For A More Effective Physical Therapy Direct Patient Care
* Number 9 *
report on Physical Therapy Skills written by Bahram
Jam, B.Sc.(PT) M.PhtySt.(Manip),FCAMT
All Physical Therapists 'fall into a trap' once in a while. The 'trap' is assuming that a patient fits a pattern that we have seen a hundred times before. The 'trap' is treating a patient according to a 'recipe' we learned in University or at a post-grad course. The 'trap' is not having the time during the busy day or at the end of an exhausting day to read an article or the latest paper on a patient's specific condition. I am certainly guilty of 'falling into those traps'. I hope that the information you are about to read will stimulate your clinical thinking and help you ask more questions.
Future issues of the APTEI™ Report will be mailed to you (or be accessible on www.aptei.com to you) ONLY if you fax or mail your subscription form back. Sincerely, Bahram Jam
Are Mobilizations With Movements Effective?
Brian Mulligan originally introduced the concept of mobilization with movement (MWM), and due to its effectiveness it has been gaining popularity amongst Physical Therapists internationally. But,….. show me the research!
18 subjects with persistent Lateral Epicondylitis participated in a randomized, double blind, placebo controlled study, to help determine the effectiveness of a MWM technique.
Study conclusion: Painful grip strength improved significantly and DRAMATICALLY post-treatment using a lateral glide MWM technique, and did not improvement significantly following the placebo or control conditions.
Clinical conclusion: Patients suffering from 'tennis elbow' may greatly benefit from the mobilization techniques proposed by Brian Mulligan.
Reference: Vicenzino B, Buratowski S, Wright A 2001 A priliminary study of the initial hypoalgesic effect of a mobilization with movement treatment for lateral epicondylalgia. Proceedings of the 7th Scientific Conference of the IFOMT. The University of Western Australia, Perth, Australia, November 6-10;pp 460-4
Note: For a brief description of the actual technique please see "APTEI Report Spring 2001 issue"
For info on the Mulligan Concept courses, contact Jack Miller at:
Fibromyalgia…another controversy over it!
The controversial hypothesis is that compression of the brain stem may be the cause of the symptoms in some individuals with 'fibromyalgia'.
There have been a FEW cases where individuals with signs and symptoms of 'fibromyalgia' have had dramatic improvements following a decompression surgery.
The surgery involves opening up the foramen magnum by removing part of the occipital bone and possibly part of the Atlas (C1). (Obviously a drastic treatment option!)
However, MRI studies show no significant difference in the size of the foramen magnum and the brain stem in individuals with 'Fibromyalgia' versus asymptomatic individuals. (If anything, the asymptomatic subjects had slightly smaller foramen magnums!)
But, a different study DID find that fibromyalgia sufferers had 5 times as many neurological abnormalities as control subjects. This is a surprize finding, as the medical community has generally believed that patients with 'fibromyalgia' have normal physical exams, except for increased tenderness.
Reference:"THE BACK LETTER" Vol 16, No 4, April 2001 Published by Lippicott Williams & Wilkins
Personal Conclusion: 'Fibromyalgia' is a complex condition and the 'cause' is likely multi-factorial. I personally feel the diagnosis 'fibromyalgia' means…we don't have a clue what the condition is, so we will call it 'muscle pain' in Latin to make ourselves sound intelligent… and at least now the patient can be labeled!
Put Away the Goniometer for The Ankle!
References: Bennell et al1998 Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion, Aust. J Physiotherapy 44(3): 175-180Clinically, ankle dorsi-flexion (DF) is the most commonly lost motion following ankle injuries.
Functionally it will effect activities such as gait, stair climbing, running and squatting.
Restricted ankle DF may be a significant factor for recurring ankle sprains, persistent plantar fasciitis and Achilles Tendinitis.
I have personally found little value in the Goniometric method of measuring ankle dorsi-flexion ROM. I have also found little value in 'eye-balling' ROM of the ankle, as restrictions can not often be seen.
An excellent, reliable, quick and easy method of measuring ankle DF is using the "knee to wall" method. No fancy equipment required! …just a wall and a ruler.
Technique: Start with the tip of the big toe a certain distance (...lets just say 10 cm) from the wall. Then ask the patient to take the knee directly forwards (staying over the middle toe) until the knee touches the wall. If the knee touches the wall, move the foot back 1-2 cm and repeat again.
Determine how far the foot can be away from the wall and still have the knee touch… WITHOUT a compensatory heel lift ccurring.
Compare the two sides. If both ankles are symmetrical…(i.e. both 8cm or both 15cm from the wall) that is considered normal.
If the unaffected ankle/foot is 12cm and the symptomatic ankle/foot is 5cm from the wall…that may be considered significant and it should certainly be addressed with mobilizations.
Research on asymptomatic individuals, shows no significant difference in ankle DF ROM between sides, but significant variations among individuals.
Conclusion: Ankle DF ROM should not be compared with reference ranges, but with the opposite foot.
Another note: Patients really like this outcome measure, as they get exited when they improve by 1-2cm after a treatment session!
Headaches…a headache to differentially diagnose!
Reference: Vincent MB, Luna RA 1999 cerviogenic headache: a comparison with migraine and tension type headache. Cephalgia 19 (25);11-16
A quote from Prof. G. Jull of University of Queensland, Australia was: "The single most important factor which determines the potential effectiveness of Physical Therapy treatment for headaches, is accurately diagnosing if the patient actually suffers from cervical headaches."
A This study concluded that cervical headache could be differentiated from migraine or tension headache with 100% sensitivity, IF 7 criteria were present. The most important / sensitive signs for cervical headache include:
1) Unilateral headache with side consistency
e.g. if a patient reports one day my headache is on the right side and the next day it is on the left…headaches are less likely of cervical origin.
(A patient with a symptomatic right knee OA or MCL sprain will not suddenly have symptoms switch into the left knee!)
2) Headaches precipitated and aggravated by certain neck postures
e.g. Prolong reading, looking down, keyboarding, turning to look behind, looking up to the top shelf of a cupboard, etc.
3) Restricted range of motion in the neck
e.g. C0-C1 and/or C1-C2 and/or C2-3 are commonly involved with cervical headaches, hence rotation is the most obvious movement that is restricted and may be painful.
LBP? Oblique Retraining?…Use a PBU!!
Reference: Richardson C, Jull G, Hodges P, Hides J. 1999 Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain, Scientific Basis and Clinical Approach. Churchill Livingstone.
Reference: Shirley Sahrmann, Level I: Diagnosis and Treatment of Movement Impairment Syndromes. Course notes 2000.Several authors discuss the importance of retraining the external and internal oblique muscles in order to improve functional stability at the lumbar spine.
A very effective method of retraining muscular control of the lumbar spine requires the use of a Pressure Biofeedback Unit (PBU).
In crook lying place the PBU under the lumbar spine and pump it up to 40mmHg. Then ask the patient to keep the stomach flat and increase the pressure to 50mmHg by GENTLY reversing the lordosis.
Maintain a constant pressure at 50mmHg on the PBU. Then slide the heel along the floor and DO NOT allow the PBU dial to drop below 50mmHg. Maintain the needle as steady as possible.
Repeat 5-10X on each leg.
Knee Fall Outs:
Maintain a constant pressure at 50mmHg on the PBU. Then allow one knee to fall out and DO NOT allow the PBU dial to drop down below 50mmHg. Maintain the needle as steady as possible.
Repeat 5-10X on each leg.
Great point: Nearly all patients enjoy monitoring themselves on the PBU. I often leave them alone for 5-10 minutes to do these exercises and when I return they 'show off' how the needle no longer drops.
Note: Although not as 'good', one may of course simply use an appropriate sized blood pressure cuff instead of a PBU.
For more info or for purchasing the PBU ($195), please contact 1-866-APTEI-44 or 905-707-0819
The Telephone…a Serious Pain in the Neck!
Although every clinician knows prolong speaking on the telephone with the head tilted is 'bad for the neck'; it may sometimes not be emphasized enough to patients.
This factor must be discussed with patients with neck pain, particularly those with neural signs and symptoms.
Use a headset or keep the head in neutral when using the phone…sometimes it's these little changes that make the difference!!!
Excellent Evidence to Support Patellar Taping
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
A randomized blinded study was conducted to evaluate the effectiveness of patellar taping on patients with both clinical and x-ray evidence of patello-femoral osteoarthritis.
Fourteen (14) patients with chronic (1-20 years) of anterior knee pain participated in this study.
Patients were randomly assigned to three different forms of patellar taping (medial, lateral and neutral).
Results: Medial patellar taping was significantly better than neutral or lateral patellar taping for relief of pain and patient preference (P<0.05).
Study Conclusion: Patellar taping into a medial direction is a simple, safe and cheap way of providing short-term pain relief in patients with pain and osteoarthritis of the patello-femoral joint.
For complimentary info on taping concepts or for purchasing the 'special tapes' please contact:
1-866-APTEI-44 or 905-707-0819
Golfers, Low Back Pain & The Transversus
Reference: Evans C, Oldreive W 2000 A study to investigate weather golfers with a history of low back pain show a reduced endurance of transversus abdominis. The Journal of Manual & Manipulative Therapy 8(4):162-174
As the game of golf is gaining popularity, reports of low back pain (LBP) related to it is also becoming more common.
This study looked at 20 male golfers (10 with LBP and 10 without) and compared the total time each subject could maintain contraction of the Transversus Abdominis (TrA).
Conclusion: Golfers with a history of LBP had significantly less endurance of their TrA muscle when compared to golfers without a history of LBP (P < 0.025).
Clinical relevance: Golfers with LBP may benefit from a Physical Therapy intervention that includes endurance retraining of the Transversus Abdominis muscle. This can then be followed by retraining the internal & external obliques…perhaps with a PBU!
A diagrammatic representation of TrA
The New Term for RSD…is CRPS!
Reference: Stanton-Hicks M, Gordh T, Koltzenburg M 1998 Complex Regional Pain Syndromes: guidelines for therapy. The Clinical Journal of Pain (14)155-166
The new term replacing the condition "Reflex Sympathetic Dystrophy" and "Shoulder Hand Syndrome" is " Complex Regional Pain Syndrome" (CRPS).
Build rapport with the patient
A published paper reviewed the guidelines for the Physical Therapy management of this complex condition, which included:
Reassure and motivate the patient
Desensitize the involved extremity by applying GENTLE non-nociceptive (non-painful) stimulation using heat, cold, massage, pressure, vibration, soft-touch etc. to help get back normal sensory processing
Help the patient overcome the 'movement phobia' by moving the limb as much as possible
Gentle muscle strengthening, beginning with isometric exercises
Progressive stress loading activities e.g. weight bearing on the hands (pushing down on a tabletop) or weight bearing on the lower limb.
Emphasize functional use of the limb e.g. turn off light switch, pull up zipper, brush hair, open doors etc.
Obviously, other appropriate health care professionals must also address the many other medical and psychosocial issues for patients with CRPS.
Isometric Neck Exercises…please AVOID them!!
Several papers exist that support the retraining of the segmental, deep neck flexors for individuals with 'chronic' neck pain and cervical headaches.
Once the deep segmental muscles have been addressed it is essential to address the superficial muscles of the cervical spine.
In my experience, isometric neck exercises are of little value and may in fact sometimes be harmful to patients with cervical clinical instability.
(In one case, I instructed a patient to, "STOP doing the isometric neck exercises that she had been doing for the past 6 months"…within two days her neck symptoms dramatically improved.)
Rehabilitation of the knee ALWAYS includes strengthening of the quadriceps & hamstrings through range (…not just isometrically)
Rehabilitation of the shoulder ALWAYS includes rotator cuff retraining through range (…not just isometrically)
Then why is muscular rehabilitation of the cervical spine so often limited to ONLY isometric retraining?
An excellent method of retraining the superficial muscles of the cervical spine through range is by using an 'STP Neck Exerciser'. Using this simple adjustable leather strap (with Velcro) helps effectively strengthen the cervical muscles through a functional arc of motion. (Only light resistance from an elastic tubing is needed.)
(You may be creative and make your own neck exerciser!)
For more info or for purchasing the 'STP Neck Exerciser' ($25), please contact 1-866-APTEI-44 or 905-707-0819.
Cervical Kinaesthesia…a Must to Address!
Reference: Revel et al 1994 Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: A randomized controlled study. Archives of Physical Medicine and Rehabilitation. (75);895-899Following an acute ankle injury (e.g. an inversion sprain), it is common sense that ankle proprioception is reduced and that Physical Therapy management must include balance and proprioceptive retraining.
Following ankle injuries, patients are frequently put on wobble boards, uneven surfaces with eyes open or closed etc… in order to retrain proprioception. It is well known that if ankle proprioception is not addressed, recovery may be delayed and the risk of recurrence of another ankle injury may increase.
Does it not make sense to evaluate and 'treat' kinaesthesia / proprioception following cervical injuries (e.g. following an MVA)?
Is proprioception of the neck not as important as proprioception of the ankle?
One simple method of evaluating cervical kinaesthesia in a patient with a whiplash associated disorder is by asking the patient:
1) Find the 'neutral' position for your head is sitting
2) Now close your eyes and VERY slowly turn to the left or right (as far as you can comfortably go)
3) Keep the eyes closed and return to the "neutral' position again
4) Once you believe you have reached 'neutral', open the eyes
The Physical Therapist notes for two things:
1) A subtle 'cog wheeling' effect during the exercise… instead of a smooth motion
2) Inaccuracy at finding the 'neutral' again…either over or under-shooting
One treatment option: The same exercise as above! Repeat 5 times and perform 3-4 times per day.
Note: By closing the eyes, greater dependence is placed on the mechanoreceptors in the cervical spine soft-tissues. This exercise will inevitably improve an individual's awareness of where their head is in space…which is pretty important!
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 you are interested in becoming an Associate Instructor with APTEI.
(An Excellent opportunity for those serious about self-professional development! Successful candidates may potentially receive full training.)
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