Sunday, December 28, 2008

Are you an expert clinician?

ResearchBlogging.orgIf you've been reading my posts for a little while now, you might have noticed I place a high value on education. I've been teaching as an adjunct instructor for over eleven years at a local university and regularly take students on clinical rotation. After a recent four-week (entirely too short) rotation with two year-one PT students, I found myself looking back on to their experiences at the clinic and wondering what I could have done better. They both had a great experience, but I couldn't help but wonder why I wasn't quite settled with the approach I took with them.

I began looking into clinical education models across several disciplines and found there is actually quite a bit of literature out there on the subject. One article in particular caught my mind regarding the differences between what's considered to be "novice" and "expert" clinicians. I was curious for a couple of reasons. Firstly, I wanted to know if my expectations of the students were matched appropriately to their skill level. For example, how can I bring a year-one along compared to the more advanced students without either frustrating or overwhelming them? Secondly, I was pretty curious to see if, despite my experience and board-certification, I could consider myself as an expert!

Today's article comes from the PT Journal back in 1992. The articles author, Mark Jones, provides a very straightforward discussion of clinical reasoning and the nature of expertise. Since the authors/editors of these articles do a much better job of outlining their ideas than I do of encapsulating them into my blog, I have provided a link to the full text article here.

Defining Expertise

Traditional notions of expertise have related to experience. Students were often considered novices while advanced practitioners were considered experts. While this may often be the case, a more precise delineation of what constitutes expertise may be useful. The author contends that expertise be considered along duel continuum of both generic and specialized knowledge. A sub expert is someone who possesses adequate generic knowledge, but insufficient specialized knowledge of a given domain. Predictably an expert possesses both generic and specialized knowledge of the domain.
An expert is distinguished through utilization of superior organization of generic and specific knowledge, hypothetico-deductive reasoning, and pattern recognition.

Expert Practice

Clinical reasoning will be influenced by a combination of the therapist's knowledge base along with their cognitive and meta cognitive skill set. Cognitive literature suggests that these components can be improved with effort, but can suffer through neglect. This indicates that the most expert clinical reasoning comes from not only knowledge, but the ability to step back and examine our cognitive biases when dealing with a case. Additionally, the reasoning process can only be as good as the collected information. It is critical that the clinical environment be designed in such a way to optimize the collection of accurate and reliable information from the patient. Our busy clinics can impose obvious limitations on the information gathering process such as group norms, time limitations, unrealistic productivity standards, and overextended case loads.

Teaching Students to Become Experts

Obviously, getting a student to become an expert is a tall order and not entirely realistic. However, we can teach the students to exercise their clinical reasoning muscles (i.e. the brain) by challenging them to go beyond the books in determining the best course of action. As Jones puts it:

Facilitating students' clinical reasoning requires making them aware of their own reasoning process and designing learning experiences that promote all aspects of the clinical reasoning process while exposing the errors in reasoning that occur. This requires access to students' thoughts and feedback on thinking processes. That is, students should be taught to think and to think about their thinking. This can be achieved by promoting students' use of reflection to encourage awareness and promote integration of existing versus new knowledge. When combined with a better awareness of one's own cognitive processes (ie, metacognition Metacognition refers to thinking about cognition (memory, perception, calculation, association, etc.) itself or to think/reason about one's own thinking. Types of knowledge ), the students' processing of information is enhanced and clinical reasoning is facilitated. Learning experiences to facilitate clinical reasoning using both reflection and metacognition are described elsewhere.

The process of reasoning should not, in my view, be addressed to the neglect of knowledge. Rather, facilitating the clinical reasoning process will assist the students' acquisition of knowledge. In turn, good organization of knowledge leads to better clinical reasoning. The importance of one's organization of knowledge is closely linked to the accessibility of one's knowledge. Knowledge that is acquired in the context for which it will be used becomes more accessible. Although clinical knowledge is typically presented in the context of patient problems, this is less commonly the case with the basic sciences (eg, pathophysiology). Approaches to physical therapy education in which the acquisition of knowledge is facilitated by teaching centered on patient problems provide, in my opinion, the ideal environment for building an accessible organization of knowledge and fostering clinical reasoning skills.

Next Step...

Last year I implemented a clinical rotation syllabus that emphasized reading peer-reviewed literature on topics such as LBP, shoulder examination, and pain science. This year I will begin incorporating clinical reasoning activity to supplement this knowledge-based curriculum. I'm sure the students will go home with some pretty good brain cramps, but will be better clinicians for it. I know I'll feel better knowing that they got the most out of their rotation at our clinic! I hope you will find this information and the article helpful in guiding your students to become better providers.

An interesting note: I found a more recently published article on clinical reasoning in the PT Journal from 2006 and plan to review it on this blog at a future date. Great stuff!

Jones M (1992). Clinical reasoning in manual therapy Physical Therapy, 72 (12), 875-884

Saturday, December 27, 2008

Manual Therapy: What is REALLY going on?

ResearchBlogging.orgEarlier in my PT career I often called B.S. on forms of treatment that didn't seem to pass the smell test. Manual therapists in particular seemed susceptible to jumping on the bandwagons driven by chiropractors (i.e. adjustments, active release therapy, and craniosacral therapy). Not only did I try to avoid any professional association with whom I perceived as quacks, I went out of my way to disprove their methods. As you can imagine, telling someone who believes in Santa Clause "there really isn't a Santa Clause" doesn't always sit well. In fact, it made me downright unpopular with a few folks within our profession.

Being married for ten years has given me some amazing clarity with respect to how I see things. I have come to realize my relationship with my wife would never evolve without intense introspection prior to any external scrutiny I was ready to dish out in her direction. This process has allowed our relationship to blossom into something I could never have dared imagined cultivating on my own. Sitting on my front porch this morning reflecting on our journey, I had another moment of clarity: The evolution of my clinical reasoning and decision-making must precede any relevant criticism of another's.

While I think this process has subconsciously been taking place for a little over a year now, becoming aware of it really had an effect on me. I have been devouring books and peer-reviewed literature in mass quantities. Like my marriage, it has been a transforming journey. More so, the journey makes me realize just how much good work has been done within the fields of movement science. It also motivates me to think we have the opportunity to be a part of the next evolution.

Mechanisms of Manual Therapy

My motivation in writing this post, came from an article in Manual Therapy by Joel Bialosky and associates from the University of Florida. The article provides a framework of manual therapy that has yet to be previously defined to this degree.

Proposed mechanisms for manual therapy vary considerably among our colleagues. A consistent theme however is the identification and correction of biomechanical faults within the musculoskeletal system. This paradigm has been with us for some time and continues to be refined in the peer reviewed literature. However as more evidence emerges, we are discovering there is much more to our manual techniques than correcting upslips and stretching joint capsules.

In an effort to address what "more" there is to our techniques, Bialosky et al provide an elegant proposal of five potential mechanisms at play when our hands are on the patient.

Mechanical Stimuli: Our hands are capable of inducing temporary mechanical changes within connective tissue, but the lasting effects are still uncertain. We have seen positive effects from our manual techniques and assumed a mechanical response to our mechanical technique, but it may not be that simple.

Neurophysiological Mechanism: There is clearly an interaction between the peripheral and central nervous systems during manual therapy. Hypoalgesia and changes in sympathetic activity following joint mobilization technique have been consistently documented in recent literature. Notably the changes in pain threshold and sympathetic activity often occur distant to the site of the manual technique. Something within the patient is clearly interested in what we do!

Peripheral Mechanism: Local tissue injury sets off a cascade of events both near and far within the body. Manual therapy has been recently shown to reduce inflammatory chemicals such as cytokines and substance P along with increasing systemic opioid release. The "good feelings" associated with manual therapy have often been attributed to correction of mechanical faults, but peripheral mechanisms may provide a more reasonable description the therapeutic effect.

Spinal Mechanisms: Renown pain physiotherapist David Butler refers to the spinal cord as an amplifier for sensory modalities. Manual interventions have been recently implicated in modifying both afferent and efferent activity within the spinal column. The bottom line is that the spinal column isn't simply a conduit, but an active participant in determining the effects of manual care.

Supraspinal Mechanisms: Admit it. There have been times where we've thought privately that a condition or response to treatment was "all in the patient's head". Turns out there may be more truth to this statement than we'd previously imagined. Recent animal and human studies implicate specific regions of the brain in mediating the pain experience. Moreover psychosocial factors such as patient expectation and placebo are very likely to affect the outcome of our manual intervention.

Time for Change?
I can't even begin to tell you how sick I am of this word in 2008, but in this case it is appropriate. The moment our hands come in contact with a patient, their nervous system is instantly interested in what's going on. Not only that, but it will play a major role in determining the outcome of the intervention. Once we've gotten used to this idea (and it does take some time), how do we take advantage of it in our treatments? I'd really like to hear your thoughts and am getting excited for 2009!

J BIALOSKY, M BISHOP, D PRICE, M ROBINSON, S GEORGE (2008). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model Manual Therapy DOI: 10.1016/j.math.2008.09.001

Wednesday, December 24, 2008

Merry Christmas to Everyone

I'd like to take this opportunity to wish everyone a Merry Christmas. Please enjoy this rendition of Silent Night in the truest spirit of the Christmas season. You may have to double-click it as the embedding feature of my blog isn't always working! Good night and may God bless you all.

Sunday, December 21, 2008

Trojan effort...grade five baby!

Early in my career I was very shy about grade five maneuvers in the clinic. I am still very cautious about their use in the cervical spine, and often find thoracic manipulations to be just as useful.

However I felt this demonstration of a lower cervical grade V from our colleagues at USC was worth showing! I particularly like the off-camera "eek!" from the female PT student after the technique.

Nice job Trojans!

Saturday, December 13, 2008

Stiff posterior capsule? Maybe not...

ResearchBlogging.orgIt is common practice for physical therapists to include an assessment of the posterior glenohumeral joint capsule in patients with shoulder pain. The rationale is that a tight posterior capsule may exert a "Diablo" effect on the proximal humerus and reducing the subacromial space. This is further substantiated by the obeservaton that GIRD (Glenohumeral Internal Rotation Deficit) often seen in throwing athletes is due to limitations of the posterior capsule. These two clinical observations form the rationale for stretching and mobilizing the posterior joint capsule.

However, there is recent evidence that questions whether the posterior capsule is truly responsible for the limitations in internal rotation commonly seen in our patients. A case report by Poser and Casonato in the Journal of Manual Therapy examined a 42 y/o male with a 12 week history of shoulder pain. This patient was the "classic" impingement case. No cervical pathology was identified and there was no evidence of capsular involvement. The primary findings were positive Hawkins and Yocum's testing along with painful resisted abduction.

Internal rotation was measured using electrogoniometry at 90 degrees of abduction. Additionally, a dynamometer was used to measure abduction force. The patient's pain levels were recorded during the pre-treatment testing. The treatment consisted only of soft tissue massage to the infraspinatus (7 minutes) and teres minor (3 minutes). The patient was positioned in a manner as to avoid any tension placed on the posterior capsule. No other treatments including or activity modifications were given.

After three treatment sessions, internal rotation improved from 68 degrees to 88 degrees and all impingement signs were nearly abolished. The authors concluded that reductions in internal rotation often seen with impingement syndrome may not be attributable to posterior capsular tightness. An alternative theory may be that shoulder pain induces a dysfunction of the posterior glenohumeral muscle musculature.

I must admit am a "mobilizer of the posterior capsule". However after reading this case report and using a bit of reasoning, I realize there may be a better explanation for loss of internal rotation we see in our patients. Although this is but one case report, it certainly made me realize I can never get too comfortable with a particular approach or conclusion. I'm not entirely ready to let go of the possibility that the posterior capsule plays a role in shoulder impingement. However, I imagine with further anatomical and histological of this area will confirm my suspicions that there are other mechanisms at play.

A POSER, O CASONATO (2008). Posterior glenohumeral stiffness: Capsular or muscular problem? A case report Manual Therapy, 13 (2), 165-170 DOI: 10.1016/j.math.2007.07.002

Thursday, December 11, 2008

More Neuroscience from the "Ortho Guy"

ResearchBlogging.orgWell the semester is finally over. Man I never thought there would be so much to my neuroscience course. It has been an eye opening process that has improved my clinical reasoning and given me a few extra tools in my therapeutic box!

I thought I might take the next few weeks to share some of the topics discussed this semester. On the surface, some of th issues related to neuroscience seem only peripherally related to orthopedic practice. Upon further review, many hit really close to home for many of my patients. I hope you will find them as interesting as I have.

Neuropathic Pain
The mechanisms of peripheral neuropathic pain have been identified more clearly in recent years. Despite the increased understanding, neuropathic pain presents a challenge diagnostically and remains an inadequately treated clinical problem. The current review by Baron outlines evidence to support four likely mechanisms for neuropathic pain followed by a symptom-based classification system. Evidence from both animal and clinical investigations are presented in the review that add strength to the proposed mechanisms. The treatise of the review is that understanding the mechanisms and symptoms of neuropathic pain will provide a clearer path to effectively managing this disorder.

Proposed Mechanisms of Neuropathic Pain
Four potential physiologic mechanisms can explain neuropathic pain. The most peripheral mechanism involves the abnormal sensitization of primary nociceptive (Aδ and C) fibers. A possible mechanism for ectopic firing of primary afferent fibers is an upregulation of sodium ion channels at various points along the axon. Areas of focal upregulation could predispose the neuron to ectopic antidromic and orthodromic impulses. Sensitization of primary fibers has been observed in both animal and human models and is proposed to be a potential cause for heat and mechanical hyperalgesia.

A second mechanism of neuropathic pain is sympathetic sensitization of primary afferent fibers. A normal primary afferent is not sensitive to catecholamines and should not respond to changes in sympathetic activity. However, animal models have demonstrated that injured afferent nerves develop sensitivity to noradrenergic sensitivity. This sympathetic sensitization of the peripheral nerve may take place along the distal branch of the nerve or even at the dorsal ganglion.

The third potential mechanism for neuropathic pain is local inflammation of the periperhal nerve itself. The nerve supply of the peripheral nerve itself is an often underappreciated anatomical an d clinical entity. The nervi nervorum are fine afferent fibers that can communicate noxious activity along the peripheral nerve itself. As such, pain from the nervous connective tissue must also be considered as a potential source for neuropathic pain. As with sympathetic sensitization of the nerve, peripheral nerve inflammation can occur along the distal branch or the dorsal ganglion.

The fourth and final mechanism is central sensitization in the dorsal horn of the spinal cord. Repetitive simulation of primary afferents can result in progressive upregulation of post-synaptic NMDA receptors in the dorsal horn. Under prolonged stimulation, the receptive fields of dorsal horn neurons expand to include Aβ low-threshold mechanoreceptors. This creates potential for mechanoreceptor activity to trigger pain signaling neurons in the dorsal horn; a phenomenon recognized as dynamic mechanical allodynia. Additional mechanisms for mechanical allodynia are proposed including injury-induced C-fiber degeneration and reorganization in the dorsal horn. The mechanisms of central sensitization have been demonstrated in both animal and clinical investigation.

The author utilizes the preceding mechanisms to propose a symptom-based classification system for neuropathic pain to include:

  • Static mechanical allodynia - gentle static pressure evokes pain
  • Punctuate mechanical allodynia - normally stinging but not painful stimuli evokes pain (Von Frey hair)
  • Dynamic mechanical allodynia - gentle moving stimuli at the skin evokes pain
  • Cold allodynia/hyperalgesia - duh!
  • Temporal summation - repetitive application of the same painful stimuli worsens symptoms
  • Sympathetically maintained hyperalgesia - difficult to assess, but improves with sympathetic blockade

These criteria can be used by the clinician to more precisely describe the underlying physiology of the neuropathic event and possibly lead to more effective management strategies.

Clinical Relevance to the Physical Therapist

Traditional symptom-based classification systems have focused on nociceptive or tissue-based models of pain. The present review offers a neurophysiologic dimension to the assessment of the patients’ pain experience. If this classification system can be validated, more specific treatment approaches can be designed. The classification system may have particular relevance for the practicing physical therapist. Physical therapists are able to modulate input, processing, and output paradigms of the human nervous system through movement. As movement involves activation of both ascending and descending pathways, it is likely to have some role in modulating one or more of the mechanisms underlying neuropathic pain.

It is sometimes difficult for me to wrap my head around some of the issues related to pain. However, I've always wondered why a seemingly homogenous population of patients (say post-op TKA) have such varied therapeutic courses. Of course there are the biomechanical factors that are often very intuitive, but there must be something to account for all the variations we see! A better understanding of these mechanisms may help us identify the patients at risk from deteriorating into a more involved pain state and get them back on their feet more quickly.

Baron, R (2000). Peripheral Neuropathic Pain: From Mechanisms to Symptoms Clinical Journal of Pain, 16, 12-20

Sunday, December 7, 2008

Problems commenting on my blog?

Hey folks. I just discovered that the comments portion of my posts has been deleted. I am working with Blogger to correct the problem. Thank you!

Saturday, December 6, 2008

Peripheral nerve function during shoulder arthroplasty
The incidence of peripheral nerve injury during shoulder arthroplasty is reported between one and four percent. However as these numbers are based on retrospective chart review, the actual incidence of intraoperative nerve dysfunction has not been clearly revealed.

The present study utilized intraoperative nerve monitoring to identify the frequency, type, and predisposing factors for peripheral nerve injury during shoulder arthroplasty. Thirty consecutive patients undergoing shoulder arthroplasty participated in this study. Continuous intraoperative nerve monitoring of the brachial plexus was performed by a neurophysiologist. Brachial plexus functioning was monitored by both EMG activity and transcranial electrical motor evoked potentials (MEPs) from six extremity muscles. A significant intraoperative nerve event was defined as a sustained neurotonic EMG activity or a 50 percent reduction in transcranial MEPs from one or more muscles. Both arm and retractor positions were recorded and modified to relieve stress on the brachial plexus when an event took place. If the patient had an intraoperative “nerve alert”, he/she had a follow-up EMG at least four weeks following the surgery.

Seventeen patients had a total of 30 intraoperative nerve alerts. Of the 30 alerts, none returned to baseline with retractor repositioning. However 23 did return to baseline with repositioning of the extremity to a neutral position. Four of the seven patients who did not experience an intraoperative return to baseline MEPs had positive postoperative EMG results. The incidence of nerve dysfunction was associated with a history of prior shoulder surgery and passive external rotation of less than 10° with the arm at the side (P < .05). The authors conclude that intraoperative nerve injury during shoulder arthroplasty is likely greater than reported and certain patients with prior history of shoulder surgery or limited external rotation may be candidates for routine nerve monitoring.
A Great Study

The present study won the 2005 Neer Award from the American Shoulder and Elbow Surgeons. It is a very elegant example of the intersection of neuroscience with orthopedics. Shoulder arthroplasty represents the classic mechanical approach to orthopedic dysfunction. Yet without understanding the neurologic implications of these procedures, we may not fully appreciate the patients’ postoperative courses.

Although the sample size is not overwhelming, 16.7 % of the patients in the study had postoperative EMG changes resulting from an intraoperative neuropraxic event. Interestingly the authors noted that almost half of the nerve alerts occurred within the brachial plexus and not the peripheral nerves themselves. Mechanical strain data indicate the greatest tensile load on the brachial plexus with the arm in 90° of abduction, external rotation, and extension. Intuitively, this makes sense as this is a common intraoperative position for this procedure.

Implications for Physical Therapists

The results of the present study could have implications for the practicing therapist as well. It may be reasonable to assert preoperative improvement of passive ER could reduce the intraoperative traction placed on the brachial plexus. Additionally, the therapists should be aware that in the absence of intraoperative nerve monitoring, there is a possibility that an intraoperative neuropraxic event took place during the procedure. While certainly not something to speculate openly to the patient, it does make a reasonable case for early neural mobilization of the brachial plexus following shoulder arthroplasty in addition to the standard ROM progression.

S NAGDA, K ROGERS, A SESTOKAS, C GETZ, M RAMSEY, D GLASER, G WILLIAMSJR (2007). Neer Award 2005: Peripheral nerve function during shoulder arthroplasty using intraoperative nerve monitoring Journal of Shoulder and Elbow Surgery, 16 (3) DOI: 10.1016/j.jse.2006.01.016

More with less: Conservative management of massive rotator cuff tears

Massive rotator cuff tears within the medically unfit population are a difficult clinical scenario for the medical profession. The nature of the pathology often indicates a surgical intervention, but the procedure is often deemed to be too high risk. The present investigation prospectively assessed 17 patients with massive rotator cuff tears after treatment with an anterior deltoid rehabilitation program. Patients were videotaped attempting active shoulder elevation both before and after the rehabilitation program.

Each patient was given a standardized instruction that involved 12 weeks of daily pendulum exercises and supine active flexion. The protocol was to be performed 3 -5 times daily. As the patient tolerated, they were instructed to gradually increase the resistance of the flexion along with progressively moving to an inclined position. At a minimum follow up of 9 months following the rehabilitation program, the patients were reevaluated. All components of shoulder motion were improved with particular emphasis on forward elevation which improved from 40° at baseline (range 30°-60°) to a mean of 160° at follow up (range 150°-180°). Although seemingly clinically significant, the statistical significance of these findings was not reported. The authors recommend a structured deltoid rehabilitation program for elderly patients with massive rotator cuff repairs.

Massive rotator cuff repairs are clinically challenging even in younger populations. Medically unfit patients with this condition present with even more challenges. While the results of the study speak for themselves, the underlying mechanisms provide some impressive insight into the potential and paradoxical role of the deltoid in normal shoulder elevation. The deltoid has traditionally been thought of as a superior translator of the humeral head within the subacromial space. In the absence of an intact rotator cuff drawing the humeral head inferiorly, augmenting deltoid activity should impair the individual’s ability to comfortably elevate the shoulder. However both this and other recent evidence seriously questions the traditionally-held belief that the deltoid is a humeral head elevator. In fact, a report in Clinical Orthopedics by Gagey found the deltoid to prevent superior migration of the humeral head.

The implications of these findings are significant to say the least. First and foremost, if massive rotator cuff tears can be effectively rehabilitated in the medically unfit population, what about the medically fit population? Would this not make the case for a retooling of our current approach to conservative management of rotator cuff pathology prior to considering surgical intervention?

Secondly, as clinicians we are traditionally cautioned against “biasing the deltoid” during active shoulder movements in the presence of rotator cuff pathology. The present investigation provides further evidence against the notion that feed forward biasing of selected muscles may not be necessary to achieve a significant functional improvement. In fact, in this case the patients were only given verbal instruction to follow a written protocol and given no specific feedback regarding their performance of the activity. Again the implication is that the patient’s inherent feedback mechanisms were sufficient to perform and progress the activities.

This fairly straightforward study is not without limitations, but the implications for our daily practice are important. Therapists should be increasingly aware that patients can achieve significant improvements in motor control and function in the presence of severe mechanical impairments, and that these improvements can occur without micromanagement of specific movement patterns as traditionally outlined. This doesn’t negate the potential role of the therapist in the rehabilitative process, but it should raise questions as to the exact nature of our role in our patient’s recovery of this condition.

O LEVY, H MULLETT, S ROBERTS, S COPELAND (2008). The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears Journal of Shoulder and Elbow Surgery, 17 (6), 863-870 DOI: 10.1016/j.jse.2008.04.005

Monday, November 10, 2008

Lubbock and Legacies

I just got back from my most recent trip to Lubbock, TX. The atmosphere in that west Texas town was electric as the Red Raiders took another step toward a potential national championship in football. As a Longhorn (whose team lost to Tech the previous week) I was really impressed with the enthusiasm and passion of this town for its team.

The purpose for my visit was to attend the contact session for my Neuroscience in Orthopedics course. As with many of this year's adventures, it was another eye-opening experience. When I set out this year to improve my understanding and clinical reasoning, I had no idea just how much I'd learn or how many great people I'd meet.

We spent the entire weekend exploring topics ranging from receptor biochemistry, peripheral and central sensitization, neuropathic pain, and a variety of other issues related to the assessment and treatment of painful conditions. The material was engaging and prompted a number of great clinical stories from my classmates. My laptop left the session about 200 megs heavier with journal articles. Interestingly, not even one of them included a clinical prediction rule!

One of the most truly humbling features of my trip was the opportunity to meet several fascinating members of our physical therapy community and the field of medicine. I briefly met one of the founding members of the World Institute of Pain, anesthesiologist Gabor Racz, MD. The interaction was brief, but it was great to talk with someone who has contributed so much to the field of pain science. I also had a chance to meet clinician and author Omer Matthijs. His hard work and clinical experience continue to set the right kind of examples for our profession. While the classroom experiences I had were memorable and continue to evolve my clinical reasoning, the fellowship with my peers and instructors made an even more lasting impact.

One of the talks led by our professor Phil Sizer drifted somehow into a brief but powerful mention of the legacy we all leave within our profession. In light of my encounters with Dr. Racz and Omer Matthijs, this tangent really resonated with me. It got my mind going, and I began thinking of the legacy I might leave behind. I also turned my attention to the legacies many of our peers are creating and I was hit with a sense of optimism for our profession.

It has been nearly a year since starting this blog and it has already been a transforming experience for me. I truly appreciate your joining me on this journey and hope it, in some way, inspires you to reflect on the legacy you may be creating. It is my sincerest hope our collective efforts within the profession will continue to carry the torch for those who have worked so hard to light it. Until next time!

Sunday, October 12, 2008

Electrotherapy on the Web

Modalities have become the poor cousin for many outpatient physical therapists. Myself included. We often look down upon that ultrasound or TENS unit because it isn't "evidence-based" or doesn't involve the latest CPR-derived manual technique / exercise. Despite this sentiment shared by many therapists, the use of therapeutic modalities persists in most outpatient centers. This had me wondering: Where is the latest evidence on electrical modalities in physical therapy? In searching for my answer, I stumbled on a very useful website.

Electrotherapy On the Web

This is a website is run by professor and physiotherapist Tim Watson of the University of Hertfordshire in the U.K. The website includes a surprising number of useful links and guidelines for the use of electrotherapeutic modalities. Professor Watson includes a number of easily downloadable resources for the practicing physical therapist. If you utilize electrotherapy in any capacity or are simply wanting to learn more, I strongly suggest a visit.

I don't know how much more I will be using electrotherapy in the clinic, but I can say this website will assist in making better decisions regarding their use. Enjoy!

Monday, September 29, 2008

Cutting or bleeding edge?

Hurricane Ike came and went, but it almost feels like he's still hanging around the Gulf Coast. The devastation was truly remarkable particularly for places like Galveston and the Bolivar Peninsula. If you've never been through a good sized hurricane, I wouldn't recommend it. My Alma mater, UTMB - Galveston, is finally getting back on its feet, seeing patients, and teaching PT students again. My thoughts are with them and any other folks devastated by this storm. We finally got the lights turned on and life is returning to normal, which for me means getting back to blogging on a more regular basis. The clinic has never been busier so there is definitely plenty to talk about.

For a self-proclaimed "ortho-guy" I certainly have been immersed in a great deal of neuroscience this year. I had a brief yet spirited set of interactions with the folks on SomaSimple, and currently enrolled in a class titled "Neurosciences in Orthopedics" at Texas Tech. I have to admit the study of neuroscience is really filling in a lot of gaps in my understanding of orthopedic conditions.

Neuroscience is creating some very novel therapeutic inventions. The paradigms of neuroscience are building on theories such as David Butler and Lorimer Moseley's work on pain as well as Michael Shacklock's neurodynamics. The exploration of neuroscience arises from an understanding that traditional orthopedic paradigms aren't always hitting the therapeutic bullseye. For example what explains the persistent symptoms of lateral epicondylalgia or anterior knee pain? These conditions often defy objective diagnositic testing and treatments based on the traditional tissue-healing inflammatory model. I would encourage anyone interested in learning more about these approaches to visit the sites listed above.

As with any treatment approach, I remain cautiously optimistic. As my father, a practicing family physician and medical veteran, often cautions me: It's good to be on the cutting edge, but avoid getting caught on the bleeding edge. New and different aren't synonymous with correct and irrefutable. We must continue to develop our understanding of human function without strictly adhering to old paradigms. At the same time, we must be prepared to embrace emerging theory without getting caught-up in the latest fad. At the end of the day, sound theory supported by strong evidence will continue to guide the best practitioners of this profession. I believe the field of neuroscience will meet the test of both theory and evidence and continue to provide salient answers.

One final note, I hope to make more regular contributions to my blog and appreciate everyone hanging in there with me. I'm in the midst of balancing my contributions to this blog with teaching, studying, treating, and recovering from coastal natural disasters! As this semester rolls on, I hope to contribute more regularly. Thanks and have a great weekend!

Wednesday, September 10, 2008

Calcaneal and Plantar Nerves: Overlooked contributors to heel pain syndromes?

So I'm sitting here in my living room watching coverage of the latest impending apocalypse (Hurricane Ike) churn in the Gulf. You might think it's an odd time for this Gulf Coast native to be thinking about heel pain, but here I am...thinking about heel pain. We can discuss the reasons I have no life at a later date.

Diagnoses seem to come in spurts in this clinic and I've recently been referred several cases of both infracalcaneal and retrocalcaneal heel pain. As with many of my treatment approaches, my tactics regarding heel pain have evolved considerably over the years. Despite this ongoing refinement, I still find heel pain to be both fascinating and frustrating clinical entity. For me, it is the LBP of the foot.

I recently did a literature search on the various incarnations of heel pain and was relieved to find I'm not the only one out there navigating through the fog. There are still gaping holes in our knowledge and understanding of this condition. In the midst of my literature search, one article stood out enough that I felt it worth mentioning.

Overview and Methods

The article was published in 2003 in the Journal of Foot and Ankle Surgery. The authors set out to determine if sensory abnormalities existed in the medial and lateral calcaneal nerve distribution in patients suffering from plantar heel pain. The study examined 97 feet in 82 patients reporting symptoms consistent with plantar fasciits including poststatic dyskinesia and tenderness to palpation along the medial calcalneal tubercle. Patients were excluded from the study if they had comorbidities such as radiculopathy or an equinus foot. Neurosensory testing was performed using a pressure-specified sensory device used to detect compression or entrapment of both large and small nerves.

Results and Conclusions

The authors found a significant number of patients with plantar heel pain display abnormal sensibility within the branches of the posterior tibial nerve. Abnormal sensibility was noted particularly within the medial calcaneal nerve (P<.0008) and lateral calcaneal nerve (P<.0001).

It is our belief that entrapment of the MCN plays an important role the development of plantar heel pain, and we were able to quantify abnormal sensibility in the cutaneous distribution of both the MCN and/or the MPN in a significant number of patients with plantar heel pain. The observed nerve dysfunction is most likely secondary to entrapment of the nerve trunk, or trunks, as a result of repetitive mechanical irritation. In response to this pathologic stimulus, we hypothesize that the injured nerve trunk undergoes in-continuity fiber disruption and intra- and perineural fibroplasia. Because 49.48% of our patients displayed abnormal sensibility in the cutaneous distribution of both the MCN and MPN, a proximal neural origin such as proximal tarsal tunnel entrapment of the PTN, or even lumbosacral radiculitis, plexopathy, or sciatic nerve impingement, should be considered in these patients.

Clinical Implications?

A treatment theme that seemed to resonate with me in this article was that of regional interdependence. For example, two of my patients with heel pain also have persistent lumbar pain - one with motor radiculopathy ipsilateral to the heel pain. These comorbidities may play more of a role in distal pathology than previously appreciated. Secondly, the findings of this article could lend support to the notion that neurodynamic movements such as lower extremity nerve gliding could play a role in more distal conditions such as heel pain. In addition to our traditional mechanically-based therapeutic regimen, it may make practical sense to consider structures such as the peripheral neural tree as possible contributors to the patient's problem.

Here's hoping all my neighbors along the Gulf Coast stay dry this weekend!

Rose JD, Malay DS, Sorrento DL (2003). Neurosensory Testing of the Medial Calcaneal and Medial Plantar Nerves in Patients With Plantar Heel Pain The Journal of Foot and Ankle Surgery, 42 (4), 173-177

Saturday, September 6, 2008

Is Pain in the Brain?

I finally leaped into the 21st century and discovered I can post specific YouTube videos on my blog. This is an excellent lecture from the University of California on the origins of pain. Dr Basbaum is as sharp as they come on this topic and this is a very entertaining and informative lecture on pain science. I hope you are able to get something out of it!

Friday, September 5, 2008

Physical capacity and low back pain: Is there a connection?

ResearchBlogging.orgWe frequently advise patients that having strong trunk muscles and better lumbar mobility are important strategies to prevent future episodes of LBP. These types of recommendations go a long way to emphasizing autonomy versus dependence in managing this common musculoskeletal problem.

However, emerging evidence has spawned some serious questions and criticisms of our current paradigm regarding exercise and low back pain. For example, we still don't have a clear picture as to whether specific exercise programs or just activity in general is more effective at preventing LBP. We have even less specific guidelines regarding key exercise parameters such as volume or intensity of activity.

A recent systematic review in Pain raises even more difficult questions regarding the relationship between LBP and trunk strength, endurance, or mobility. After all inclusion criteria were met, the authors reviewed 24 articles. Relevant findings provided some very interesting food for thought.

  • Trunk muscle strength and low back pain: Thirteen quality studies and four low-quality studies met the inclusion criteria and were reviewed. The authors found inconclusive evidence to support a specific relationship between trunk muscle strength and low back pain.

  • Trunk muscle endurance and low back pain: Eight high quality studies and four low-quality studies were reviewed. In this case, there is strong evidence that there is no relationship between trunk muscle endurance and risk for LBP.

  • Trunk mobility and low back pain: Seven high-quality studies and one low-quality study were reviewed. There was inconclusive evidence connecting lumbar mobility and low back pain due to conflicting results.

It should be acknowledged that there are some significant methodological limitations within this systematic review. There was substantial heterogeneity between many of the studies which should prompt the reader to cautiously interpret the results. However, as we are often keen to site evidence to support our interventions, we must all be prepared for the eventuality that our current paradigm may not be as rock-solid as we think.

Exercise will continue to be a significant part of my plans of care in the management of low-back pain. I doubt this will change dramatically, but systematic reviews like this have me looking even harder for the best available theoretical and clinical evidence to support my approach. Until next time!

H HAMBERGVANREENEN, G ARIENS, B BLATTER, W VANMECHELEN, P BONGERS (2007). A systematic review of the relation between physical capacity and future low back and neck/shoulder pain Pain, 130 (1-2), 93-107 DOI: 10.1016/j.pain.2006.11.004

Saturday, August 2, 2008

Are you CPR Certified?

ResearchBlogging.orgFortunately I'm not talking about through the Red Cross. As important as this life-saving skill is, it may be just as important to understand the nature of a more trendy form of CPR in the world of rehabilitation science: The Clinical Prediction Rule.

Prescriptive clinical prediction rules on topics such as lumbar manipulation, traction, and even anterior knee pain have emerged recently in our rehabilitation literature. The fact these reports exist underscore the fact that we are actively engaged in evolving into an evidence-based profession. However as has been recently and contentiously bantered on more than one discussion forum, as evidence builds it will become even more important for us to understand how to interpret and utilize this evidence in the most appropriate manner. In the case of such a potentially powerful tool as a CPR, we need to have a very clear understanding of its potential uses and possible pitfalls.

To this end, I would like to suggest two articles. The first is by Childs and Cleland published in our PT Journal in 2006. It provides excellent insight into the utility, establishment, and validation of a clinical prediction rule. The second article is actually an editorial in the Journal of Manual and Manipulative Therapy titled "The Potential Pitfalls of Clinical Prediction Rules". It is authored by Chad Cook, the editor-in-chief of JMMT, and provides a good overview of the potential misuses of a CPR.

Clinical prediction rules have been around for quite some time and have significant utility in a variety of clinical settings. They will no doubt be powerful allies in our quest for strengthening our clinical decision making. However, the most appropriate use of the CPR will occur with its judicious application and not blind allegiance. Whether we embrace it or not, the age of evidence-based medicine is upon us and is here to stay. Using evidence-based medicine with a clear understanding of what it truly is (and isn't!) will allow us to continue practicing the science of physical therapy without the trappings of becoming an automaton.

Instead of relying on my synopsis, I eagerly invite you to read these articles for yourself with the hope you will use them in the most appropriate manner for your patients. Enjoy!

Childs, J.D., Cleland, J. (2006). Development and Application of a Clinical Prediction Rule to Improve decision making in physical therapist practice. Physical Therapy, 86, 122-131.

Cook, C. (2008). Potential Pitfalls of Clinical Prediction Rules. Journal of Manual & Manipulative Therapy, 16(2), 69-71.

Wednesday, July 30, 2008

Missing in Action: The Diagnosis of Acetabular Labral Tears
I recently had an interesting hip case come through the clinic. After practicing only six years, I've discovered there are some joints for which I have more clinical intuition, and the hip certainly isn't one of them. As a result I found the need to do some catching up.

Unfortunately, the referring physician was not much help in this case with a referring diagnosis of "hip pain". While interviewing the patient, he revealed the physician had spent approximately three minutes with him and performed no physical exam. The only diagnostic puzzle-piece we had was that he did not have any signs of OA on plain film.

During the examination the patient had focal hip pain that I gradually suspected was intraarticular in nature. I recently posted the case on if you'd like to see it in more detail.

In researching the case, I found a very good article from the Journal of Bone and Joint Surgery on acetabular labral tears. The authors retrospectively examined sixty-six individuals with confirmed labral tears via arthroscopy to determine what clinical variables were most closely associated with the pathology. The clinical findings were as follows:

  • 86 percent of the cases reported moderate to severe pain

  • 92 percent reported symptoms localized to the groin and that activity worsened symptoms

  • Only 39 percent had a Trendelenberg sign or observable limp

  • 95 percent had a positive impingement sign of the hip

Although the clinical features of acetabular labral tears were useful, a more telling set of statistics emerged from this report:

  • Nearly 20 percent of the patients were referred for a surgical procedure to a uninvolved site

  • The patients were seen by an average of 3.3 providers prior to establishing a definitive diagnosis

  • The average duration of symptoms from onset to successful diagnosis of the tear was 21 months

The findings of this study were directly applicable to this case. He and I had been discussing the likelihood that this was not a simple muscle strain as postulated during his initial visit. After a underwhelming four week follow-up experience with the referring orthopedist, I referred the frustrated patient to a physician known for performing an actual physical exam. An immediate MRA to the hip was ordered.

Not surprisingly, the MRA was positive for significant intraarticular pathology including a subchondral defect, moderate OA, and a fatty tumor encroaching upon the posterior branch of the obturator nerve. Labral pathology is questionable. The orthopedist suspects one may be present and will investigate this intraoperatively along with a surgical oncologist.

I think this provides a good example of how physical therapists can be a potential diagnostic gateway for our patients. Unfortunately, we can't take for granted the referring physician always brings their A-game to the exam room. Also if we are angling to be direct access providers, our clinical diagnostic skills will need to remain sharp. In this case, my exam certainly wasn't specific for the myriad of pathology present in this gentleman's hip. However it was sensitive enough to detect that there was certainly more to the story. Hopefully this story will have a happy ending.

Burnett, R.S. (2006). Clinical Presentation of Patients with Tears of the Acetabular Labrum. The Journal of Bone and Joint Surgery, 88(7), 1448-1457. DOI: 10.2106/JBJS.D.02806

Saturday, July 19, 2008


After traveling to a small Central American country and seeing what honest and hardworking folks have to do to eek out a living, you can imagine my disgust at firing up my homepage this morning to find this article. I had no idea that not wanting to work was a disability, but apparently it is slightly more en vogue than I had previously appreciated. I feel sorry for any family or significant other he is likely dragging through this process along with him. Nice going Albert...

We've all seen bogus or marginally-valid disability claims and the behavior can be both pitiful and appalling to our profession. Physical therapists should wholeheartedly support and advocate for those with legitimate disabilities. However, we should be equally vigilant in guarding against the abuse of a system designed to aid those with true physical disability.

This topic has even caught the attention of Newt Gingrich who is a spokesperson for the Institute for Healthcare Improvement. Regardless of what you may think about Newt's politics, he brings the issues to the table in a logical, albeit sometimes controversial, manner.

I am not aware of any APTA-based initiatives to ensure the proper use of our federal disability system, but there may be one out there. It might be a good idea to keep this on our radars as well. It would be interesting to see just how much money CMS could be saving preventing fraudulent disability claims instead of focusing on alienating the rehabilitation profession through ever-tightening regulatory guidelines.

More research-based blogging to come later this week! Have a great weekend.

Friday, July 18, 2008

Back from Belize!

Hey all. Just got back from an incredible trip down to Belize with my beautiful wife for our 10-year anniversary. If you've never been, I strongly recommend it! Our experiences couldn't have been better. We didn't let any grass grow under our feet with lots of diving, snorkeling, fishing, bike riding, and even a little spearfishing local-style.

The time spent away from television was a real joy to sit back and reflect on our marriage, our careers, and our future. It also made me realize that those of us in health care and education (my wife) need to make sure we take some time to truly get a way from the daily grind to charge the batteries as we all tend to burn the candle from both ends. A good trip away from television, iPods, and email did both of us some good. Now we are back home on terra firma and BOTH locked and loaded for the next ten years of our lifelong adventure together.

I promise not to morph this into a blog about my personal life, but just couldn't hold back my enthusiasm and energy on the heels of such a great trip. It looks like we've got some good things in the scientific literature to discuss and even a few political topics to take on! For example: Was the recent Medicare bill really a victory for physical therapists? We'll talk about that later.

Thanks everyone for hanging in during this brief pause in the blog. I will be kicking-out posts on later this week.

Saturday, June 28, 2008

Forget 2020...How about Vision 2008?

I know we are all fired up about the utopia that will be 2020, but it might be a good time to take an honest look at the here-and-now.

The Good

I am amazed at some of the pessimism and complaining that runs rampant in our profession. I think some of this general crankiness comes from a serious lack of perspective. Firstly, we now generate more relevant clinical research not only in our own journals, but in many well-respected journals of the medical profession. Secondly, despite relevant misgivings about the current state of our education and training, we are arguably kicking out more well-rounded and academically prepared therapists into the work force. Lastly, although I hear PT's complain about their pay entirely too much, salaries have never been higher. Basically there has never been a better time to be a physical therapist and we are doing some things very well.

The Bad

At the same time, we do have our share of important issues to deal with. Reimbursement is declining across the board. Regulation of our practice (guided by the flagship CMS) is at an all time high. While innovation is being championed in the form of inspiring new clinical research, emerging and potentially useful practice patterns are too often fractured by suffocating reimbursement and regulatory guidelines. To whom should we cast the first stone?
  • Ourselves in not policing our practice patterns when the money was good.

    Thanks to our gluttonous billing patterns of yesteryear (Can you say "HUMing?), we are currently paying the price. Everyone was doing it it's ok right? Right.

  • Third party payors in realizing they could actually make more money by regulating us more tightly (say cheese ACN). Sometimes, its hard to explain how the corporate world could be even more irritating than the federal government. The blame shifts again back on us however, as we have gently rolled over for these jerks and it continues to pay off...for them.

  • The federal government in wielding restrictive legislation with the precision of a sledgehammer. The result is an inexplicably complex federal health care system that is confusing to it's beneficiaries and frustrating for it's providers. Are we sure we want to turn the whole thing over to these hacks? If your answer is 'yes', you clearly have never picked up a copy of our federal tax code.

  • Our patients in creating a culture of unaccountability from of our actions. The founders of our country would probably get nauseated at the sight of our behaviors.
    Despite incontrovertible medical evidence, public awareness, corporate and federal funding, our nation continues to resist adopting healthy behaviors. Trips to the local gym aren't nearly as frequent as those to the troughs of the local all-you-can-eat buffet. Pictures like the well-nourished gentleman above would be hilarious if they weren't so sad.

The Ugly

One might say we aren't handling these challenges very well. We whine at legislative defeats, but refuse to contribute to our PAC. We bemoan the pitiful reimbursement from third-party payors, but continue to feed off these scraps. We get upset at fringe providers who continue to practice voodoo like craniosacral and myofascial therapy, but don't have the guts to force our own professional organization to marginalize them. Lastly, we complain our patients are fat and smoke too much, yet don't take enough time to counsel them in an appropriate manner. Basically, we aren't contributing much to a solution.

Working Toward a Solution

We are free to blame the federal government, third party payors, and even patients for our problems. In the end, it's wasted energy without salient action. Those actually doing the heavy lifting for our profession are too busy to complain. They are busy actively researching, teaching, and advocating for a profession that largely doesn't act like it wants to play in the big leagues. The next time you complain about reimbursement, POPTS, payors, or patients, you may want to take an inventory to decide just which side of this funny little equation you are on.

Sorry, but treating patients isn't enough. We get paid to do that remember? Conscious effort beyond the call of duty is required to shift this equilibrium toward a favorable outcome. Contribute to our profession beyond the time-clock. Teach. Perform clinical research. Write your congressman. Give time to your local school district, community, or church. Doing something will always trump complaining about everything.

Lastly. I would be remiss if I didn't state the obvious: It is an election year with serious implications for the future of our health care system. Please vote! Remember. Our vision for 2020 is worthless without action in 2008.

Thursday, June 26, 2008

Preventing Stiffness after Rotator Cuff Repair Postoperative rehabilitation of the shoulder can be both rewarding and frustrating for even veteran physical therapists. While a significant number of patients recover with little to no disability, the process is not free of clinical land mines.

One of the more notable land minds for the postoperative shoulder is stiffness. If you've practiced long enough, you've probably developed some sense of what kind of patients or perioperative variables may be associated with the stiff shoulder. My running hypothesis was that it had a lot to do with preoperative stiffness and disability, much like we often see with knee arthroplasties.

Today's article, from Clinical Orthopedics and Related Research, prospectively examines the relationship between preoperative and postoperative characteristics that might predict patients more likely to become stiff following shoulder surgery.

The sample consisted of 209 patients with primary rotator cuff repairs. Operative procedures were standardized to a reasonable degree and involved subacromial decompression and rotator cuff repair. Interestingly the postoperative course was fairly well managed but did not involve supervised rehabilitation. The subjects were instructed in a 3-month home exercise program. Range of motion and manual muscle force were assessed preoperatively and at 6, 12, and 24 weeks by physical therapists. Lastly the patients were administered a Shoulder Service Questionnaire at the final postoperative follow up at a mean of 76 weeks (95% CI, 68-84 weeks).

The sample was retrospectively divided into two groups based on PROM at six weeks post-op:

  • Group A (Early motion recovery): Patients who ranked in the upper quartile of ROM for at least three of the four primary measured motions of flexion, abduction, external rotation, and functional internal rotation.

  • Group B (Shoulder stiffness): Patients who ranked in the lower quartile for at least three of the four motion categories

The subjects meeting the criteria for early motion recovery (39 total) and shoulder stiffness (36 total) were compared using ten descriptive and clinical characteristics. In reading the article, the progression of each characteristic is interesting to observe regardless of statistical significance. However, there were a few very interesting statistical and clinically significant findings.

  • Preoperative functional IR (hand behind the back) was the best predictor for postoperative shoulder stiffness

  • Age, gender, arm dominance, preoperative symptom duration, worker's compensation, type and size of tear were not predictive of shoulder stiffness

These were interesting findings of themselves but what followed really caught my attention:

  • The total range of motion achieved for group A (early motion) and group B (shoulder stiffness) were remarkably similar at 76 weeks. This finding indicates a delay in regaining full shoulder ROM rather than a permanent loss in ROM as has been previously proposed.

  • Although pain levels for group A were significantly better than group B, these differences only lasted up to the 12th postoperative week. After this they became remarkably similar. Again, this raises questions as to whether early postoperative pain and stiffness predicts permanent pain and disability as has been proposed.

  • Postoperative pain and stiffness for group B was at its worst at the six-week point, and then steadily improved until the final follow up to be comparable to group A.

I was really impressed with this study for a few reasons. I typically push the worry button around 4-6 weeks post-op if the patient isn't' making satisfactory progress or has high pain levels. I might be inclined to loose a few less hairs now - believe me I cherish them dearly!

Secondly, this study provides some relief that postoperative stiffness may not predict long-term pain or disability. In fact many of the subjects achieved good results regardless of their early postoperative course. It will be nice to present this kind of information to patients who are struggling in the clinic next to their "group A" cohorts!

More research on this topic needs to be done as the present study does contradict some of the conventional wisdom we have in the clinic regarding postoperative shoulder stiffness. What this study does provide is very good fodder for discussion and opens up more dialogue for improving our outcomes following this fairly common procedure. Take care and talk to you soon!

Trenerry, K., Walton, J.R., Murrell, G.A. (2005). Prevention of Shoulder Stiffness after Rotator Cuff Repair. Clinical Orthopaedics and Related Research, &NA;(430), 94-99. DOI: 10.1097/01.blo.0000137564.27841.27

Sunday, June 22, 2008

Cutting Edge Technology: The Spell Check

Wow...just realized I submitted my last blog prior to spellchecking!! If you want a good laugh or just like bad spelling, please read my most recent blog entry on pain in your reader or inbox.

If you are merciful, please visit my website and read the literate version of the Persistent Pain blog entry. Sorry about that! See you next time.


Thursday, June 12, 2008

Persistent Pain: An Independent Disease State? I recently began reading C.S. Lewis' The Problem of Pain. As with many of Lewis' writings, it is remarkable in both it's depth and simplicity. So many questions arise when it comes to the issue of pain, particularly for this therapist. Because I don't like weak links, I figured I'd better start looking for answers!

One aspect of a good question is that it often gives rise to more even better and more clinically relevant questions. Many physical therapists (myself included) emerge from entry-level training with a rather unsophisticated understanding of pain. We are more apt to enter the workforce with a strong understanding of pathoanatomy and biomechanics as it pertains to movement. If our goal is for our profession to evolve into becoming entry-level providers, we should have no tolerance for blind spots.

In the coming weeks, I will be incorporating the rather complex subject of pain as it pertains to common orthopedic conditions we encounter. More importantly, I will place emphasis on relevance to both assessment and treatment. I hope you will get as much out of the articles as I have in researching them. Mercifully, the topics will appease those of you with an appetite for physiology versus psychology.

Today's article comes from the Journal of Pain and Symptom Management on the issue of persistent pain and is truly an eye-opening read. Based on our study of pathophysiology, the concept of persistent or chronic pain doesn't always connect with our understanding of the inflammatory process. While there is clearly an inflammatory component to the acute pain our patients' experience, the relationship between tissue damage and persistent pain becomes much less clear in more.

The review provides evidence for "independent, pain-perpetuating pathophysiologic changes that occur after, or in the absence of, acute painful conditions or concomitant painful conditions." The review's author, anesthesiologist Michael Cousins, makes a very strong argument for persistent pain as a distinct pathological entity warranting specific attention from diagnosis through management. Cousins' contention is that failure to acknowledge the distinct physiology of persistent pain is likely to result in suboptimal care.

Contrary to much of the cognitive-behavioral pain literature I've tried to choke down over the years, this article provides the reader with some pretty significant pathophysiology supporting the concept of persistent pain as a distinct entity. I was particularly impressed with the physiology of peripheral sensitization, spinal cord events, and central nervous system changes that result from persistent pain. There is a relatively brief discussion of psychologic and environmental contributors,but the weight of the article is devoted to the biologic processes behind persistent pain.

Pain is not something orthopedic therapists may find particularly interesting or even relevant to their daily practice. The "no pain no gain" philosophy does have its time and place. However, what if there is a better way? I have no illusions of becoming the next pain-guru nor will I turn this into another freaky pain-blog, but I think we can take our practice to the next level by improving our understanding of pain in an orthopedic setting.

COUSINS, M. (2007). Persistent Pain: A Disease Entity. Journal of Pain and Symptom Management, 33(2), S4-S10. DOI: 10.1016/j.jpainsymman.2006.09.007

Saturday, June 7, 2008

The Pelvic Floor and an Unexpected Lesson...
It's been six months since starting this blog and I'm amazed what the process has taught me to this point. Sitting down in front of a computer has given me numerous opportunities to learn more about our profession, enhance my clinical skill, and in this case, grow up a little.

If you know me personally, I tend to be a pretty fun-loving and somewhat irreverent guy who is prone to cracking wise about a variety of topics. In most settings, this characteristic is simply what makes me "me". In the context of a public discussion on a physical therapy website, it could transform "me" into a bit of a jerk.

I recently made a pretty insensitive comment regarding pelvic pain on the Rehab Edge forums. I won't delete the post as accountability and transparency is something I believe in and don't think running away from what I said is the right approach. In response to my comments, two ladies associated with a blog called Pelvic Pain Matters descended upon me with what turned out to be understandable mix of outrage and disappointment.

With a strange sense that I really might have stepped in it with my comments, I ran them by my wife, mother, and academic mentor from physical therapy school. The result of my informal poll was unanimous and a bit humbling: I was a total jerk for what I said. Not the easiest things to hear from three people who you respect and admire, but the consensus struck a chord nonetheless.

Pelvic floor dysfunction is not an area I have previously held any interest in addressing as a orthopedic clinician. In fact, it is not likely to ever be an area I develop a strong skill set in assessing or managing. However, it is worth noting that pelvic floor dysfunction is a distinct clinical issue that can be present in a broader population than I had previously understood.

JOSPT: Lumbopelvic dysfunction, Incontinence, and the use of Rehabilitative Ultrasound

In keeping with the theme of this blog, today's entry comes to us from JOSPT on the topic of lumbopelvic dysfunction and stress urinary incontinence. The paper is a case study on a 35 y/o female soldier presenting with stress urinary incontinence and left buttock pain. These symptoms were limiting her tolerance for physical activity necessary to complete basic training.

The study's authors utilized a multimodal approach to managing what was determined to be an SIJ dysfunction coupled with active pelvic floor insufficiency contributing to stress incontinence. Of particular focus in the study was the use of rehabilitative ultrasound as a biofeedback device to retrain the pelvic floor musculature.

At a six-week follow up, the patient had no subjective or objective signs of SIJ dysfunction or stress urinary incontinence. This allowed her to complete all the requirements of basic training without limitation. A six month telephone follow up was equally positive with no evidence of lumbopelvic dysfunction or incontinence.

What can this study tell the orthopedic therapist?

While I wasn't bowled over with the methodology or outcomes of this particular study, I did learn quite a bit regarding pelvic floor dysfunction. Firstly, I discovered just how prevalent pelvic floor pain and/or dysfunction can be in both men and women. Secondly, I got a better appreciation for the biomechanics of the pelvic floor and its possible role in low back pain. Lastly, I gained an appreciation for another clinical syndrome physical therapists may be able to benefit.

What has this process taught me?

Well...that remains to be seen! Some might say you can take the boy out of the locker room but it's hard to take the locker room out of the boy. I might agree with this statement. However, there comes a time when us boys have to realize we are professionals and people do read what we say on blogs and internet forums. I make no guarantees of future perfection. In fact, I'm more prepared to guarantee future imperfection. That doesn't mean I can't grow up along the way. Have a great day.

Painter, E.E. (2007). Lumbopelvic Dysfunction and Stress Urinary Incontinence: A Case Report Applying Rehabilitative Ultrasound Imaging. Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2007.2538

Sunday, June 1, 2008

Imaging and Shoulder Pain: Why we don't treat MRIs....

How many of us have heard patients tell us they'll be relieved if they could just get an MRI to "tell them what's wrong."? I'll be the first to admit I too jumped on this bandwagon early in my career. I was very eager to see an individuals MRI report to correlate their clinical symptoms. You've heard me quote a wise old PT friend of mine who said "We don't treat MRIs". Well RV, this one goes out to you. ;)

This fascination with "seeing" what's wrong has lost a bit of its luster as I've read some very interesting reports on the lack of agreement between MR and clinical presentations. We've seen this phenomenon in low back and shoulder pain where imaging studies don't necessarily correlate with the patients clinical presentation.

It'd been a while since I've seen a good study on this topic so I figured I'd look up what the American Journal of Roentgenology had to say on the issue. The article takes a whopping 1079 consecutive patients referred for shoulder MRI. The subjects were asked to complete validated shoulder questionnaires regarding pain and disability. These were correlated with the radiologists' MR findings.

What did the authors conclude?
  • MRI is highly accurate at detecting the presence of a partial or full-thickness rotator cuff lesion.

  • There was no relationship between pain or disability with the size or location of the rotator cuff tear.

  • Rotator cuff lesions may be thought of as a natural correlate of aging

  • It is not clearly identified why some rotator cuff lesions are symptomatic while others are "silent"

  • Factors such as bursitis, capsuloligamentous lesions, or cartilage lesions may confound the findings of MRI as they pertain to the rotator cuff

  • There may be "no relationship between rotator cuff tear size and the inflammatory reaction responsible for the pain and disability, like low back pain is unrelated to the size of disc herniations."

What are the author's recommendations?

  • "Despite the absence of correlation between the size of the rotator cuff tears and the level of disability,MRI provides important data that may affect the management of rotator cuff lesions and should be performed before rehabilitation or surgery."

Really AJR? Let me make sure I understand. There is little to no correlation between imaging and symptoms, yet folks should go ahead and get the MRI anyway? Even before rehab? That's a hard one to swallow. In his defense of the study's author, the investigation took place in France within a socialized health care system where utilization would doubtless be far different from ours.

Regardless of the author's curious conclusion, the study is an honest representation of how limited the value of MRI can be for common musculoskeletal complaints. It also underscores the importance for physical therapists not to get too caught up in hounding the referring physician for the MRI report.

Treat the patient, not the report!

Krief, O.P. (2006). Shoulder Pain and Disability: Comparison with MR Findings. American Journal of Roentgenology, 186(5), 1234-1239. DOI: 10.2214/AJR.04.1766

Thursday, May 22, 2008

Adverse Events of Chiropractic Care: Transparency Now!
So I've been binging on literature lately....One of my first courses at Texas Tech's doctoral program is Advanced Clinical Practice for the Cervicothoracic Junction and Thoracic Outlet. Let me be the first to say I had no idea this part of the body would be quite so involved and interesting at the same time.

Our weekly assignments involve reading research ranging from randomized clinical trials to anatomical reviews. After only one week in this program, I've already picked up some good information I can use in the clinic.

Today's article came from reading some anatomical studies on the vertebral artery. In reading more about the anatomy of this area, my mind wandered to the topic of potential risks for cervical manipulation. The most dramatic adverse events seem to focus on dire occurrances such as stroke. However, we've all seen folks come to our clinics saying they had a range of responses to chiropractic care ranging from pain and stiffness to a worsening of radicular symtoms.

I wondered in particular if the chiropractic profession was any more transparent with reporting adverse events pertaining to cervical manipulation. We've all heard the chiros tell us a manipulation has fewer complications associated with it than taking an NSAID, but we've heard this boy cry wolf before and a little hard data would be nice.

Sure enough, a trial spawned out of the UCLA Neck Pain study attempts to help us learn more. In a randomized clinical trial, a total of 336 patients with neck pain were randomized into three groups of chiropractic care:

  • Manipulation with or without heat
  • Manipulation with or without electrical stimulation
  • Mobilization with or without heat or electrical stimulation

The adverse event in this trial was "discomfort or unpleasant reactions from chiropractic care" assessed at 2 weeks from the baseline assessment. Of the 280 patients who responded, 85 patients (~30%) reported having one or more adverse symptoms as a result of chiropractic care. A total of 212 adverse reactions were reported from the 85 patients who had complications. Of the 212 adverse reactions there were:

  • 70 episodes of moderate to severe neck pain or stiffness
  • 44 episodes of moderate to severe headaches
  • 28 episodes of tiredness or fatigue

Other less common adverse events included dizziness, nausea, depression, tinnitus, arm or leg weakness, blurred vision, confusion or disorientation. Nearly 20 percent of the respondents reported the adverse events had a significant impact on their tolerance for ADL. There is plenty of good data within the results and discussion section to read over so I would encourage you to take a look through it.

The authors, one of whom is a chiropractor, concluded the following:

  • Adverse events from chiropractic manipulation are common
  • Adverse events are more likely to follow manipulation vs. mobilization
  • Chiropractors should consider mobilization over manipulation in the treatment of neck pain, particularly for those with severe pain.

I have bad news for the chiropractic profession... If you take the judicious application of manipulation based on a medical vs holistic model, you get what many well-trained manual physical therapists provide on a daily basis. This study does not bode well for a chiropractic profession that is very slow to let go of its roots in subluxation.

I don't take this study as an indictment of the chiropractic profession, as there are some very skilled manual practitioners out there. However, they dug their own hole in the form of subluxation-based care and are going to have to work hard to dig themselves out. It will be interesting to see if they can do it before the clock runs out on their profession....and believe me it is ticking. Chiropractic tuitions have never been higher and their revenues have never been lower...tick tock...tick tock....!

Hurwitz, E., Morgenstern, H., Vassilaki, M., Chiang, . (2005). Frequency and Clinical Predictors of Adverse Reactions to Chiropractic Care in the UCLA Neck Pain Study. Spine, 30(13), 1477-1484.

Friday, May 16, 2008

Tough Love: Eccentric exercise for lateral elbow pain

ResearchBlogging.orgSome issues in physical therapy just seem counterintuitive upon first glance. An emerging treatment method used in the management of tendonopathy is eccentric training. While eccentric training has obviously been around for years, researchers are beginning to see its utility in managing chronic tendon disease.

Adding mechanical stress to a tissue that is already mechanically stressed didn't match my intuition early in my career. Fortunately for many of my patients, I still had a lot to learn. We are now learning that many cases of chronic tendonopathy bear little resemblance to the inflammatory process of tendonitis. In fact, some histochemical studies of chronic tendonopathies have revealed no evidence of inflammatory tissue.

With a more sophisticated understanding of the pathophysiology of tendon disease, researchers have begun to explore treatment options that fall out of the typical inflammation-based treatment paradigms. Another (perhaps even more significant) driving force behind these investigations is that our current methods are meeting with mixed results. An emerging treatment option is the use of eccentric training in the management of chronic tendon disease.

Today's article published in the British Journal of Sports Medicine provides a framework for using exercise to manage lateral elbow pain (LEP). While not a clinical trial, the article provides a solid framework for utilizing supervised eccentric training coupled with static stretching to treat recalcitrant LEP. The authors acknowledge that more work needs to be done in this are to determine the optimal mechanical load for the lateral elbow that would elicit positive adaptations without exceeding the tissue tolerance of the musculotendinous complex.

Although I wasn't bowled over by the caliber of this report, I think it does indicate that we are moving into a more sophisticated and precise way of handing tendonopathy. The use of eccentric training reflects a deeper understanding of the pathophysiology of chronic tendon disorders. Upon first glance, it certainly doesn't fit the paradigm of a how we traditionally handled these types of problems. Good thing we are giving these issues a second glance.

Stasinopoulos, D. (2005). An exercise programme for the management of lateral elbow tendinopathy. British Journal of Sports Medicine, 39(12), 944-947. DOI: 10.1136/bjsm.2005.019836