Sunday, March 30, 2008

Clinical Diagnosis of Rotator Cuff Disease
A large percentage of my current caseload consists of shoulder pain. Often these referrals come from family practice physicians or other generalists who utilize physical therapy as a conservative precursor to an orthopedic physician. As a link in this referral chain, I look at early establishment of a appropriate rehab prognosis to be an essential function of my job.

Physical therapists are not diagnosticians, but the use of clinical diagnostic testing can give us some indication of the patients potential to respond to conservative care. A 2005 article in the Journal of Bone and Joint Surgery attempts to determine which of the numerous clinical tests of rotator cuff disease has the most clinical utility. The tests were investigated to determine their utility in assessing three degrees of rotator cuff pathology: bursitis, partial-thickness rotator cuff tear, and full-thickness rotator cuff tear. The following eight clinical tests were examined:
  • Neer impingement sign
  • Hawkins-Kennedy impingement sign
  • Painful-arc sign
  • Supraspinatus muscle strength test
  • Infraspinatus muscle strength test
  • Speed test
  • Cross-body adduction sign
  • Drop-arm sign

The authors found that sensitivity, specificity, PPV, NPV, and overall accuracy of each test showed considerable variability. The combination of Hawkins-Kennedy sign, painful arc sign, and infraspinatus muscle strength test yielded a 95% post-test probability for any type of impingement syndrome. Full thickness rotator cuff tears were found with a 91% post-test probability using a combination of the drop-arm test, painful arc sign, and infraspinatus test.

Studies such as the one cited above lend support to the notion that batteries of tests are capable of adding tremendous strength to a clinical exam for a physical therapist. Future research in our profession could look into how patients fitting into one of the three degrees of rotator cuff disease respond to various modes of physical therapy.

Park, H.B. (2005). Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome. The Journal of Bone and Joint Surgery, 87(7), 1446-1455. DOI: 10.2106/JBJS.D.02335

Saturday, March 29, 2008

SIJ Motion: I still can't feel anything
Early in my PT career, I thought I had the hands of a guerrilla. No condition made me feel more like a primate than during my evaluation and assessment of sacroiliac dysfunction. We must have spent 4-6 weeks in school studying motion and palpation tests for the SI joint and I really felt I had it down.

After a few weeks of practicing and seeing a ton of spine cases at the clinic I was working, I had an epiphany: What would happen if these tests were found to have little evidence supporting their utility? Would I change my approach? What are the alternative explanations for the patient's presentation?

Suddenly I felt a pretty anxious feeling that maybe this fear shouldn't be confined to the SI joint. What if other things I was taught in PT school were out of phase with best evidence? Did that mean I should be bitter and demand my money back because everything my instructors told me wasn't pure unbiased fact? I'll get back to these questions in a moment...

Today's investigation is recently published in the Journal of Manual and Manipulative Therapy on the clinical utility of studying SIJ motion. The systematic review explores the clinical utility of static and dynamic motion palpation testing for the SIJ. After reviewing seven articles that met the inclusion criteria for the review, the authors found the following ranges of movement at the SIJ.

Rotational motion:

  • Motion along the X axis ranged from -1.1 to 2.0 degrees
  • Motion along the Y axis ranged from -0.8 to 4.0 degrees
  • Motion along the Z axis ranged from -0.5 to 8.0 degrees

Translational motion:

  • Translational movement along the X axis ranged from -0.3 to 8.0 mm
  • Translational movement along the Y axis ranged from -0.2 to 7.0 mm
  • Translational movement along the Z axis ranged from -0.3 to 6.0 mm

The authors conclude motion and palpation testing for SIJ motion indeed may have very limited clinical utility. While not the first investigation into the utility of this type of assessment, it builds greater strength to the notion we should continually reevaluate our understanding of what it is we are assessing and treating in our patients.

Back to my earlier questions. The answers to these questions are simple. We should always be willing to at least consider changing our approaches to a clinical problem when faced with strong evidence to do so. To some, this statement may seem a plea toward a robotic 2-D approach to clinical problem solving. Believe me it isn't. True evidence based practitioners attempt to reconcile their clinical intuition with the best available evidence. Often we find this process of reconciliation difficult, but we chose this profession and all the benefits it provides us.

We must be willing to subject to the hopper of the scientific method and see what comes out of it. If we do this regularly, the process becomes less laborious and more invigorating. The end results are victories on at least a few fronts. Our patients get better outcomes and our profession grows stronger.

As far as being bitter about being taught SIJ motion testing in school in spite of overwhelming and opposing evidence? Keep in mind our instructors are there to open the door for us to learn. The responsibility is ours, not theirs, to guide our own decision making in the clinic. Keep this in mind and you will never stop learning! Have a great weekend.

Goode, A., Hegedus, E.J., Sizer, P., Brismee, J., Linberg, A., Cook, C.E. (2008). Three-dimensional Movements of the Sacroiliac Joint: A Systematic Review of the Literature and Assessment of Clinical Utility. Journal of Manual & Manipulative Therapy, 16(1), 25-38.

Saturday, March 22, 2008

A New Hope...

Recently I posted that two students would be joining me in the clinic for a six week rotation. At the behest of a PT student blogger, I have attempted to develop a more systematic approach to clinical instruction. This past week was our first week together and I have to say I am incredibly pleased with the results thus far.

I would really like to attribute the results to my carefully planned and well conceived curriculum. It always does my ego some good. However, lessons gleaned from 10 years of marriage lead me to tuck my ego away for a while and just skip to the facts. One is that both students are absolutely tireless in their desire for more information. They don't stop asking well thought out questions. Somewhere along the lines, both students learned that questions such as "Where is the sartorious?" can be looked up on their own. Consequently they continue to ask questions that will deepen their knowledge of practicing physical therapy in an orthopedic setting. The effort they are putting in and ability to think critically is largely responsible for their performances in the clinic this week.

This week I instructed them to strongly focus on taking an adequate history - an underrated skill in the clinic. By the end of the week, both students were asking relevant questions and getting relevant clinical data while making a good connection with their patients. I even had some patients commenting on their skill and professionalism.

Next week our focus will be on evaluation and examination on top of what they've already picked up working on histories. There will likely be more reading, thinking beyond the classroom, and a couple of brain cramps along the way, but this is all part of the learning process. Stay tuned for next weeks episode!

Manual Physical Therapy: We Speak Gibberish
Tim Flynn and John Childs have done it again...I wish they'd stop making so much sense. It will likely lend more credibility to our profession than we deserve at times. In the latest JOSPT editorial (March 2008) the gang outline our serious language problem in orthopedic physical therapy. They even offer some salient solutions to remedy the problem.
  • Develop a common language we can agree upon
  • Teach students manual skills versus indoctrinating them into a specific schools of thought
  • Publish a framework of common treatment techniques using a common language independent of political bias
  • Develop a glossary of technique descriptions for the Manipulation Education Manual
  • Develop a dialogue with members of the international community regarding this common language

In my first few years as a therapist, I abandoned many manual techniques because of the aforementioned political bias and risk of associating with the faith healers of the manual world. Authors who advocate a more science-based approach to our patients continue to give me hope that our profession may be ready for the responsibility of autonomy we demand. If we are able to work toward the ideals that Flynn and colleagues put out there, we'll be adhering to the rigors of science rather than the trappings of politics.

Flynn, T.W., Childs, J.D., Bell, S., Magel, J.S., Rowe, R.H., Plock, H. (2008). Manual Physical Therapy: We Speak Gibberish. Journal of Orthopedic and Sports Physical Therapy, 38(3), 97-98.

Sunday, March 16, 2008

Training to Failure: Is it truly necessary?
A brief review in the Journal of Strength and Conditioning Research by Willardson suggests otherwise. A review of the literature outlines several factors to consider when training to failure. In this review failure is defined as "the point during a resistance exercise set when muscles can no longer produce sufficient force to control a given load". The review reveals the following findings regarding the use of training to failure.
  • Optimal improvements in muscle performance occur when planned variations are implemented into the training program of advanced lifters
  • Training to failure may provide sufficient stimulus to push past an existing training plateau through greater activation of motor units and a larger endocrine response
  • Training to failure may be associated with increased risk for injury

Based on the above findings, Willardson makes the following recommendations:

  • Training to failure should not be practiced for extended periods of time in a training cycle due to increased risk for overuse injury and potentially decreasing growth enhancing endocrine response
  • Training to failure should be incorporated conservatively throughout the planned training cycle of advanced lifters and could be useful in pushing through a plateau
  • There is no reason for recreational lifters or older adults to lift to failure
  • Strength and conditioning professionals should consider the goals of the individual when designing an optimal load for their client

The review concludes there is more research needing to be done regarding the issue of training to failure on performance measures such as muscular power, hypertrophy, and local endurance. Willardson states there remains a great deal we have to learn regarding the precise physiological mechanisms at play regarding the outcomes of training to failure.

Willardson, J. (2007). The Application of Training to Failure in Periodized Multiple-Set Resistance Programs. Journal of Strength and Conditioning Research, 21(2), 628-631.

Friday, March 14, 2008

Cervical Radiculopathy: Who will respond to physical therapy?
A recent article in the Journal of Physical Therapy attempts to answer this question through a prospective cohort study. The purpose of the study was to determine if factors discovered during either the examination or course of treatment were able to predict clinical outcomes for patients with cervical radiculopathy.

This study took 96 consecutive patients with a diagnosis of cervical radiculopathy. The patients underwent a clinical exam and completed standardized outcome tools such as the Neck Disability Index (NDI), Patient Specific Functional Scale (PSFS), and Numeric Pain Rating Scale (NPRS). Treatments were not standardized and left to the discretion of the physical therapist. Short term-success was defined as surpassing the minimal clinically important change for ALL outcome measures at discharge or last reexamination.

The study revealed eight predictor variables identifying individuals likely to show short-term success from physical therapy intervention. Three were based on historical data, one from clinical examination, and four from intervention selection. Based on likelihood ratios the authors cited the following cluster of variables as most significant:

  • Age of less than 54 years
  • Dominant arm not affected
  • Looking down does not worsen symptoms
  • Multimodal treatment (manual therapy, cervical traction, deep neck flexor strengthening for at least 50% of visits)

Having three of the four variables present led to an 85% posttest probability the patient would experience short-term success. Having all four variables present were associated with a 90% post-test probability.

While the authors acknowledge some key limitations in their study, their findings do suggest a possible set of clinical variables useful to the practicing therapist treating cervical radiculopathy. Studies such as this are likely to begin to discriminate between patients likely to benefit from physical therapy and those needing referral to other health care providers.

Cleland, J.A., Fritz, J.M., Whitman, J.M., Heath, R. (2007). Predictors of Short-Term Outcome in People With a Clinical Diagnosis of Cervical Radiculopathy. Journal of Physical Therapy, 87(12), 1619-1632.

Wednesday, March 12, 2008

To Run or Not to Run: A guideline for post-menisectomy patients

A recent review in the Journal of Manual and Manipulative Therapy explores the following questions regarding menisectomy, risk for osteoarthritis, and recreational running. Through a comprehensive search of available literature on the issue, the author of the article Bob Baumgarten attempts to address the following questions :
  1. Is it advisable for individuals to continue recreational running following menisectomy?

  2. Are there identifiable risk factors physical therapists can use to identify patients likely to develop OA following a menisectomy?

The review highlights several key relationships that may shed light on the answers to these questions. Specifically, Baumgarten examines the relationships between:

  • Anatomy and functional role of the meniscus

  • Etiology and classification of osteoarthritis

  • Diagnostic measures of osteoarthritis

  • Recreational running and osteoarthrits

  • Menisectomy and OA

Baumgarten concludes that there is likely an elevated risk for early onset of OA in a post-menisectomy population. However, it is premature to declare this risk a certainty. He goes on to state there is insufficent high-level evidence to suggest concret clinical guidelines for recreational runners following menisectomy.

Some general guidelines however may assist the provider in decision making regarding their patients who are considering a return to running. Risk factors for early development of osteoarthritis include:

  • Greater than 1/3 of the meniscus removed during menisectomy

  • Preexisting articular cartilage degeneration

  • Degenerative vs traumatic meniscal injury

  • Gender (females > males)

  • BMI equal to or greater than 30

  • Lateral compartment involvement

  • Genu valgum or varum with lateral or medial menisectomy respectively

Patients possessing fewer risk factors may be at lower relative risk for developing early symptomatic osteoarthritis arthritis. Based on the author's findings, it may be advisable to recommend patients with a higher number of risk factors participate in less stressful aerobic activity to maintain the benefits of physical activity without incurring increased risk for early OA and subsequent disability.

Baumgarten, B. (2007). To Run or Not To Run: A Post-Menisectomy Qualitative Risk Model for Osteoarthritis when Considering a Return to Recreational Running.. Journal of Manual & Manipulative Therapy, 15(1), E1-E15.

Saturday, March 8, 2008

Physical Therapy and Cults...

I think we're all guilty to a certain degree. We like the self-affirmation that comes along with being correct. A good diagnostic catch in the clinic...a good outcome when you weren't sure their would be. The sports analogy is snatching victory from the jaws of defeat.

But like the great poet Rudyard Kipling said in his famous coming-of-age poem "If", becoming a man involves knowing successes and failures should be kept in perspective. You are never 'always right' nor 'always wrong'. This simple humbling lesson should be in the back of our minds during our personal and professional lives. At least it should be.

Yet some in our profession would speak as if this weren't the if some are indeed always right or always wrong. Most notably, these ideologues tend to speak in absolutes with very little equivocation. They will actively recruit easily led individuals and defend the faith at any cost. Questioning is met with often harsh admonishment that you must be part of some central orthopedic conspiracy designed to bring them down. It's the behavior expected of someone who always got picked last for kickball.

Interestingly , there are likely credible features to some of these approaches that have some basic science and case-studies to support their unique way of looking at the clinical world. However, unless they submit to the rigorous scrutiny of consistent peer-review, they must be placed in the bin of other popular but unsubstantiated therapies. As evidence mounts, a groundswell of support will emerge for new "cutting edge" treatment methods.

Make no mistake, the credibility and growth of our profession will stand upon our willingness to back what we say and do with evidence. No amount of emotion or ideology will ever compensate for a lack of it. Ideology without evidence is faith healing.

If your goal is to become one of the emerging leaders in conservative management of movement-based disease, I implore you to be vigilant in maintain the ideals of evidence-based practice as articulately defined by Sackett. I also strongly suggest reading an editorial in the Journal of Manual Therapy entitled "Manual Therapy Cults" (Rivett, 1999).

This is an exciting time in our profession. There are providers out their busting their tails to make us better as a profession. I say busting their butts because this process will not be easy. Nothing worth earning is or should ever be easy. We need to move beyond being part of the problems in our profession by becoming part of the solution.