For A More Effective Physical Therapy Direct Patient Care
* Number 8 *
report on Physical Therapy Skills written by Bahram
Jam, B.Sc.(PT) M.PhtySt.(Manip),FCAMT
Leg Length Discrepancy…Is it a contributing factor to Mechanical Low Back Pain?
This study looked at the prevalence of leg length discrepancy (LLD) in 653 patients with chronic low back pain (LBP) and 359 asymptomatic subjects. The study concluded:
LLD of >5mm and >10mm was significantly more prevalent in LBP patients when compared to the asymptomatic subjects.
LLD of >15mm was significantly and dramatically more prevalent in LBP patients when compared to the asymptomatic subjects.
The study also suggested that some patients with chronic LBP and/or sciatica may benefit from a heel lift in the shorter leg; in particular those whose lifestyle involves spending much of their day on their feet…e.g. waitresses, soldiers, athletes, construction workers, etc.
Study conclusion: LLD equal to or greater than 15mm should be considered significant as it certainly correlates with an increase in the incidence of LBP.
Clinical conclusion: It is imperative for Physical Therapists to consider and measure LLD in patients with mechanical LBP, when weight bearing activities are an aggravating factor.
Reference: Friberg o. 1983 Clinical symptoms and biomechanics of limbar spine and hip joint in leg length inequality. Spine. (8);643-51
Don't Water Down Your Treatment Chasing the Ultrasound Gel!!
One of the realities of Ultrasound (US) application when using gel as a coupling agent has also led to its most common misuse. Gel spreads!
Chasing this tantalizing gel onto the far reaches of your patient's anatomy dramatically decreases the dosage of your treatment.
US dosages are based on the 'effective radiating area' of the transducer head (which is always smaller than the head itself).
Since the effects of ultrasound are dose specific, by doubling the size of the treatment area (easily done if you're not paying attention) you have cut the dose to 1/4 of that intended. By tripling it, you're left with 1/9.
Less than optimal results of US treatments perhaps reflect more about careless application than the efficacy of the modality.
Submitted by: Murray Tough, BA, BPHE, B.Sc.PT, M.Sc.., Kingston, Ontario
Disappointing Study Conclusion:
Exercises NOT recommended for patients with acute and chronic Low Back Pain (LBP)!!?*!?#
References: Maurits T, Malmivaara A, Esmail R, Koes B. 2000 Exercise therapy for low back pain. Spine (25) 21: 2784-2796
This study was recently published in Spine where they systematically reviewed 39 randomized controlled studies. The authors surprizingly concluded that… "Specific back exercises are not recommended for patients with acute and chronic low back pain."
This study also concluded… "There is strong evidence (Level 1) that extension exercises are not effective in the treatment of acute LBP." …and "There is moderate evidence (Level 2) that extension exercises are more effective than flexion exercises."
But…in the same article it is also stated…"There is strong evidence (Level 1) that exercise therapy is more effective than usual care by a general practitioner for chronic LBP."…referring to the Australian study on specific transversus abdominis and lumbar multifidus retraining. (O'Sullivan et al 1997)
And…another study published in Spine in 1990 concluded that the McKenzie method of treatment for patients with acute LBP was significantly superior to the control group with respect to return to work, sick leave from work, number of recurrences of LBP within one year and pain score (P< 0.001). (Stankovic & Johnell 1990)
And…the 5-year follow-up study on the patients who were treated according to the McKenzie principal was also published in Spine in 1995.
Conclusion: Patients who received treatments according to the McKenzie principal 5 years earlier had significantly (P<0.01) less recurrences of pain and had significantly (P<0.03) less sick leave compared to the control group. (Stankovic & Johnell 1995)
Again…another high quality study reported a significantly greater decrease of pain with extension exercises than with flexion exercises for patients with prolapsed intervertebral discs. (Nwuga & Nwuga 1985)
1) O'Sullivan PB, Twomey LT, Allison GT. 1997 Evaluation of specific stabilizing exercise in the treatment of low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine (22):2959-2967
2) Stankovic R, Johnell O. 1990 Conservative treatment of acute low back pain: A prospective randomized trial. Spine (15):120-3
3) Stankovic R, Johnell O. 1995 Conservative treatment of acute low back pain: A 5-year follow-up study of two methods of treatment. Spine (20):469-72
4) Nwuga G, Nwuga V. 1985 Relative therapeutic efficacy of the Williams and McKenzie protocols in back pain management. Physiother Prac (1):99-105
Personal comment: Is it not time that clinicians and researchers woke up to face reality? There is no ONE single magic exercise that "cures" mechanical lumbar pain. I find it so frustrating and disheartening when studies compare a single or a group of exercises with another single exercise or treatment method. For example studies compare the effectiveness of pelvic tilts, isometric abdominal strengthening, back extensor strengthening, general gym programs, extension exercises, flexion exercises, spinal manipulations or mobilizations etc. to each other or to a control group.
Many of these research studies have inconclusive results…isn't it obvious that there is no ONE magic treatment approach for acute or chronic LBP?
Human beings are not machines made up of mechanical pieces and therefore it is ridiculous to believe that there exists one approach that will consistently be effective for all patients with LBP. The human body is extremely complex and every single patient is a unique individual with a unique clinical presentation that will benefit from a unique Physical Therapy treatment approach.
Patients with mechanical LBP may benefit from any one of or a COMBINATION of the many Physical Therapy management options, including:
Education on rest
Corsets / braces
General gym exercises
Specific stretching exercises
Re-assurance of recovery
Custom made foot orthotics
Heel lifts to correct leg
Trigger point therapy
Mechanical / manual traction
Myofascial release technique
Hot and cold packs
Muscle energy techniques
Specific muscular control retraining
Is it rational to do a study using a homogeneous population of patients with LBP i.e. putting them all under one big category…"low back pain"? To make matters worse, studies attempt to treat them ALL using one or two treatment approaches…these types of studies are doomed to failure.
In reality, there are many different causes for acute and chronic LBP and the treating Physical Therapist must use clinical reasoning to determine the most likely clinical syndrome and then decide on the most effective treatment approach for that INDIVIDUAL.
Acute Low Back Pain…
Bed Rest, Exercise or Ordinary Activity?
Reference: Malmivaara A, Hakkinen U, Aro T, et al 1995 The treatment of acute low back pain-bed rest, exercises, or ordinary activity? N Engl J Med (332);351-5
A randomized controlled trial study assigned 186 patients with acute (<3weeks) low back pain to one of the three treatment groups:
i) Complete bed rest for two days with only essential walking allowed.
ii) Exercises as prescribed by a Physiotherapist in ONE SESSION including extension and lateral movements to be performed hourly and 10 times in each direction.
iii) The control group who were told to avoid bed rest and advised to continue their routines as actively as possible within the limits permitted by their back pain.
Results at the 3-week and 12-week follow-up sessions:
1) The patients in the CONTROL group had better recovery than those prescribed bed rest or exercises.
2) The patients in the CONTROL group were significantly better with respect to the duration of pain, pain intensity, lumbar flexion, ability to work as measured subjectively, Oswestry back-disability index, and number of days absent from work.
3) Recovery was slowest among the patients assigned to bed rest.
Study conclusion: Among patients with acute low back pain, continuing normal activities within the limits permitted by pain leads to more rapid recovery than either bed rest or back mobilizing exercises.
Basically: Patients who received "Physical Therapy exercises" were worse off in every way when compared to the ones who were simply left alone!
Personal conclusion: This was not a 'fair' evaluation of the effectiveness of Physical Therapy management of acute low back pain. The patients were only seen once, which rarely occurs in real practice and the patients were given almost a 'recipe' exercise of repeated movements.
Patients should not be expected to respond favourably if they are treated like 'machines in an assembly line' and provided with a same routine of exercises.
Patients in the Physiotherapy exercise group were instructed to repeatedly perform the same exercises for the entire 12 weeks or until their pain resolved, without having another chance to visit the Physiotherapist to be instructed on modifying, adding to or perhaps discontinuing them.
I find it sad when these types of published studies give an inaccurate and warped impression to other medical professionals about the effectiveness of Physical Therapy intervention for patients with acute low back pain.
Vertebral Artery Blood Flow… can PTs realistically test it?
Reference: Rivett D, Sharples K, Milburn P Stdy conducted at School of Physiotherapy, University of Otago, PO Box 56, Dunedin, New Zealand. Presented at the 2000 International Federation of Manipulative Therapists conference, Australia
Some Physical therapists commonly use pre-manipulative screening tests involving cervical end-range rotation and extension. It is hypothesized that these tests help screen patients who are not appropriate to receive cervical manipulations, due to a potential risk of having vertebro-basilar insufficiency (VBI).
This study compared the commonly used VBI tests to Duplex ultrasound with colour Doppler flow imaging.
Study conclusion: "Pre-manipulative testing (i.e. end-range cervical rotation and extension) does not distinguish between patients with varying degrees of vertebral artery flow impedance and is generally unlikely to be able to detect the patient at increased risk of stroke following manipulation."
Thanks to: Michael Westway, B.Sc. P.T. FCAMT of Calgary, AB for bringing this study to my attention.
Personal opinion: Since the present pre-manipulative screening tests are the 'best' tests we have at the present time, they should still be used until a better option is found.
Better option: Physical therapists have at their hands many options for treating cervical pain and cervical headaches, such as mobilizations and research based muscular control and kinaesthesia retraining.
Although cervical spine manipulation can be highly effective, I rarely need to practice it; as my personal philosophy is… 'use it as a last resort'!
For an excellent reference on the 'better option' read:
Jull GA 2000 Deep cervical neck flexor in whiplash. Journal of Musculoskeletal Pain 8(1/2);143-154
Diagnosing Meniscal Lesions…
not so hard if there is a "good" history!
1) History of a specific trauma involving tibia or femoral rotation on a weight bearing foot
2) Reports of "clicking" since the injury
3) Reports of knee "buckling or giving way"
4) Reports of knee spontaneously "locking"
Meniscal Tests…as accurate as MRI!!
Reference: Muellner T et al. 1997 The diagnosis of meniscal tears in athlete's; A comparison of clinical and MRI investigations. American Journal of Sports Medicine (25):1;7-12
Magnetic resonance imaging (MRI) is considered to be a "gold standard" test for diagnosing meniscal lesions, however it is not easily accessible, it is expensive and usually involves being on a long waiting list.
This study supported that taking a good history and using a group of tests to stress the meniscus may be as accurate, sensitive and specific as MRI.
| ||Clinical||Testing MRI|
The testing consisted of all the 6 tests outlined below: (monitoring for symptom reproduction of pain or 'clicking')
Test #1: Joint Line Tenderness
Simply palpate the anterior and posterior tibio-femoral joint.
Test #2: McMurray's Test
Medial and lateral rotation of the tibia performed in various stages of knee flexion.
Test #3: Apley's Test
With the patient in prone and the hip extended to neutral-flex the knee >90° and then rotate and compress the tibia.
Test #4: Bohler's Test
Same technique as when testing for the collaterals but we are concerned with the compressive aspect of this test.
Test #5: Steinman's Test
Sitting with knee hanging over the exam bed; medial and lateral rotation of the tibia in performed.
Test #6: Pary's Test
Flex the knee to 90° and apply a varus stress-this compresses the medial meniscus posterior horn.
Clinical conclusion: This study shows us the importance of correlating many tests in order to achieve a more accurate "Physical Therapy diagnosis". This is a practice we should use with most of our investigations.
Prepared by: Dana Clark, B.Sc.P.T., FCAMT of Toronto, ON
STOP using Neural "TENSION" Tests!!
The old term "Neural Tissue Tension Tests" almost implied 'stretching' of the nerves, which is an incorrect assumption. The mentality that we must 'move' neural tissue if it is restricted in also inaccurate.
Reference: Hall T, Elvey R. 1998 Adverse mechanical tension in the nervous system? Manual Therapy 3(3):140-146
The term "Neurodynamics Testing" (NDT) is more accurate and has much greater acceptance with the medical community.
(E.g. in charting write: NDT med.n. bias +ve)
Effective for Calcific Tendinitis
A randomized, double-blind study was conducted comparing US treatments to sham US on 61 patients with symptomatic calcific tendinitis of the shoulder.
Patients in the treatment group received within six weeks, 24 15-minute sessions of pulsed ultrasound (frequency, 0.89 MHz; intensity, 2.5 W per square centimeter; pulsed mode, 1:4).
Results: After six weeks of US, calcium deposits had resolved or decreased by at least 50 percent in 47% of the patients, as compared with no significant change in the sham US-treatment group (P=0.003).
At the end of the six weeks, patients who had received ultrasound treatment had greater decreases in pain and greater improvements in the quality of life than those who had received sham US treatment.
Clinical Conclusion: Ultrasound treatment helps resolve tendon calcifications and is associated with clinical improvement of symptoms and function.
Excellent published evidence to support Physical Therapists using ultrasound for patients with symptomatic calcific tendinitis of the shoulder.
Personal comment: If you have never applied Ultrasound for 15 minutes continuously to one area…consider it for your next patient with calcific tendinitis!
Reference: Ebenbichler G et al. 1999 Ultrasound therapy for calcific tendinitis of the shoulder. The new England Journal of Medicine
SI Joint…Study supports it may be involved in patients with Persistent Low Back Pain
Reference: Schwartzer A, Aprill C, Bogduk N. 1995 The sacroiliac joint in chronic low back pain. Spine 20(1):31-7
43 patients with chronic low back pain were investigated with sacroiliac (SI) joint provocative injections and analgesic blocks under image intensifier using radiographic contrast.
1) The prevalence of SI joint pain in patients with LBP appears to be as high as 30% as 13 of the 43 patients had relief of symptoms after the local analgesic block.
2) Groin pain was highly associated with response to SI joint block
Are SI Tests of any Predictive Value? No?
Reference: Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N 1996 The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (21):22;2594-2602
Twelve of the 'best' SI joint tests chosen by an expert panel were evaluated against the 'gold standard' test of pain relief with an intra-articular injection of local anaesthetic into the SI joint.
Study conclusion: "Sacroiliac joint pain cannot be diagnosed from history or physical examination.
If the diagnosis is to be made, controlled diagnostic blocks are, at present, the only means to make that diagnosis."
(In other words, Physical Therapy assessment for the SI joint is a 'waste of time'!)
In that study they quote "It remains possible that a major part of the so-called sacroiliac
pathology is a pathology of the soft tissues surrounding the joint. The
‘gold standard’ diagnostic block may be accurate for diagnosing pain within the
joint (intra-articular), but NOT as accurate for diagnosing pain from the soft
tissues surrounding the SI joint complex!
Please Feel Free to Contact APTEI…
1) If you are interested in contributing to this report
2) If you are interested in instructing a post-graduate Physical Therapy related course, I would be happy to assist you in the course organization
3) If your Clinic / Physiotherapy department is interested in hosting an APTEI course in the future
I hypothesize that many of the SI tests stress the soft-tissues surrounding the joint (i.e. the ligaments) and not the actual intra-articular structures.
Is it possible that the so-called 'gold standard' diagnostic blocks are not so 'gold' when it comes to diagnosing sacroiliac joint extra-articular pain?
Although studies seem to indicate that various SI tests are in fact 'useless', I will personally continue to perform them clinically and rely on them for determining the treatment for my patients with LBP.
Reliable SI Joint Provocative Tests
Reference: Wurff P, Hagmeijier HM, Meyne W 2000 Clinical tests of the sacroiliac joint: a systematic methodological review. Manual Therapy 5(1);30-36
The authors of this article reviewed 11 studies and conclude:
1) The validity and reliability of most sacroiliac tests are poor. "Therefore, at this time, it is questionable whether any SI joint tests are of any value for clinical practice."
2) The Gaenslen test and the Thigh thrust test seem to be clinically reliable test
3) The Patrick's test and the Gapping test may be reliable but studies contradict each other.
Patrick's Test / FABER test
Effective Mobilization for Lateral Epicondylitis
Reference: Vicenzino B, Wright A. Effects of a novel manipulative physiotherapy technique on tennis elbow: a single case study. Manual Therapy 1995; 1(1): 30-35 (This article was also reprinted in the March/April 1999 issue of the Orthopaedic Division Review, CPA)
I have had great and immediate positive results using the lateral glide technique as described by Brian Mulligan on my patients suffering from 'tennis elbow'. To apply the technique…
1. Ask the patient to grip in the position that produces their symptom e.g. in elbow extension and pronation
2. Ask the patient to relax, then a sustained lateral glide mobilization is applied to the proximal forearm either with a belt or with the hands.
3. While the lateral glide is maintained, the patient is asked to form a grip again and hold for approx. 3 seconds…frequently the patient will report that this time the grip is pain-free.
Note: To achieve this positive effect, the mobilization must be applied in the 'right' direction with the 'right' amount of force…, which varies among all individuals!
4. Step #3 may be repeated 10 times and 3 sets may be required to eliminate the normally painful grip.
Note: The technique must be pain-free; never continue if the patient reports of pain.
All other therapies may still be used in conjunction with this technique.
A Please Feel Free to Contact APTEI…
1) If you are interested in personally contributing to this report, I would be happy to assist
2) If you are interested in instructing a post-graduate Physical Therapy related course, I would be pleased to assist you in the course organization to the best of my abilities
3) If your Clinic / Physiotherapy department is interested in hosting an APTEI course in the future
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