blinded from the examiner’s assessment.

 

Assessing the CP can predict conservative compared to surgical treatment requirements with 84% specificity and 54% specificity. The odds ratio (OR) for surgery in the NCG was calculated to be 6.17, with a 95% confidence interval (CI).

 

 

 

 

 

Considering a total knee replacement?

knee-replacement

Considering a total knee replacement?

 

There are increasing numbers of total knee replacements performed yearly. Medicare is initiating a bundled payment initiative for all facilities in 2017 and many are participating for the previous 2 years. What does this mean for the patients? Theoretically, it means more efficient care, with better outcomes, because patients will be more closely monitored. For instance, the hospital, and those employed by the hospital, stands to profit moreso than normal when patients have great success rates with more efficient care (see fewer visits performed).   From my perspective it is about 2 things: 1. Improve patient’s outcomes 2. Do this with less expense. Our country spends a large percentage of our money on healthcare, but when looked at from a broad perspective, we do a poor job of keeping our people healthy. Whatever the reason, this needs to change.

 

Those of us in healthcare understand that the insurance company drives the type of treatment that a patient can receive. Most patients, in my experience, will not pay out of pocket for care that they feel entitled to and will stop care when the entitlement is exhausted. We, as healthcare professionals, have to do a better job of demonstrating value to patients. I spend, like many people, over $1,500/year in order to have a cell phone with internet access. This amount of money would pay for 1 visit of PT per week for almost 6 months, if the patient paid out of pocket. BLASPHEMY! Why should I pay for something that the insurance company will cover?

 

The insurance companies are becoming more aware of our downfalls as a profession. One major downfall is one of the deadly sins…GREED! When patient’s have to take more responsibility for their own health care and have to share more of the costs of health care, then the patient will become more aware of how his/her dollars are being spent…or go broke in the process. Gratefully, I work for a company that doesn’t push profit as much as it pushes “right patient, right time, right treatment”. Patients need to see that not all therapy is the same and sometimes…just sometimes…the patient can have both high quality therapy at a low cost.

 

Bringing us to today’s post. Come and knock on our door…we’ve been waiting for your…and the kisses are hers and hers and his…three’s company too. When I think of single leg stance, I think of the flamingo stance. When I think of the flamingo stance, I think of terri/torrie/cindy (blond from the show) standing on one leg while at the zoo. Moral of the story is: patients with better balance do better overall. Patients can achieve better balance by working on the skill over time. Depending on the source, the NIH reports that it takes upwards of 50 hours of practice to improve balance. Go practice now.

 

Can you stand on one foot?

Can you do this with eyes closed?

Can you do this equally on both sides?

Can you do the eyes closed version for at least half as long as the eyes opened version?

 

If not, go see a PT. You can look at the APTA website or your state’s local website (Illinois Physical Therapy Association) in order to find a provider.

 

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).

Arm symptoms because of neck issues?

SCIATICA 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.

Clinical Prediction Rules

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

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

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

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

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

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

 

INTRODUCTION:

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

intervention approach for conditions commonly treated in PT.

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

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

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

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

attempting utilization).

 

METHODS:

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

 

methodological criteria

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

prognostic factors.

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

 

DISCUSSION

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

 

CONCLUSION:

  1. Follow-up validation studies are needed.

OREO COOKIE FRACTURES

ht_oreo_cookie_jef_120301_wmainOREO COOKIE FRACTURES

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

EXCERPTS TAKEN FROM:

 

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

THAT JUST CHAPS MY ARSE!

101_1749THAT JUST CHAPS MY ARSE!

 

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

 

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

 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

EXCERPTS TAKEN FROM:

 

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

GHOST WRITER

Ghost rider

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

 

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

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

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

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

 

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

 

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

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

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

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

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

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

 

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

  1. high-impact compared to major journals

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

Feelings…about back pain

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.