Tag: cervical radiculopathy

Traction: useful or not?

I use traction sparingly. It is a last resort if the patient is going to have a surgery. If I have tried everything in my power and knowledge to help a patient, and the patient continues to not improve, then traction it is. It is my Hail Mary.

  1. “Physical therapists may choose from myriad intervention options for LBP, but the effectivenss of many of these options is questionable”

Do you feel good about coming to therapy yet? An awesome question to ask your therapists is; “What does the research say about xyz?” or better yet “Does the research support xyz for my condition?”

It’s funny, in school we all learn that ultrasound brings more blood flow to an area…SO FRIGGIN WHAT? Does that blood flow actually fix me? Not really, but it brings more blood flow! That’s an expensive transportation of blood. Do you know what else brings more blood flow…Hickies. That brings more blood flow. Ask your therapists to suck on your skin for a while to see if that will also bring more blood flow. It will probably cost you a little more for that service though…I digress. There is not much, if any, CURRENT research that supports the use of ultrasound for back pain. If your therapist tells you that ultrasound will help, ask how? If they tell you the blood flow thing…ask them to pucker up.

  1. “Authorities have recommended traction for conditions including protruding Intervertebral discs, spinal muscle spasm, and general pain and stiffness”

This is what I learned when I was in school. Seems archaic that we were taking general recommendations from “authorities” to try to fix the second largest complaint to the common cold. At least research has advanced from the opinion of authorities.

  1. “several systematic reviews and clinical guidelines conclude that the effectiveness of traction is limited…little evidence to recommend traction…clinically important benefits of lumbar traction were demonstrated for neither acute nor chronic back LBP…traction should not be used…41% of the physical therapists in the UK used traction”

Boy can those statements be any stronger. Traction should not be used because it is not very effective for low back pain (LBP). Now if you want to use traction because it makes you feel better, then go ahead. Sugar pills work for some people also. (Not trying to come across as sarcastic, but I’m sure it sounds that way). If you have preference for a specific intervention, then that intervention may be likely to help you. I have a patient that believes that ultrasound of the back muscles helps. No matter how much education I have provided, I’d be better off talking to the wall. Needless to say, we have a great conversation during the ultrasound, while the patient is propped up on his elbows and lying on his belly. For those that know, these positions can help/fix up to 65% of back pain patients.

  1. “Our findings suggest that a majority of APTA Orthopaedic Section members use traction…In contrast, approximately one third of respondents indicated that they would use tractions for patients in a manner that is contrary to that classification”

There is a clinical prediction rule in the derivation (creation) phase that indicates a certain type of patient may benefit from traction. This is less than 10% of the patients in the clinic. This rule has not been replicated yet, so it is more like an educated guess at this point. Other research has reported the above, in which traction has no added benefit to an exercise program. Also, exercise increases blood flow (see above). The sad part is that about 1 in 3 therapists are using traction contrary to how it should be used. Have you seen that therapist? They are typically the ones applying hot packs, Hickies and massage.

  1. “employing soft tissue mobilization or massage was identified by approximately 65% of our respondents as a supplement to traction. Given limited evidence for the effectiveness of massage for treating LBP…the extent to which physical therapists in the United States use soft tissue mobilizations/massage in managing LBP may be concerning”

WOW! I was totally talking out of my a$$ in the above paragraph, but my a$$ is also supported by research. Who knew?

  1. “there is a growing body of evidence that higher levels of professional preparation influence clinical decision making and, potentially, patient outcomes”

Look there has been a backlash in our profession for what is called “alphabet soup” after our names. This means that some therapists have gone on for “extra” training and certifications. This is important. Unfortunately, our profession has deemed it inappropriate to put down all of the certifications after our name. The only way to know what your therapist knows is to ask. I personally have the initials:

DPT (Doctor of Physical Therapy), cert. MDT (certified in Mechanical Diagnosis and Therapy). None of the above initials were given to me…I earned them.

Thanks for reading this. If I go overboard at times and offend you, there are other blogs to read. Have a good night.

Quotes taken from:

Madson TJ, Hollman JH. Lumbar Traction for Managing Low Back Pain: A survey of Physical Therapists in the United States. J Orthop Phys Ther. 2015;45(8):586-595.

Comparing McKenzie to a cognitive behavioral treatment strategy

Got back pain?

 

This is a study that compares two different treatment approaches head to head. Bout damn time that we are looking at two approaches and comparing them in a study. We (health care researchers) typically compare one treatment against no treatment. This is good and all, but then we believe that all treatments work and work equally. These are the types of studies that need to come out, so that as a health care provider, I am providing the best treatment to help your problem.

 

  1. “A recent UK survey estimated the (1-month period) prevalence of spinal pain to be 29%”

 

This means that during any one month period about 1 in 3.5 people are experiencing back pain, over on the other side of the pond. Think about that! If you have one person on each side of you, one of you will have back pain during the month.

 

  1. “The lifetime prevalence of these conditions is also high—it is estimated that »70-85% of the population will experience some spinal pain during their lifetime”

 

Again, 8 out of 10 people will have back pain during their lifetime. This is starting to sound grim. Pain is not normal. What are we doing to ourselves? Why do we keep having back pain at such an alarming rate? I have my opinions, based on some research, but it hasn’t been fully substantiated yet. I will pull out the research at a later date of course.

 

  1. “In 1998, the cost of lower back pain alone to the UK National Health Service was estimated at 1 billion (pounds), with over 200 million (pounds) being spent on physiotherapy”

 

So…what’s this got to do with us? That’s the UK. The numbers aren’t too far off of what we are spending on back pain. See the link from a previous post in which I discuss monetary figures.

https://movementthinker.org/2016/03/17/a-little-bit-of-crazy/

 

  1. “guidelines state that in the first instance patients should be encouraged to remain active, with the prescription of anti-inflammatory drug and/or analgesia where required.”

 

There is an opiod epidemic spreading world wide. I realize that opiods and anti-inflammatories are a long ways away from each other, but to think that back pain will be fixed with medication only is dreaming. NSAID’s are not always the answer either. http://www.aafp.org/afp/2002/0401/p1319.html

 

Robin Mckenzie states in his textbook (paraphrased): a mechanical problem needs a mechanical answer and a chemical problem needs a chemical solution. The first question has to be: is the pain mechanical or chemical?

 

To remain active is the same advice that I could get from my dad. You’ve heard the advice countless times I’m sure…especially if you’ve ever been hit by the ball while standing in the batter’s box…”walk it off”. Hell, my dad was a laborer. He didn’t go to medical school, but gives the same advice. I pay for better than that. I can get the advice for free back in Elwood.

 

  1. “Physiotherapy treatments aimed at alleviating the physical causes of back and neck pain include: advice, exercise programmes, massage, mobilization and manipulation”

 

Some big takeaways from this sentence are what was left out of the sentence. At no point did the authors talk about ULTRASOUND!, ELECTRICAL STIMULATION!, TRACTION!, VAX-D (sp)! CUPPING! or any of the other passive fads that make clinics money for doing thoughtless work. Look…if the above (in capital letters) makes up a part of your treatment, you have to question your practitioner as to why and what are the expectations of the intervention. I know what my expectations are…lining the owners pocket with greenbacks.

 

  1. “a new type of intervention for treating back and neck pain has recently been developed, triggered by growing awareness that psychosocial factors play an important role in musculoskeletal complaints. These behavioural interventions have different compositions depending on the specific theory underpinning the approach.”

 

To think that the “biopsychosocial” approach is new is a fallacy. It is a newer concept to put a name to it, but even those that simply have “mechanical” training understand that in order to use “mechanical” training, we have to get through the psychosocial constructs of each patient.

 

  1. “elucidating whether a treatment offers good value for money in terms of cost vs benefit must also be considered”

 

This is an interesting topic that is finally coming to the forefront in healthcare. I’m going to go to the extremes to make a point. Let’s say that you have a heart problem and a surgery that costs 100,000$ will keep you alive for decades, but a surgery that only costs $1,000 can keep you alive for a year. Which would you take? Costs vs benefits become very apparent in this scenario. This article will scale the topic down to back pain.

 

  1. “The trial compared two physiotherapists delivered interventions for musculoskeletal back and neck pain, which aimed to promote return to normal activities…Solution Finding Approach, was a brief physiotherapy intervention based on cognitive behavioral principles…a patient-centred view and, in this context, aims to help patients identify reasons for their pain and to provide solutions and long-term management strategies”

 

This essentially says: this approach consists of few physical therapy visits in order to help you figure out why you have pain and to provide solutions to long term management of your pain.

 

Remember this because it is important for the next section.

 

  1. “The second approach was the more traditional biomechanical approach used by physiotherapists, the McKenzie approach, which involves classification of patient’s spinal condition and the prescription of specific therapeutic exercises.”

 

This one states the following: The therapist will help you figure out why you have pain, through a classification system, and issue solutions (exercises) in order to provide long term management of your pain.

 

Sounds fishy…I don’t know if I like either method since they both sound so similar. Those that know me, know that I am biased. I am certified in the McKenzie method, formally known as Mechanical Diagnosis and Therapy.

 

  1. MeKenzie approach…has been clearly documented…commonly used by physiotherapists…conducted a biomechanical assessment using repeated movements of the spine and, based on these findings, prescribed specific exercises for the patients to work on repeatedly themselves…relies on active compliance with the exercises and advice.”

 

MDT (McKenzie method) was created a long time ago. I know the history like the back of my hand, but it seems like too much to type out here. Look up his biography, “Against the Tide” to read how this man revolutionized the way spines and now extremities are treated…by those that have studied the method. In a time in which not many believed him, and many went so far as to ridicule his methods, it took almost 50 years to confirm his thoughts through science.

 

Anyway, we use repeated, sustained, resisted and speed based positioning in order to elicit a change in symptoms. Manual techniques can also be used to elicit a change. Once we see a change that is documented with having good results…we stop there and send you home with the exercise, position or movement.

 

  1. “All the physiotherapists delivering the McKenzie approach were experienced in this method and had undertaken McKenzie Institute training (courses A-D).”

 

This is important. Scott Herbowy, one of the highly trained professors of the method, published a study in the recent years regarding the training and outcomes of those using the methods. It seems realistic to believe that someone that has taken courses A-D would have the same reliability and outcomes as someone that has taken the same courses and passed a competency exam. This is not true though. Those that have not yet passed the test appear to be inconsistent in classifying patients using MDt. See the study below to learn more:

 

http://www.ncbi.nlm.nih.gov/pubmed/24253786

 

  1. “…both the McKenize and Solution Finding approaches lead to improvements in patient outcomes over time, with no significant differences between the two treatments.”

 

Both treatment ideas provide similar improvements over time. This indicates that just in terms of improvements, it doesn’t matter which method is used (albeit neither group of therapists were highly trained in using the intervention attempting to be studies). I liken this to asking an auto mechanic to work on a Boing Jumbo Jet. Yes…the mechanic understands engines, but there’s a difference in specialties.

 

  1. “The McKenzie treatment required on average, one extra subsequent visit to the physiotherapist”

 

This means that seeing a therapist semi-trained in MDT will cost you an extra $100 dollars compared to seeing someone semi-trained in the Solution Finding Approach. Is this a bad thing? We will see.

 

  1. “the Solution Finding Approach is slightly cheaper than the McKenzie approach but confers marginally lower benefit”

 

Dave Ramsey has a free radio show about finances. One of his taglines is “the advice is worth what you pay for.” Obviously he’s kidding, but we all know that the better stuff in life isn’t free. When it comes to your health, how much more are you willing to pay? Are you willing to pay “slightly” more?

 

  1. “The policy maker needs to decide whether she or he is willing to invest additional health care resources funding the McKenzie approach”

 

Look, you need to find someone that has this certification or diploma training if you have back pain. Countries are debating whether or not more money should be put into training therapists in this method. Some of us have paid for the training out of pocket in order to become better therapists, with the end goal of providing great care to patients.

 

  1. “the additional cost associated with the McKenzie treatment is worth paying, given the additional benefit it provides”

 

NEED I EXPAND ON THIS SENTENCE? This benefit is from people that aren’t even “minimally competent” to provide this service. Imagine how much more benefit or less cost that you would have from someone that is competent in using the method.

 

This study was performed in the UK. There is no reason for me to believe that back pain differs that significantly from those experiencing back pain in the US. I have to correlate that those seeing a McKenzie Credentialled therapist will see even better results or spend less money over the long haul than that those seeing someone using cognitive behavioral therapy.

 

Quotes taken from: Manca A, Dumville JC, Torgerson DJ, Moffett JAK, et al. Randomized trial of two physiotherapy interventions for primary care back and neck pain patients: cost-effectiveness analysis. Rheumatology 2007;46:1495-1501.

MRI’s fact vs fiction

 

This was a great article. It puts numbers to the faces seen on MRI’s. I like numbers…kind of like Rainman. Numbers comfort me. Enjoy the read. There is some higher level thinking in the below quotes. If you have any questions, leave a post either here or on the movementthinker Facebook page.

 

  1. “Magnetic resonance imaging (MRI) provides clinicians with a noninvasive mechanism for viewing lumbar anatomy in great detail”

 

READ AND RE-READ THE ABOVE STATEMENT.

Question #1 from the above statement: Can an MRI tell me what is causing your pain?

 

Question #2: Can an MRI tell me how to treat you?

 

Question #3. Does the MRI differentiate between abnormal structures that cause pain and abnormal structures that don’t cause pain?

 

The answer to all of the above questions is NO! Everyone seems to think that they need an MRI before they come to therapy…as if I am going to just treat them on a whim without the MRI…or that the MRI will somehow give me a paint by number way of treating the symptoms. This does not exist. The MRI can be helpful in a small percentage of patients that are either seeking or needing surgery, but aside from that it is just something for me to read after I have performed my clinical assessment of the patient and come up with my own conclusion. Now…if my conclusion matches the MRI then awesome! Well…at least for me. If it doesn’t match the MRI…that sucks because now I have to go back and reassess to see which one of us is more right…the PT or the MRI.

 

  1. “For example, large variations in lumbar disc and radicular canal morphology have been identified in both symptomatic and asymptomatic individuals”

 

This means that an MRI is very good at determining what is not normal, as compared to a textbook, but the variations of normal is so wide that the test may not tell us much.

 

  1. “…challenge for examiners in their attempts to differentiate between observations that are “symptom generators” and those that are benign variations”.

 

When a radiologist reads your MRI, they are the ones that are determining what is going on in the pictures, they spend on average of 30 seconds per picture. In 30 seconds, they have to figure out what is abnormal. Then, if they have found something abnormal, they have to determine if it can cause your symptoms. All of this is performed without ever evaluating the most important aspect of the symptoms…YOU! The radiologist never sees you. If you look at the bottom of your report (assuming that you have already had an MRI), you will typically see the phrase “patient would benefit from clinical examination to correlate imaging”. This is the radiologist saying; “Look, I only have the pictures. I can tell you with a degree of certainty what the MRI says…does this fit your symptoms?”

 

  1. Patients were classified according to this table:

 

  1. Primay LBP (low back pain): pain in the back or buttock

 

  1. Posterior thigh referral: pain in one or both back/lateral thighs with or without LBP

 

  1. L1-L3 distribution: pain in the anterior thigh and top of foot

 

  1. L4-5 distribution: pain in the mid and distal anterior thigh, anterior leg and top of the foot.

 

  1. S1-S2 distribution: Pain in the lateral border of the foot and bottom of the foot

 

  1. Bilateral distribution: any combination of the above in both legs instead of one leg.

 

  1. Atypical: none of the above.

 

This is an overall pain pattern distribution. Unfortunately, this is not drilled in PT school. I was about 2-3 years out before I figured this out on my own and then after discovering it, I looked it up. It’s funny…if you don’t know what you don’t know, then you don’t know how to find it. I think that PT’s schools should heavily bias students in this direction for learning. Think of it. If you knew that for every dollar you invested, you would get an 80% return if you simply knew a few tricks…would you learn those tricks?

 

Roughly 80% of the population will have back pain at some point in his/her life. This is either the primary or secondary reason for physician office visits (depending on which research you read) and the one that it competes with is the common cold. Think about that…back pain is about as “common” as the cold.

 

  1. “All images were initially screened for evidence of neoplastic, inflammatory or infectious disorders…”

 

This is all of the very bad stuff that needs to be ruled out if someone is going to look at an MRI. This is stuff that won’t get better with therapy. If you have certain characteristics, your PT may refer you back to your physician in order to rule out the nasty stuff.

 

  1. “…study involved 408 participants…55% had acute pain…50 participants reported a recurrence of previous symptoms within the past 2 months…303 participants reported chronic symptoms of longer duration than 2 months”

 

This sounds about right. Those with back pain may have it go away, but it will come back. Those whose pain doesn’t come back is mostly because…IT NEVER WENT AWAY!

 

  1. “…the most common location of symptoms was in the S1-S2 segmental, followed by the L4-L5 distribution. Bilateral radicular patterns were the least frequent.”

 

This means that a high percentage of patients had symptoms radiating into the foot, from the back. Fewer patients experienced symptoms into both legs. If both legs are causing you pain…at the same time…you are among the few.

 

  1. “The presence of weakness in ore of both lower extremities was reported by 175 participants (42.9%)”

 

If your back symptoms are bad enough, they will start to cause a “power outage”.   For instance, I use a specific analogy in the clinic. If your lamp doesn’t turn on when you flip the switch…what is wrong?   A common answer is that the light bulb is burned out. How many light bulbs will you go through before you realize that the bulb is working fine? When a muscle is weak, it is like the above idea. I can give you strengthening, but I would have to give you about 6 weeks of strengthening exercises in order to determine if “just muscle weakness” is the problem. This is like changing the light bulb daily for 6 weeks. I doubt that you would actually do this. Most people may do this once or twice and then just give up. When I give you strengthening exercises, you will do them for a couple of days and then give up because you won’t see much change.

 

What else could cause the light to not turn on? There could be a fray in the cord. This also happens in the body. If there is a nerve (electrical wire) that is not working appropriately, then the muscle won’t contract…the light bulb won’t turn on. This one becomes a little harder to figure out because we would have to try to find the location of the “fray”.

 

The final thing is the easiest to check for…the lamp isn’t plugged in.

 

It’s funny because I frequently have students. Recently, I had a patient that struggled to go up the stairs. She noted that her leg was weak. Students always want to make a muscle stronger. They are good at that. Unfortunately, her hip muscle wasn’t plugged in. After performing 30 repetitions of repeated extension in lying, her hip strength went from weak to moderately strong. Her ability to ascend stairs was visibly improved and the patient was surprised that her sensation of strength had improved. The student asked “why don’t we learn this in school?” I don’t know. I have the same question.

 

  1. “Disc extrusion was significantly related to the presence of distal lower extremity pain…not significantly related to weakness…not significantly associated with the presence of paresthesias or numbness”

 

What is a disc extrusion? This guy does a great job of explaining it: http://www.bodiempowerment.com/disc-bulge-why-is-my-disc-bulging/

Why reinvent the wheel?

 

  1. “Overall 149 of the participants (37%) had MRI evidence showing some degree of nerve or thecal sac compression…The most common segmental level of compression was L4-L5, followed by L5-S1…There was a significant association between the side of nerve compression and the side of pain…of the 256 patients with no evidence of nerve compression visible on MRI, 151 (58%) indicated unilateral lower extremity symptoms”

 

This means that some patients that have an MRI will show that the disc has caused some sort of nerve compression. When this happens, you will typically have pain on the side of the compressed nerve. On the flip side though, you can have pain on in one leg that is not coming from the nerve. Think like this…nerve compression can cause leg pain, but not all leg pain is caused by nerve compression.

 

  1. “participants who reported weakness had a greater prevalence of nerve compression, and those without weakness had a lower prevalence of nerve compression”

 

Again, the nerve supplies electricity to the light bulb. If the electricity is not getting there because of a problem with either the plug or the cord, then the muscle won’t work.

 

  1. “Roughly 63% of the participants had no evidence of nerve root compression on MRI. Of these, 35% had pain patterns referring distally to the knee”

 

THIS IS HUGE! PT’s in school learn that if you have pain below the knee that there must be some nerve that is compressed. This is not always the case. Any structure that has a nerve going to it can cause pain to radiate in a pattern specific to that nerve. For instance, in the neck we know that if we irritate the nerve in the joint, it could refer pain into the shoulder blade. It doesn’t have to be a “PINCHED NERVE”!

 

  1. “the presence of disc extrusion or ipsilateral, severe nerve compression at one or multiple sites is strongly associated with distal leg pain. Mild to moderate nerve compression, disc degeneration or bulging and spinal stenosis are not significantly associated with specific pain patterns.”

 

I enjoy weightlifting. When I see a snatch done well, it is like poetry. I can’t explain the entire movement in one fell swoop other than to say it is beautiful. When I see someone do this movement, with little experience, we can officially say that: yes you went from point A to point B, but not well.

 

When we see a severe nerve compression or disc extrusion, we can say “YUP I KNOW WHAT THAT IS.” Anything past that is a guess as to what is causing your symptoms, based on the MRI.

 

Quotes taken from the following:

 

Beattie PF, Meyers SP, Stratford P et al. Associations Between Patient Report of Symptoms and Anatomic Impairment Visible on Lumbar Magnetic Resonance Imaging. Spine 2000;25:819-828.

 

 

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).

 

 

 

 

 

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.

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.

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.