Feedly Friday: 5 articles you should read this week

Feedly is a news aggregator app that offers a place to gather and read all the news from your favorite blogs, journal publications, podcasts, and Youtube channels.  This news is organized into various collections and you receive updates when new stories, videos, journal articles are published. It is basically a Facebook on steroids that gathers research for you in one place.

Here is what came across my Feedly that I thought was worth a read:

This weeks articles come from The Manual Therapist, Physiospot, Claire Patella, AJSM, and The PT Journal.

• In this blog post,  Dr. Esummarizes findings of EMG activation of the gluteal muscles and tensor fascia latae (TFL) during different rehabilitation exercises.
• In this blog post, they highlight study in that compares conservative and operative treatment for meniscal lesions. They conclude that there was no siginifcant difference between exercise therapy and meniscectomy for pain.
• In this infographic video,  Claire Patella depicts the differences between irritation to  patella femoral joint pain and infrapatellar fat pad

 

• In AJSM, authors Rathleff et al investigate the 2 year prognosis of knee pain among adolescents with and without diagnosis of patella femoral pain (PFP). They conclude PFP is not a self-limiting condition and greater focus on early detection and prevention is needed.
  • Rathleff MS, Rathleff CR, Olesen JL, Rasmussen S, Roos EM. Is Knee Pain During Adolescence a Self-limiting Condition? Prognosis of Patellofemoral Pain and Other Types of Knee Pain. Am J Sports Med. 2016;44(5):1165-71.
• In this study in the PT Journal, the authors investigated with chronic low back pain can identify those who respond better to MDT compared with back school. They had an interesting result finding that older people had 1.27 points more benefit I pain reduction from MDT than younger patients after 1 month of treatment. However, limitations in research design may limit this conclusion.
  • Garcia AN, Costa Lda C, Hancock M, Costa LO. Identifying Patients With Chronic Low Back Pain Who Respond Best to Mechanical Diagnosis and Therapy: Secondary Analysis of a Randomized Controlled Trial. Phys Ther. 2016;96(5):623-30.

Manual Monday: Nerve Mobilizations

Neurodynamic testing is part of a regular examination of a patient complaining of low back pain. The straight leg raise (SLR) is an easily performed test that objectifies lower extremity nerve mechanosensitivity. This assessment tool is very valuable as it can also be prescribed as an intervention.  Let’s look at the utilization of this test as both an assessment and intervention.

Neurodynamic tests are sequences of movements designed to assess both the mechanics and physiology of the nervous system. (1) The mechanical component includes the nerves ability to slide through its sheath as it courses from the spine distally into the extremity. The physiological component include irritates to the nerve itself such as “inflammation, ischaemia, and altered ion channel activity resulting in sites of abnormal impulse generation.” (1) If either of these components are impaired it will cause an increase in mechanosensitivity resulting in pain as the nerve attempts to accommodate the strain due to the movement of the lower extermity during the SLR.

The psychometric properties of the SLR as a neurodynamic test in the assessment of radiculopathy as a result of lumbar disc herniation was outlined in a cochrane systematic review. The authors found (2):

• the SLR showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10 to 1.00, pooled estimate 0.28, 95% CI: 0.18 to 0.40)
• The crossed SLR showed high specificity (pooled estimate 0.90, 95% CI: 0.85 to 0.94) with consistently low sensitivity (pooled estimate 0.28, 95% CI: 0.22 to 0.35).

Therefore, the SLR is a sensitive test in detecting impairments in LE neuodynamics, however, as indicated above it is not a specific test in determining why this impairment is occurring. An interesting side note: if the SLR is combined with crossed SLR there is more certainty that the nerve is being impaired by a lesion at the disc.

A positive assessment item, such as the SLR, can often result in one of the best patient-specific interventions. However, evidence-based dosage of this intervention is unknown. The authors of one recent article have suggested the following guidelines (1):

•  Some of the mechanisms associated with the benefits of joint mobilizations may be similar to those of neurodynamic treatment.
• If neurodynamic mobilizations exert their effects through a hypoalgesic or viscoelastic response, then using a longer treatment duration (3 x 2 minutes) is not different than using a shorter duration (3 x 1 minute)  if the desired outcome is to improve pain-restricted ROM. However, neurodynamic treatment, irrespective of treatment duration, may help to increase pain-restricted ROM.

Check out this article by Cleland, Childs, et al (3)  where they demonstrated significant improvement in reducing short-term disability and pain, and centralization of symptoms in patients with non-radicular low back pain when including nerve mobilizations.

In conclusion, the SLR is a very valuable assessment tool in the clinician’s arsenal that can be easily turned into an effective intervention. There is supporting evidence to suggest short treatment duration more efficient than longer treatment duration to improve pain-restricted movement. However, the subgroup of patient who may benefit the most from this intervention and by which mechanisms are still unknown and are a point or further research.

Work Citied

1. Neal hanney R, Ridehalgh C, Dawson A, Lewis D, Kenny D. The effects of neurodynamic straight leg raise treatment duration on range of hip flexion and protective muscle activity at P1. J Man Manip Ther. 2016;24(1):14-20.
2. Van der windt DA, Simons E, Riphagen II, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev. 2010;(2):CD007431.
3. Cleland JA, Childs JD, Palmer JA, Eberhart S. Slump stretching in the management of non-radicular low back pain: a pilot clinical trial. Man Ther. 2006;11(4):279-86.

 

 

PT-First: Asymptomatic Imaging Findings

In every field of study, popular perspectives often surface that create a paradigm shift. We see many shifts within the fast-paced field of physical therapy. These changes are suppose to bring about progress as more research and deeper understanding is developed. However, as the paradigm pendulum swings it often overshoots its original goal and we end up in the extreme ranges of all-or-nothing. Let’s look at one current movement in the field of physical therapy and see how this may pose a danger when applied without clinical reasoning.

Recently, there has been a push on social medial to encourage patients to receive “PT-first.” This movement suggests that it is more cost effective to obtain physical therapy consult/treatment first before completing imaging studies. There is several articles supporting this claim. 1-2 In a recent article by Fritz, Brennan et. al (2015), they outlined the “American College of Radiology guidelines recommending against imaging during the first 6 weeks for uncomplicated LBP with or without radiculopathy.” They further described that imaging should be completed only if patient’s mechanism of onset include trauma, objective findings suggestive of neoplasm or infection, and progressing neurologic deficits. (Fritz, Brennan et al 2015)

However, these guidelines can significantly miss their intended target if taken to the extremes. This can be seen in the young athletic populations concerning bone stress reactions in the pars interarticularis. The prevalence of such as been reported as high as 47% in this population.3-4 Stress fractures generally do not develop due to one traumatic incident rather over a length of time. Therefore, these patients would likely receive PT first and be discouraged from completing imaging  based on reported guidelines.

For this patient population, this may pose a hazardous situation due to the fact that stress fractures in the lower back are not always associated with pain.5 This may result in patients receiving care in which the clinician may be successful in decreasing pain and improving function; however, tissue-healing has not occurred. 5 Without being limited by pain, these athletes would likely  return to full activity to early. This would undoubtedly pose the risk of progression of the stress fracture rending that segment unstable.

So as the pendulum swings to receive “PT-first” and avoid unnecessary imaging, it is a must that clinicians utilize sound clinician reasoning to refer patients when indicated. As highlighted above missing a diagnosis can be just as costly if not more than an unneeded MRI. 

Work Cited

1. Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011;41(11):838-46.
2. Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine. 2012;37(25):2114-21.
3. Radcliff KE, Kalantar SB, Reitman CA. Surgical management of spondylolysis and spondylolisthesis in athletes: indications and return to play. Curr Sports Med Rep. 2009;8:35–40
4.  Micheli LJ, Wood R. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med. 1995;149:15–18
5. Millson HB, Gray J, Stretch RA, Lambert MI. Dissociation between back pain and bone stress reaction as measured by CT scan in young cricket fast bowlers. Br J Sports Med. 2004;38(5):586-91.

 

 

 

Soft Tissue Saturday

It is not uncommon to see foam rollers sitting in the corner of just about every gym nowadays. No matter what the exercise routine includes, everyone is foam rolling from crossfitters to yogis. Is this just another fad of the exercise industry? Or does this soft tissue technique have the research to back up its recent popularity.

In the International Journal of Sports Physical Therapy, a systematic review was published last year in which the authors analyzed the current evidence to determine if foam rolling is an effective stretching method and whether or not it effects muscle recovery.  It included 14 articles in the review looking at joint ROM, muscle performance, and muscle recovery.

Article Conclusions:

• Joint ROM can be improved with utilization of the foam rollers
  • One study found that rolling on mediolateral axis vs anteroposterior axis may produce greater results.
  • Also foam rolling combined with static stretching may have better effects after exercise.
• Foam rolling after exercising can decrease perceived pain if completed within 10-20 minutes afterwards.
• Foam rolling  does not augment or decrease muscle performance but may change the perception of fatigue

How you should use foam rolling based on current evidence:

1. Pre-work out rolling will not negatively affect muscle performance like static stretching but may decrease perceptions of muscle fatigue (
2. Post-work out  to decrease delayed onset muscle soreness
3. Integrated with your static stretching routines to augment ROM gains.

Work cited:

1.  Cheatham SW, Kolber MJ, Cain M, Lee M. THE EFFECTS OF SELF-MYOFASCIAL RELEASE USING A FOAM ROLL OR ROLLER MASSAGER ON JOINT RANGE OF MOTION, MUSCLE RECOVERY, AND PERFORMANCE: A SYSTEMATIC REVIEW. Int J Sports Phys Ther. 2015;10(6):827-38.
2. Kay, AD, Blazevich, AJ. Effect of acute static stretch on maximal muscle performance: a systematic review. Med Sci Sports Exerc.2012;44:154-164.