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Research Reviews
A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy
van der Plas A, de Jonge S, de Vos RJ, van der Heide HJ, Verhaar JA, Weir A,Tol JL
Br J Sports Med. 2011.
Reviewed by Julia Chevan, PT, Cert. MDT (1-20-2012)
Study Purpose: Eccentric exercise has been examined in previous literature as an approach to treating Achilles tendinopathy with promising results. Most studies have short-term follow up periods. The longest follow-up with any participant group to date has been one year. In addition, outcomes measurement in clinical trials on eccentric exercise for Achilles tendinopathy have inconsistently used an outcome measure like the Victorian Institute of Sports Assessment - Achilles (VISA-A) that is validated and provides information about pain, physical activity and severity. This study was conducted to evaluate the long-term (5-year) outcomes from an RCT that employed the "Alfredson" program for intervention. Methods: The original RCT was a comparison of eccentric exercise to eccentric exercise with the addition of a night splint. Since the night splint had no effect in the original study, this component had been dropped and all participants were merged into a single group. At the end of the RCT participants were provided no further instructions or recommendations. All participants in the original RCT were contacted in follow-up phone calls and 47 participants of the original 58 provided data for the current study. The researchers collected the following data points: VISA-A score, participant pain status, participant satisfaction with status, treatments received since the end of the RCT and an Ohberg score from the ultrasound exam of tendon thickness and neovascularization. Results: VISA-A score improved at the 5-year follow up from both the baseline and the 1-year follow up score. Approximately 40% of patients were pain-free; 48% had received one or more alternative treatments and finally, 47% showed neovascularization at the 5-year follow-up. Conclusions: Although the outcome measure assessing pain and activity showed improvement in the long term Achilles pain is likely to persist at a mild level. Comments: This long-term follow is interesting due to the findings of what patients do post-treatment and the implications that in spite of seeking out alternative interventions to eccentric exercise the symptoms may remain. Although the data come from the participants in an RCT on eccentric exercise the findings themselves are not related to validating the use of eccentric exercise. As observational data, the findings raise a number of questions about how patients manage their recurrent and lasting symptoms post intervention.
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Evaluation of the McKenzie Intervention for Chronic Low Back Pain by Using Selected Physical and Bio-Behavioral Outcome Measures
Al-Obaidi S, Al-Sayegh N,Ben Nakhi H, Al-Mandeel M
PM&R. 2011. Vol 3 (7): 637-646
Reviewed by Charles Sheets, PT, Dip. MDT (8-25-2011)
This study assessed the outcome of sixty-two patients with chronic low back pain who demonstrated the centralization phenomenon and received the McKenzie intervention using selected bio-behavioral and physical performance measures (the Roland Morris Disability Questionnaire and Fear Avoidance Belief Questionnaires, time for repeated sit to stand, trunk forward bending, and customary and fast walking). All tests and measures were significantly improved at both five and 10 weeks after treatment, although pain, fear and reported disability regressed slightly at ten weeks. This article provides additional support for the effectiveness of MDT for patients whose symptoms centralize. This article focused on patients with chronic low back pain, and showed a significant clinical and statistical effect for a variety of measures. While there are multiple articles that demonstrate positive effects of MDT for pain, disability and fear among patients who centralize, this article further describes the consistent functional improvements that were noted with treatment. These functional improvements were obtained without performing specific functional training, and nearly all changes were maintained at the 10-week mark. This indicates the potential for MDT to provide measureable changes in physical function in the absence of specific training.
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The efficacy of systematic active conservative treatment for patients with severe sciatica. A single-blinded randomized controlled trial.
Albert HB, Manniche C.
Spine. 2011.
Reviewed by Paul Nelson, PT, Cert. MDT (7-26-2011)
This study by Albert and Manniche was a prospective single-blind randomized controlled trial with the objective to evaluate the efficacy of active conservative treatment, and to compare two active conservative treatment programs for patients with severe sciatica. One hundred eighty-one patients who met the inclusion criteria were included and randomized to one of two treatment groups. There were no statistically significant differences between the two groups on any factors. Duration of sciatica varied, 16% had sciatica for less than a month, 61.3% for 1-3 months, 17.7% for 3-6 months, and 5% for 6-12 months. Inclusion criteria:
Patients were included if: 1) They were 18-65 years of age. 2) Had radicular pain of dermatomal distribution to the knee or below in one or both legs. 3) Leg pain was >3 on a 1-10 point scale at first visit to the clinic. 4) Duration of sciatica between two weeks and one year. Exclusion criteria:
Patients were excluded if: 1) They had Cauda Equina Syndrome. 2) Pending worker’s litigation. 3) Previous back surgery. 4) Spinal Tumors. 5) Pregnancy. 6) A language other than Danish. 7) An inability to follow the rehabilitation protocol due to concomitant disease such as depression or heart failure. Treatment programs: The patients were randomized to one of two treatment programs. Both treatment programs contained identical information and advice, but differed in the type of exercise program that was included. Information included thorough information regarding the anatomy of the spine, the pathogenesis of a herniated disc, and the natural healing process without surgery. Special emphasis was placed on activity with warning that increased leg pain with activity was a warning sign of overstepping current physical limitation. Medication: Only Paracetamol and NSAIDs were recommended. Treatment Groups:
Symptom-guided exercises: Consisted of back related exercises: Directional end-range exercises and postural instructions guided by the individual patient’s directional preference. Patients were instructed in stabilizing exercises for the transverse abdominis and multifidus muscles, and dynamic exercises for the outer layers of the abdominal wall and back extensors. Sham exercises: Consisted of optional exercises that were not back related, but were low dose exercises to stimulate and increase in systemic blood circulation. Treatment lasted for eight weeks with a minimum of four and a maximum of eight visits. Outcome:
Global Assessment: 89.2% of patients experienced a global improvement of better or much better by the end of treatment, and it was sustained at one year post-treatment at 91.1%. More patients in the symptom-guided exercises group experienced improvement than in the shame exercises (p<0.008)
Nerve root compression signs: 95% of patients had between two and four positive neurological signs, with a mean of 2.8 signs. The symptom guided exercise group demonstrated a greater improvement than the sham exercises at both time points. Conclusion: Active conservative treatment was effective for patients who had symptoms and clinical findings that would normally qualify them for surgery. Although participating patients had greater faith in the sham exercises before treatment, the symptom-guided exercises were superior for most outcomes. Comments: This study continues to demonstrate that symptom-guided exercises, and awareness of posture and peripheralization produce good outcomes. Graded movement and return to function were emphasized to patients in this study. It should be noted, however, that a formal mechanical assessment was not undertaken and an exhaustive search for a directional preference or centralization was not commenced. Treatments in the symptom-guided group was a amalgamation of directional exercises, postural instruction, segmental stability with transverse abdominis/multifidus co-contraction, as well as general strengthening into flexion and extension. Hanne and Manniche make the point that the results of the study could be reproduced by “any physiotherapist with current knowledge of the treatment of low back pain and sciatica.” The algorithm that is used breaks the treatments into four groups, one designed for an acute patient (chemical pain), one to assess directional exercises, one to increase fitness and re-establish muscular strength, and one to regain function. A discussion is also undertaken on conservative treatment versus surgery. Hanne and Manniche reiterate that 95% of the patients had two or greater nerve root compression signs and it was “still possible to improve their pain and function with active conservative treatment.” Only 3% developed symptoms so severe that referral to a neurosurgeon became necessary. “At the end of treatment, 89% of patients, and at the one year follow-up, 91% of patients reported being better or much better - these numbers match or surpass the results reported by surgical interventions.” The discussion moves on to the premise that surgery provides faster relief from pain and return to work. Hanne and Manniche state, “ that argument is not supported by the results of the this study, as after eight weeks of treatment, 74% of the symptom-guided exercises group and 60% of the sham exercises group were back at work, and many had been working throughout the treatment period. In Denmark, surgical intervention cannot match this.” It would seem that this study helps to support active treatment protocols, and a positive outlook for patients with sciatica that receive appropriate active conservative treatment.
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Is it time to discard the term "diagnosis" when examining a person with uncomplicated axial neck pain?
Haldeman S
Spine J. 2011. Mar;11(3):177-179
Reviewed by Mitchell F. Miglis, DC, Cert. MDT (4-15-2011)
See post below: Magnetic resonance imaging of subjects with acute unilateral neck pain and restricted motion: a prospective case series
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Magnetic resonance imaging of subjects with acute unilateral neck pain and restricted motion: a prospective case series
Fryer G and Adams JH
Spine J. 2011. Mar;11(3):171-176
Reviewed by Mitchell F. Miglis, DC, Cert. MDT (4-15-2011)
These two articles are reviewed together because the second is a commentary, appearing in the same journal, which places the first in appropriate context. It raises valid questions regarding the quest for diagnostic certainty for most, if not all, mechanical pain syndromes of the spine and extremities. In the first article on MRI imaging and acute neck pain, Fryer and Adams examine the hypothesis that inflammation in or around the facet joints may be the source of acute unilateral axial neck pain. Five subjects, three women and two men between the ages of 18 and 50 who were otherwise healthy, were selected on the basis of acute onset (less than 48 hours) of unilateral, non-traumatic neck pain. The authors refer to this presentation as 'crick in the neck' or acute torticollis. Subjects were scanned with a 0.35 Tesla MRI unit. There were no MRI findings showing clear evidence of synovial effusion or inflammation around the facet joints of the cervical spine. In addition, "Signs of muscle edema, altered alignment, disc and facet arthrosis, and spinal stenosis were noted, but these did not appear to be related to the symptomatic segmental level or side of pain". The authors concluded that: "The current case series failed to find any indication of inflammation in the deep spinal structures using MRI". They were also examined by palpation, with findings that "the side of focal tenderness was the same as the symptomatic side in all cases, and the segmental level identified as tender corresponded to the symptomatic region...in all subjects but one, who was unable to identify a localized region of most intense pain". Fryer and Adams conclude that inflammation was either not present or that it was too subtle to image with their relatively low field strength magnet. Thus, they argue, their study cannot rule out inflammatory changes associated with acute neck pain. They found that: "Minor pathologies were detected in all subjects but were likely unrelated to the current presentation of pain or the findings on palpation". This is consistent with the broader literature on spine and extremity imaging in which abnormalities are commonly found but correlate poorly with symptoms. Degenerative changes seen in the current study were found on both sides, but the symptoms were unilateral. This study has several weaknesses: There were only five subjects and the MRI field strength was weak. However, as Haldeman points out in his commentary, it is unlikely that adding more subjects would result in a different outcome since this is not the only study which has failed to find a strong correlation between common diagnostic tests and axial neck pain: "Virtually every clinical study that has compared more than one test in a group of patients has resulted in either no correlation or a small statistical but clinically insignificant correlation. A few examples include the failure of diagnostic blocks to correlate with C2-C3 segment axial rotation or local tenderness and the failure of MRI to correlate with discography."
Haldeman notes that: "For the past 50 years or more, spine care clinicians have been preoccupied, almost to the point of obsession, in their search for the single 'diagnosis', 'pathology', 'cause' or 'generator' of uncomplicated axial neck pain. There is no easier method to generate heated controversial debate than question the credibility of a clinician's favorite method of diagnosing the structure or pathology he or she believes is the source of the patient's pain and, therefore, likely to be amenable to whatever treatment the clinician is offering." Haldeman lists nearly 30 diagnostic procedures used in the quest to identify the pathology of uncomplicated spine pain, concluding that: "it is now possible to spend a great deal of time and thousands of dollars in the search for the structural source or pathological cause of the patient's pain. The question that repeatedly comes up is whether any of this testing is informative to the clinician or of benefit to the patient". Haldeman describes four problems with current thinking about uncomplicated neck pain, and may apply as well to other spinal areas and to the extremities: - There is no agreed-upon gold standard for the diagnosis of neck pain. All the tests cited by Haldeman have high false positive rates and, without a gold standard, false negative rates are unknown.
- There is no widely practiced and standardized assessment process across clinicians of different specialties.
- There is no correlation between clinical findings and MRI findings for uncomplicated neck pain.
- Diagnostic labeling of the patient with uncomplicated neck pain has not been shown to have a positive impact on prognosis or outcome. On the contrary, there is some evidence that a specific diagnosis can negatively affect prognosis and, in most cases, treatments based on these diagnoses have only a modest impact on pain and disability.
Haldeman argues for further research on clinical prediction rules in place of diagnostic labeling. He realistically notes that it is a 'pipe dream' to hope that spine care clinicians will suddenly standardize their myriad approaches, but he presents a strong case for changing the emphasis of future research away from diagnostic labeling and toward a more functional approach. The principles of mechanical diagnosis and therapy (MDT) emphasize this functional approach while avoiding unhelpful or misleading diagnostic labeling for uncomplicated spinal and extremity pain. In addition, the proven reliability, validity and prognostic power of the MDT lumbar spinal assessment is evidence that a standardized approach already exists and merits further investigation, especially in relation to the cervical spine and extremities. In the latter case, evolving MDT clinician experience suggests that applying MDT principles to extra-spinal tissues may prove to have prognostic and therapeutic benefit as well, while at the same time avoiding the pitfalls of diagnostic labeling.
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Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review.
Kent P, Mjøsund HL, Petersen D
BMC Medicine. 2010. 8:22
Reviewed by Paul Nelson, PT, Cert. MDT (1-21-2011)
Objective:
This systematic review was undertaken in order to determine the efficacy of targeted versus non-targeted manual therapy and/ or exercise in adults with non-specific low back pain (NSLBP). Inclusion criteria:
Randomized controlled trials of targeted manual therapy and/or exercise for NSLBP that used trial designs capable of providing information on targeted treatment (treatment effect modification) for the outcomes of activity limitation and pain. Included trials were required to be hypothesis-testing studies published in English, Danish or Norwegian. Exclusion criteria:
Observational studies and uncontrolled studies; studies comparing non-targeted interventions; and studies comparing two targeted interventions. Participants:
Experiencing NSLBP and could not be pregnant. Participants could have low back and leg pain as long as 85% of the participants were over 18 years of age and had no symptoms or signs of neurocompression. Studies with participants with specific low back pain were excluded. Types of Intervention:
Mobilization, manipulation and traction were classified as ‘manual therapy’ unless they included therapeutic exercise and were then classified as ‘exercise’. The clinical prediction rule had to be clearly identified before the trial commenced. Outcome measures:
Self-reported pain and activity limitation. (Oswestry and Roland-Morris) Main results:
2,690 non-duplicate papers were identified, 42 papers were retrieved, four controlled trials met the inclusion criteria. The studies investigated three clinical prediction rules for targeting treatment: McKenzie directional preference-based exercise, the Delitto Treatment Based Classification method and the Flynn manipulation prediction rule. The McKenzie study showed statistically significant improvements in the short-term activity and short-term pain limitation due to matched treatment effect. The size of the effect ranged from 22.8% to 33.8%. The Delitto study showed matched treatment effects of 12.9% of baseline scores for short-term activity limitation and 8.5% for short term pain. Neither measure was statistically significant. The Flynn studies:
Childs et al. compared targeted spinal manipulation plus range-of-motion exercises with the control of treatment of guidelines-based exercises. The results showed a treatment modifier effect size of 21.1% of baseline scores for short-term activity limitation and 8.5% in intermediate-term activity limitation but neither was statistically significant. Hancock et al compared the results of spinal mobilization with the controlled treatment for detuned ultrasound. The result showed a treatment modifier effect size of 8.4% of baseline scores for short-term pain and 0.6% in intermediate-term pain. Conclusions:
The authors concluded that there is very cautious evidence supporting the notion that treatment targeted to subgroups of patients with NSLBP may improve patient outcomes but that target specific subgroups have yet to be adequately researched. Comments:
This article demonstrates that once again Mechanical Diagnosis and Therapy was the only group to show statistically significant changes vs. two other clinical prediction rule sub-grouping studies. With an exhaustive search for directional preference in the evaluation to assess whether or not mechanical therapy is appropriate for the patient, MDT allows the clinician to make confident decisions regarding how to treat patients, and which direction in which to take them. Although this is not news to MDT practitioners, it is another validation of what clinicians do day in and day out.
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A radiographic analysis of the influence of initial neck posture on cervical segmental movement at end-range extension in asymptomatic subjects.
Takasaki H, Hall T, Kaneko S, Ikemoto Y, Jull G
Man Ther. 2010. DOI:10.1016/j.math.2010.07.005 (E-Pub ahead of print)
Reviewed by Mitchell F. Miglis, DC, Cert. MDT (11-26-2010)
In this biomechanical study, the authors test the hypothesis that cervical spine extension from a fully retracted starting position results in greater lower cervical spine extension than does either retraction or extension alone. They also assess the degree of cervical spine extension during a fully protracted and then extended neck position. In MDT, cervical spine extension has been reported to be the predominant directional preference in the management of cervical spine derangement syndromes (Hefford 2008).
Furthermore, the method of achieving end-range extension in the lower cervical motion segments has been chin retraction followed by neck extension. It has been hypothesized that this sequence of neck movements produces the greatest lower cervical spine extension, in comparison to extension only or to simple chin protrusion (McKenzie and May 2006). The latter is believed to create relatively greater upper cervical spine extension. To test these hypotheses, the authors selected 20 asymptomatic young volunteers (10 male, 10 female; mean age 25.3 +/- 3.4 years). Subjects performed three test positions in random order: Extension, retraction plus extension and protrusion plus extension. They were instructed to leave their mouths open on all extension movements. The examiner applied gentle passive overpressure at maximal range. The authors took lateral radiographs comparing each of the three final positions to the neutral starting position. Bony landmarks were carefully defined and pre- and post-movement parameters measured and compared. Mean segmental extension at C6-7 increased 53.4% using retraction plus extension compared to extension only. The authors opined that this “cannot be ignored from a clinical perspective”. The overall data support the hypothesis that “neck extension from a neck retraction position induces greater extension in the lower segments while neck extension from a head protraction position induces greater movement in the upper-mid cervical region”. In summary, the current study demonstrated that initial neck position has a differential effect on the pattern of upper and lower cervical spine extension movement in healthy, young, asymptomatic volunteers. These findings “support the rationale for retraction followed by extension when exercise aims to influence the lower cervical segments as employed in the MDT concept”. Further studies are required, however, to test the generalizability of these findings to different age groups and to symptomatic subjects. References
Hefford, C McKenzie classification of mechanical spinal pain: profile of syndromes and directions of preference. Manual Therapy 2008;13(1):75-81. McKenzie, R and May, S. The cervical and thoracic spine: Mechanical diagnosis and therapy, vol. 1, Raumati Beach: Spinal Publications New Zealand, Ltd; 2006. pp. 58-60, 235-6.
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Treatment-based subgroups of low back pain: a guide to appraisal of research studies and a summary of current evidence.
Kamper SJ, Maher CG, Hancock MJ, Koes BW, Croft PE, Hay E
Best Pract Res Clin Rheum. 2010. 24.181-191.
Reviewed by Charles Sheets, PT, OCS, Dip MDT (8-14-2010)
When looked at as a whole, the majority of studies on treatment for low back pain result in findings of little or no difference with a variety of interventions. A possible cause for this is that studies often include subjects with very different characteristics. A response to this problem has been efforts to include sub-classification of patients. The aim of these sub-classification schemes is to identify subgroups of patients who will respond to one treatment as opposed to another. This article provides guidance on to how to interpret research on subgrouping.
The authors propose the process of evaluating treatment-based subgroups should be a three-stage process: (1) hypothesis generation–proposal of clinical features to define subgroups; (2) hypothesis testing–a randomised controlled trial (RCT) to test that subgroup membership modifies the effect of a treatment; and (3) replication–another RCT to confirm the results of stage 2 and ensure that findings hold beyond the specific original conditions. A key to identifying the effect of treatment on the subgroups is a design where patients are classified in one subgroup or another, receiving the treatment or the control. This is represented by the four cells of a 2x2 table, and was used in the Childs et al. trial, which reported that the effect of spinal manipulation was greater in those who were positive on a clinical prediction rule than in those who were negative. Another version of this approach compares the outcomes of patients who were randomised to receive treatment matched to their classification (subgroup) with patients who received treatment not matched to their classification. An example of this is the study of Long et al. where subjects with a directional preference were allocated to exercise in the matched direction, the opposite direction, or all directions; this is represented in a 3x3 table. Unfortunately, many researchers continue to use flawed designs to estimate if subgroups influence treatment effects. One mistake is to give all subjects the same treatment and to compare outcomes in those in the subgroup and those not. Without a control group, this design can determine the prognostic value of the subgroups, but cannot estimate the effect of treatment. Currently, there are a large number of hypothesis-generating studies in physical therapy, but very few hypothesis-testing, limiting the ability to determing the validity of most subgroups. There is preliminary evidence that patients exhibiting directional preference may make up a subgroup with a specific treatment effect, but this has not been fully supported. The authors note that best evidence from current research is likely the group effect from a large high-quality trial or systematic review. Childs JD et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004 Dec 21;141(12):920-8. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine (Phila Pa 1976). 2004 Dec 1;29(23):2593-602.
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Prevention and management of chronic back pain
Weiner SS and Nordin M
Best Practice and Research Clinical Rheumatology. 2010. Vol 24(2):267-279
Reviewed by Andrew Marsh PT, Cert. MDT
(7-13-2010)
Historical summary:
Low back pain is well known to be a significant problem both for the patient and for the cost on society. The research on nonspecific lower back pain has had some new larger randomized trials reach press, and show some efficacy at various stages. This article presents the latest data in an evidence based format, defining nonspecific LBP, natural history, evaluation of direct treatment and management, comorbidities, patient expectations, preferences and outcomes, treatment goals, reassessment and self care, passive treatment (massage and manipulations) exercise, cognitive behavioral therapy, multidisciplinary care and finally surgery. Each section is reviewed for current data for support or lacking support for each area of treatment. The main message is still to remain active; passive treatments are used in conjunction with active ones and there are no current indications for surgery for non-specific LBP. The clinical value of this paper to the MDT practitioner is the basic support for the system of active treatment and patient empowerment to self treat.
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Sciatica
Valat JP, Genevay S, Marty M, Rozenberg S and Koes B
Best Practice & Research Clinical Rheumatology . 2010. 24: 241-252
Reviewed by Mitchell F. Miglis, DC, Cert. MDT (6-30-2010)
This paper is a review of the pathophsyiology, clinical features and treatment options for sciatica. The authors describe sciatica as a symptom rather than a diagnosis and review the current literature. They note that both nerve root compression and inflammation are important for the production of radicular leg pain. They cite a series of observations which refute a purely mechanical hypothesis for sciatica, including: 1.Presence of disc herniations in asymptomatic subjects. 2.Pressure on a normal nerve root does not cause pain. 3.Pressure on adjacent nerve roots does not cause pain. 4.Severe symptoms may occur without evidence of nerve root compression. 5.Outcome might be favorable despite persistence of disc herniation and 6.Discectomy has only moderate long-term success. Regarding the diagnosis of sciatica, they note that if a patient reports the typical dermatomal or myotomal leg symptoms combined with a positive result on one or more neurological tests indicating nerve-root tension or neurological deficit, the diagnosis of sciatica appears justified. In addition, “Signs and symptoms that help to distinguish between sciatica and non-specific low-back pain are unilateral leg pain greater than low-back pain, pain radiating to foot or toes, numbness and paraesthesia in the same distribution, straight-leg-raising test induces more leg pain and localized neurology, which is limited to one nerve root.” The clinical course of acute sciatica appears favorable. Without surgery, 80% of patients recover within 8 weeks. There are no clear factors identified which predict a poor outcome. Non-surgical and surgical treatment options are reviewed. Currently available conservative treatments reviewed may, the authors note, decrease pain without modifying the long-term clinical course of sciatica. Based on four randomized controlled studies, surgery (discectomy) is effective in the short term but the results are similar to conservative outcomes at one year and beyond. The authors conclude that for patients with sciatica of more than 6-8 weeks duration and without major neurological deficit, “there seems to be a reasonable choice between surgical and prolonged non-surgical treatment. Preference for treatment may be influenced by the severity of the symptoms, patients’ willingness to wait for spontaneous healing, and their aversion to surgical risk”.
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Changes in Head and Neck Posture Using Office Chair With and Without Lumbar Roll Support
Horton S, Johnson G, and Skinner M
Spine. 2010. Vol. 35(12): 542-548
Reviewed by Review by Dave Scotton, PT, CertMDT (6-5-2010)
The purpose of this study was to investigate whether placement of a lumbar roll while seated on an office chair influences the position of head and neck posture, more so than other typical adjustments of the chair. The study used a custom made office chair. It allowed adjustments of both the backrest and seat pan tilt. Each of these has been shown to influence the angle of the lumbar lordosis. It has been widely discussed that the spinal curves are interrelated, and thus controlling the lumbar lordosis influences the head and neck posture. They looked at 30 healthy male participants, without any previous history of back or neck pain. Each participant had reflective markers placed on the midpoint of the tragus of the ear and on the spinous process of C7. The craniovertebral angle was then determined for each of the test positions: back rest at 90°, 100°, 110°, and seat pan tilt of 7°. Each position was tested with and without a standard McKenzie lumbar roll. The order of the test positions was randomized for each person. The seat height was adjusted to allow 90° hip and knee flexion with their feet resting on the floor. The results showed that there were significant changes in the resting head and neck postures (i.e. more retracted head and neck posture) when the backrest was reclined from 90° to 110°. Tilting the seat pan backward was essentially the same as positioning the backrest at 100°. The addition of the lumbar roll only produced significant changes when the chair was in the 110° angled position. It was interesting that the results with the lumbar roll had limited influence with the backrest in the more upright positions. It would be interesting to see a follow-up study using a population that has neck pain and seeing if using the lumbar roll has an effect on their pain.
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Variables associated with Active Spondylolysis.
Gregg C, Dean S, Schneiders A
Phys Ther in Sports. 2009. 10, 121-124.
Reviewed by Paul Nelson, PT, Cert. MDT (3-26-2010)
This study was a retrospective non-experimental study, designed to investigate variables associated with active spondylolysis. The authors studied 82 patient records to determine the association between symptomatic, physical and demographic characteristics, and the presence of active spondylolysis. Six exploratory variables were included:
1. Age (Greater or less than 20 years old)
2. Gender (Male or Female)
3. Injured period (Greater or less than three months)
4. Onset of symptoms (Sudden or Gradual)
5. Sports participation (Yes or No)
6. Single Leg Hyperextension Test result (Positive or Negative)
The Single Leg Hyperextension Test (SLHT) involves the patient standing on one leg and actively extending the lumbar spine. Specificity and sensitivity have been poor for this test. Of the 82 participants, 26 were found to have a positive Single Photon Emission Computerized Tomography(SPECT) scan indicating a positive spondylolysis. When the results from the univariate regression analysis were calculated, there was a statistically significant association between the scan and age (p=.001) and gender (p=.001). There was no significant association with any other variable. The variable with the least association was the SLHT (p=.47). Subsequently, a multivariate analysis was done for the age and gender variables. The multivariate analysis showed a significant association between the outcome of the SPECT scan, age and gender. The results indicate that age and gender has a significant association with the diagnosis of active spondylolysis. Males who are aged less than 20 years of age have over three and a half times the odds of having a positive bone scan for active spondylolysis. This study shows that a special test, in this case the SLHT, had no predictive value in assessing whether or not a patient had active spondylolysis. Special tests have long been held to be of immense value to physical therapists in diagnosing orthopedic problems, however, the reliability, sensitivity and specificity can be very suspect. For a therapist who relies on pain behavior through repeated movements or sustained postures versus reliance on special testing, a McKenzie trained therapist can establish if the patient has an active derangement, a dysfunction, or postural syndrome. If the patient fits into the “other” category and is a male below 20 years of age, there might be good reason to refer for further imaging.
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No effect of traction in patients with low back pain: A single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy.
Schimmel JJP, deKleuver M, Horsting PP, Spruit M, Jacobs WCH, van Limbeek J.
Eur Spine J. 2009. 18:1843-1850.
Reviewed by Renee Spinella, PT, DPT, Cert. MDT (2-17-2010)
Researchers investigated the affect of adding Intervertebral Differential Dynamics Therapy (IDD) to a standard graded activity program in patients with chronic (greater than three months) low back pain (LBP.) Previous studies of IDD Therapy incorporated small sample sizes and tested IDD as a single treatment. Fifty-six participants who met the inclusion criteria were included and randomly divided into two groups. One group followed a standard protocol that begins with using one-half of a person’s body weight minus 10 pounds, then gradually increased by 5 pounds until the subject was receiving half of their body weight plus 10 pounds. A second SHAM group received treatment that equated to less than 10% of their body weight. Both groups received intermittent traction with a 60 second distraction and 30 seconds of partial relaxation. Each session lasted 25-30 minutes for a total of 17 repetitions. Subjects received five sessions per week for the first two weeks, then three sessions per week for two weeks, and finally two sessions per week for an additional two weeks for a total of 20 sessions in 6 weeks. Two weeks after the participants began traction, a graded activity program was initiated. The exercise program lasted one hour per session, two sessions per week. Subjects did not receive traction on the same day as the exercise program. Both groups reported significant improvements in their pain rating, on the Oswestry Disability Index and Short-Form 36 scores. Also, both groups reported a reduction in their pain medication use and satisfaction with their results; no differences were found between the groups in any measure. This indicates that statistical analysis shows the two groups are comparable with post hoc analysis used to test the validity of their assumptions. This is the first study ever performed that investigated IDD Therapy, which was performed as a randomized controlled trial that was also single blind and single centre. Other strengths include treatment consistency of the patients over the entire course of treatment. In addition, patients were blind with regard to their treatment group. Finally, researchers used well-established instruments to measure outcomes. As a result of this study, researchers concluded that traction appears safe for use with patients with chronic LBP. Despite this, traction did not offer additional benefits and, therefore, it is suggested that traction should not be used as a treatment option for chronic LBP. These results were in contrast with other studies; however, these studies were deemed methodologically flawed for several reasons. This study was limited because the treating therapist could not be blinded to the treatment since they had to administer the proper traction settings. There was also a drop-out rate of 7%, though this was spaced equally between the groups. Finally, these researchers varied the recommendations from the manufacturer for the prescribed traction. Despite this, the study was well-designed and rigorously conducted and therefore their conclusions are credible. There are currently a number of devices in the marketplace offering variations of computerized lumbar traction. Most come with poorly substantiated, but great claims of success with the cost to the consumer of this treatment being very high. This good quality randomized controlled trial should help consumers and clinicians to understand that this financial outlay is not likely to achieve a more favourable outcome than a sham intervention. Hopefully, this will lead to greater awareness by the public that solutions to their back pain may not lie in the use of sophisticated and expensive medical devices.
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Dynamic Bulging of Intervertebral Discs in the Degenerative Lumbar Spine
Zou J, Yang H, Miyazaki M, Mosishita Y, Wei F, McGovern S, Wang J
Spine. 2009. 34(23):2545-2550
Reviewed by Charles Sheets, PT, OCS, Dip.MDT (1-8-2010)
This article describes the bulging patterns of degenerative intervertebral lumbar discs under different postural loads. The authors note that symptomatic lumbar disc degeneration is a leading cause of pain and disability, and add that chronic low back pain has been linked to the degenerative lumbar spine. The authors sought to determine the effects disc degeneration had on the biomechanical and kinematic behaviors of the spine. The operational definition of disc bulging in this study was “the extension of the disc beyond the intervertebral space”. The authors utilized an upright MRI to observe a total five levels (L1- L2, L2-L3, L3-L4, L4-L5 and L5-S1) in three positions (upright axial neutral position, upright axially loaded flexion and extension). The authors developed a grading system consisting of five grades (i.e. Grade I – minimal degeneration, Grade II – mild degeneration, Grade V – severe degeneration) to classify the degree of intervertebral disc degeneration. The authors correlated the magnitude of disc bulging at each level in the lumbar spine with disc degeneration and dynamic postural loading. They found that disc bulging increased in magnitude with increasing degeneration at each level in the lumbar spine, with Grade I discs demonstrating the expected sagittal migration in response to postural load. However, more degenerative discs behave less predictably, and spine extension may result in significant posterior disc bulging. Moderately degenerated intervertebral discs demonstrated greater bulging than mildly degenerated discs. Severely degenerated discs showed a trend toward greater bulging, but this was not significant. Grade I discs at all levels moved posteriorly in flexion and anteriorly in extension when compared to neutral posture. However, mild to severe degenerative discs behaved differently in response to postural loads. Extension resulted in significant posterior bulging, while flexion did not demonstrate obvious anterior derangement. For the MDT clinician, this correlates with the frequent finding that extension in standing in itself is rarely a reductive procedure and often can only be introduced once reduction has been initiated in lying. The authors made an interesting statistical choice in this study, as they used a t-test to analyze multiple comparisons. The statistical analysis using a variation of ANOVA would have been a more appropriate choice in this study, to decrease the likelihood of finding a difference where one does not truly exist. Overall, this study supports previous findings that indicate consistent findings of nuclear migration in patients with normal discs, while the nuclear movements are less consistent in degenerated discs.
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The prognostic value of symptom responses in the conservative management of spinal pain. A systematic review.
Chorti AG, Chortis AG, Strimpakos N, McCarthy CJ, Lamb SE
Spine. 2009. 34:2686-2699
Reviewed by Charles Sheets, PT, OCS, Dip.MDT (1-8-2010)
This article reviews the prognostic value of clinically induced changes in spinal symptoms with the conservative management of spinal pain. The authors note the purported value of assessing clinically induced changes in the patient’s condition via patient response, and the ability of these findings to assist in the assessment and subsequent treatment used to guide prognostic and management decision. The authors identified primary research from prospective longitudinal studies of spinal pain in adults presenting with a current episode of spinal pain with and without radiating symptoms. The search engines used consisted of Ovid-MEDLINE, Ovid –EMBASE, Ovid-CINHAL and Ovid-AMED; after application of exclusion criteria, the authors chose 22 articles for inclusion in this systematic review. The review found no association between most symptom responses and clinical outcomes. The only aspect of symptom response that was found to inform patient management was changes in pain location and/or intensity with repeated spinal movement testing or as a response to treatment. There was limited evidence found for the prone instability test in low back pain patients attending a stabilization program, and conflicting evidence for neurodynamic testing. The authors’ conclusion suggests that additional investigation of symptom response in spinal pain, specifically with regard to symptom changes in location and intensity is needed before symptom response can be used to inform prognosis and management. This review, while far from definitive, gives further support to the tenets of the McKenzie method as a way to determine prognostic factors and the effect of intervention involved in patient outcome. Among the multiple aspects of patient response assessed in this paper, change in pain location and/or intensity with repeated spinal movements, consistent with MDT, were the only findings to have a strong relationship with prognosis. Whether this is due to the strength of the centralization phenomenon or the strength of the research performed on this phenomenon remains to be seen.
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A Qualitative Investigation of Red Flags for Serious Spinal Pathology.
Greenhalgh S and Selfe J
Physiotherapy. 2009. 95:3, Pgs 149-236
Reviewed by Mitchell F. Miglis, DC, Cert. MDT
(11-2-2009)
“Red flags” are prognostic variables for serious pathology such as tumor, infection, fracture or cauda equina syndrome. While it has been estimated that only about 1% of low back pain cases result from serious pathology, the consequences of missing such a case can be devastating. The major international guidelines on managing low back pain have all recommended screening for red flags. Yet, with few exceptions, the prognostic strength of individual red flags or combinations of red flags is unknown. In addition, there are a profusion of red flags cited. One recently published clinical guideline for physiotherapy listed 119 items in the subjective history and 44 items in the objective history as red flag items (1). Fortunately, only 11 of red flags appear consistently in the literature, according to the current authors. These are: Unexplained weight loss, previous history of cancer, night pain, over 50 years of age, violent trauma, fever, saddle anesthesia, difficulty with micturition, intravenous drug abuse, progressive neurology and systemic steroids. This paper identifies three additional red flags which are not contained in the existing international guidelines. It does so in an interesting way: by interviewing “experienced palliative care clinicians” who work with patients for whom a diagnosis of serious pathology already exists. Seven senior hospice workers in the northwest of England participated in a qualitative interview process which resulted in the identification of the following three items being most strongly associated with serious spinal pathology: 1. Band-like trunk pain (commonly bilateral)
2. Vague non-specific lower limb symptoms (such as heaviness or legs ‘not doing what I want them to do’) and
3. Decreased mobility (with mild foot drop or leg drag). The value of this study to the MDT therapist is that it informs clinical reasoning in cases of suspected red flag pathology by identifying three red flags not previously included in standard guidelines but well-known to specialists in hospice care. When an MDT history and/or assessment is atypical or the subsequent response to therapy becomes atypical, the above red flags may raise the index of suspicion for sinister pathology. The authors conclude: “front-line musculoskeletal clinicians may find it useful to consider these items within the subjective history at an early stage in the patient’s journey”. (1) Chartered Society of Physiotherapy. Clinical guidelines for the effectie physiotherapy management of persistent low back pain. London: CSP:20007.
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The dynamic disc model: a systematic review of the literature.
Kolber MJ, Hanney WJ
Phys Ther Rev. 2009. 14.181-295
Reviewed by Mitchell F. Miglis, DC, Cert. MDT
(10-30-2009)
The intervertbral disc has been implicated as a common source of low back pain. In the McKenzie method, positional changes of the disc nucleus in response to applied loads has been hypothesized as one possible explanation for favorable clinical responses. This hypothesis has been called the dynamic disc model. In this paper, the authors perform a systematic review of available research relating to the dynamic disc model in human discs. A total of 12 articles were obtained which described the response of the nucleus pulposus in response to movements and/or positions. No studies were identified which examined cervical spine discs or thoracic spine discs above the level of T10. Nine of the 11 studies examined sagittal movements and identified posterior migration of the nucleus in response to lumbar flexion and anterior migration in response to lumbar extension. One study looked at rotation and found nucleus migration away from the direction of rotation. Four of the studies identified an unpredictable pattern of nucleus migration when degeneration was present within the disc. The authors conclude that the majority of reviewed studies identify a predictable pattern of nucleus pulposus migration in response to loading and positioning. When loaded in the sagittal and frontal plane, the nucleus migrates away from the direction of loading. One study of scoliotic spines noted nuclear movement away from the convexity (away from the side of compression). An important exception is noted for degenerative discs, where patterns were not consistent. Thus, this systematic review supports the hypothesis that in un-degenerated discs, there is a predictable pattern of nuclear migration (anterior for extension, posterior for flexion) consistent with the dynamic disc model. The authors conclude that “Based on the available research it appears that the annulus must be intact and the hydrostatic mechanism must be functioning for this model to act in a predictable pattern”. These findings may not, at this time, be generalized to the discs of the cervical or thoracic spine. Finally, the authors remind both clinicians and researchers that patient responses such as centralization and peripheralization as advocated by McKenzie and others should dictate the selection of interventions. For MDT therapists, this recommendation is integral to the approach. One take home message from this systematic review and other, more recent research papers, concerns the unpredictable response of the degenerated disc to loads. This underlying biomechanical exception serves to remind MDT therapists to keep an open mind during the assessment process, to accept paradoxical or contradictory findings at face value and to allow each patient’s unique response to loading strategies to unfold without being hindered by examiner bias.
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Prevalence of and Screening for Serious Spinal Pathology in Patients Presenting to Primary Care Settings With Acute Low Back Pain
Henschke N, Maher CG et al
Arthritis and Rheumatism. 2009. Vol. 60, No.10, pp. 3072-3080
Reviewed by Mitchell F. Miglis, DC, Cert. MDT
(10-30-2009)
The purpose of this study was to determine the prevalence of serious spinal pathology in acute low back pain patients presenting to a primary care setting and to evaluate the diagnostic accuracy of recommended “red flag” screening questions. While a number of clinical guidelines have recommended these red flag questions, many of the questions have not been externally validated in a primary care setting. In addition, their diagnostic accuracy has not been established because they arise from studies of poor methodological quality. In this study, 170 primary care clinicians in Sydney, Australia (73 general medical practitioners, 77 physiotherapists and 20 chiropractors) screened a total of 1,172 patients with an initial episode of acute low back pain. Patients were asked 25 red flag questions derived from four guidelines and discussion with experts in the field. The reference standard consisted of close followup for 12 months. All patients with subsequent serious pathology were examined by one of two study rheumatologists. Clinicians were able to identify about half of the cases of serious pathology at the initial consultation. The most common serious pathology was vertebral fracture. The estimate for the prevalence of previously undiagnosed serious pathology in patients presenting to primary care providers for an initial episode of acute low back pain was 0.9%. The authors note that in Australia patients must see a primary care clinician before referral to a specialist. In contrast, in countries where patients have direct access to specialists (as in many parts of the U.S.), the prevalence would be even lower due to specialist self-referral. Because the prevalence of relevant pathology was too low for many of the red flag questions, the diagnostic accuracy of these questions could not be determined for the sample size. Nevertheless, some red flag questions were positive for a large proportion of participants, most of whom did not have serious pathology. This high false positive rate leads the authors to recommend caution in interpreting single positive red flag findings and to recommend further studies to identify, instead, clusters of red flag questions with better predictive power. For the most common red flag finding (vertebral fracture) the following cluster was informative: prolonged use of corticosteroids, age >70 and significant trauma.
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Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.
Cook JL and Purdam CR
Br J Sports Med. 2008. 2009;43;409-416
Reviewed by Andrew Marsh, PT, Cert. MDT (9-28-2009)
Tendinopathy is a common diagnosis, with many variable ways to present in the clinic. Some acute, chronic, sub acute, and with all age ranges. Mechanism of injury is also varied from impact to overuse, with typical pathology sharing common characteristics. This paper presents a new continuum for tendinopathy, which includes the common thread of pathology through the various stages of repair. With treatment being tailored to the pathology and how it responds loading forces. The tendon healing phase needs to be better understood to allow more efficient treatment as well. This model is based on basic physiology of tendon repair and the healing process as well as clinical sciences combined to give the practitioner a solid thought process for treatment. Physical layout of the paper also makes for easy presentation. The clinical value of this paper to the MDT practitioner is the ability to produce a treatment thought process related to tendinopathy, which is logical and similar to the overall paradigm for our force progressions. Good evidence based support for the decision making process, even though that process is in the early stages of production.
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Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain AND Orthopedists’ and Family Practitioners’ Knowledge of Simple Low Back Pain Management
Buchbinder R, Staples M, Jolly D and Finestone A, Raveh A, Mirosky Y, Lahad A, Milgrom C
Spine. 2009. Vol. 34, Number 11, pp 1218-1226 and Vol. 34, Number 15, pp 1600-1603.
Reviewed by Mitchell F. Miglis, DC, Cert. MDT
(8-5-2009)
Guidelines for the management of low back pain are designed to help health care professionals effectively manage low back pain by promoting good standards of medical care and avoiding substandard practices. By basing guidelines on evidence rather than consensus or anecdote, such guidelines are designed to improve outcomes, reduce risks and lower costs. Since the first such low back pain guidelines were published (Québec Task Force, 1987), many other groups have published similar guidelines with multiple updates. Most major industrialized nations currently have such guidelines, including the US, Australia, New Zealand, Israel and most European countries. The two papers above indicate that adherence to these guidelines may be poor among both generalist and specialist physicians. In the first paper (Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain), researchers in Australia sent questionnaires to general practitioners about the management of low back pain, asking for their agreement or disagreement with a series of guideline recommendations. 3,831 questionnaires were returned. Surprisingly, physicians who declared a special interest in low back pain were more, rather than less, likely to deviate from published guidelines. They believed, for example, that patients with acute low back pain should be prescribed complete bed rest until the pain goes away (17.8% vs. 9.2%; RR: 1.89 [95% CI: 1.53-2.33] and that patients with low back pain should not return to work until they are almost pain free (24.5% vs. 15.8%; RR: 1.55 [95% CI: 1.31-1.83]. In addition, they believed that lumbar spine radiographs are useful in the work up of acute low back pain (RR: 1.36 [95% CI: 1.21-1.52]. The authors conclude that “A self-reported special interest in LBP among general practitioners…was associated with back pain management beliefs that are contrary to best available evidence” and that this “may not be in the patient’s best interests.” The authors speculate about the possible causes of this paradoxical finding but, in the end, call for further research to determine whether these beliefs are amenable to change and, if so, how. In the second paper (Orthopedists’ and Family Practitioners’ Knowledge of Simple Low Back Pain Management), a questionnaire about the treatment of uncomplicated low back pain was given to orthopedists and general practitioners attending national meetings. 255 orthopedists and 140 family practitioners responded. A sample of the results includes the following: 53% of orthopedists vs. 8% of family physicians recommended a class of drugs different from the guideline recommendations; 67% of orthopedists and 46% of family physicians incorrectly recommended some form of bed rest and 53% of orthopedists and 8% of family physicians failed to respond that no imaging was necessary. The authors conclude that “Physicians are not well aware of current recommendations for LBP management” and “Orthopedists are significantly less knowledgeable than family practitioners.” The authors again speculate as to the underlying causes of this disparity between published evidence and actual clinical practice. They suggest publication of specific guidelines for orthopedists and “possibly spine surgeons” to improve adherence of these groups to the guidelines. Together, these two papers, published in a top-level international spine journal are a wake up call indicating possible widespread failure to incorporate evidence-based back care into clinical practice among both generalist and specialist physicians. The causes of this inconsistency are likely multi-factorial, and neither of the above papers presents a consistent or compelling explanation for this failure. Further research is needed to determine the underlying factors which may be targeted to correct this problem. Given the widespread prevalence of low back pain, related disability and its costs, this disjoint between evidence and practice in the management of low back pain should be a priority for health care researchers and reformers.
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An adherent nerve root-Classification and exercise therapy in a patient diagnosed with lumbar disc prolapse.
Melbye M
Man Ther. 2009.
Reviewed by Mitchell Miglis, DC, Cert. MDT
(6-26-2009)
In the absence of red flag signs or symptoms, the McKenzie Method (Mechanical Diagnosis and Therapy or MDT) classifies mechanical spine pain syndromes into three major named subgroups plus an ‘other’ group for conditions not meeting the major named subgroup criteria. The three major subgroups are: derangement syndrome, dysfunction syndrome and posture syndrome. The above report presents a case of dysfunction syndrome known as adherent nerve root. Dysfunction syndrome is a soft tissue structural impairment characterized by intermittent pain when loading restricted tissues at end-range. Adherent nerve root (ANR) is a type of dysfunction syndrome. ANR is believed to result from nerve root or dural adhesions following spinal surgery or recent sciatica. Constant sciatica becomes intermittent as adherence develops (1). In patients classified by MDT, spinal dysfunction syndrome has a reported prevalence of 3-6% of cases, with ANR considered to be relatively rare within this group (current study). The criteria for ANR classification are:
1. History of sciatica or surgery in the last few months that has improved but is now unchanging.
2. symptoms are intermittent in the leg.
3. symptoms in the thigh and/or calf, including ‘tightness’, and
4. consistent activities produce symptoms-typically touching toes, long sitting, walking, but
5. pain in the leg does not persist on ceasing movement or changing position. (1) It is believed that sciatica persisting beyond 12 weeks which has become intermittent may result from either a recurring derangement or ANR. (1) The current paper presents the case of a 31 year old male who meets the above ANR criteria. Onset had followed home repairs. At initial presentation, this patient’s intermittent low back and left leg pain symptoms had not changed over the previous 12 months. He had stopped bending his spine and walked with a limp. He had a major loss of forward bending, a positive left SLR, decreased left S1 dermatomal light touch sensation and absent left Achilles reflex. MRI had shown a disc prolapse with first sacral nerve root compression on the left. He had failed to respond to eight weeks of physical therapy consisting of massage and general exercises. An MDT assessment suggested two provisional hypotheses: Derangement syndrome or ANR. Further MDT testing indicated a likely ANR. The patient was given appropriate education and instructions for specific exercises to remodel the dysfunctional tissue. After 6 visits over a 5 month interval, significant subjective and objective improvements were noted: Forward bending and walking returned to normal (fingers to floor), SLR was significantly improved, sensation had returned to normal in the left leg and there were no reported symptoms other than tightness in the hamstring. The Achilles reflex remained absent. While the author notes that a causal relationship between treatment and improvement cannot be established with this type of study and other explanations for improvement (spontaneous disc prolapse resorption) are possible, the relatively rapid reversal of a longstanding clinical syndrome (18 months) following a few (6) targeted treatments is suggestive of a positive relationship between treatment and outcome. Ideally, long-term follow up (6mo., 1 year) could have been followed. The author notes that since ANR is a rare condition, randomized controlled trials (RCTs) are difficult to conduct and he calls for additional studies, perhaps to include individual case studies, case series or an RCT with N-of-1. Additionally, the validity of ANR has not been compared to any reference standard. It is, nonetheless, a well-defined syndrome sub-category. A PubMed search using the following search words: “adherent”, “nerve”, “root” and “adhesions” yielded the above paper but no other relevant research. Additional studies are needed of ANR in the lumbar spine as well as in the cervical spine. Reference
McKenzie, R and May, S, The Lumbar Spine: Mechanical Diagnosis and Therapy, 2003.
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Course and Prognostic Factors for Neck Pain in the General Population: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders
Carroll LJ, Hogg-Johnson S, van der Velde G, Haldeman S, Holm W, Carragee EJ, Hurwitz E, Côté P, Nordin M, Peloso P, Guzman J, Cassidy JD
J Manipulative Physiol Ther. 2009. Vol 32 (2):S87-S96
Reviewed by Lynda McClatchie, PT, Cert. MDT (6-18-2009)
Neck pain in the general population is frequently persistent or recurrent. Whether neck pain is able to improve, persist, reoccur or worsen over time (the course of neck pain) is important to determine, as clinicians need to know if a particular intervention improves or worsens the usual course of recovery from the pain. As well, determining the prognostic factors of neck pain may help determine effective lifestyle changes in those suffering from neck pain. Studies, which attempt to establish prognostic factors in those with neck pain, must involve subjects who have pain at the start of the study, and these people are tracked over time to identify any characteristics distinguishing those who recover from neck pain from those who do not. This article examined relevant studies looking at both prognostic factors and the course of neck pain in the general population. The “course” of neck pain differs from the natural history, in that natural history assumes that there is no intervention, and the presence or absence of intervention is often not mentioned in the included studies. Nine studies were found which examined the course and prognostic factors for neck pain in the general population. Six of these studies examined the course of neck pain, and results showed that between 50-75% of people who experience neck pain at some point will report neck pain 1-5 years later. One study showed that almost 25% of subjects who recovered to no neck pain had a recurrence of pain by follow-up. Five cohort studies and two randomized controlled trials outlined prognostic factors for neck pain in the general population. The evidence suggested that most factors which predict poor outcome in those with neck pain are consistent with the factors that increase the risk for new neck pain in a person who previously had not had any neck pain. Half of the studies showed gender had no effect on the recovery of new onset neck pain, while half of the studies showed women had a poorer recovery than men. It was concluded that gender was a weak predictor of recovery from neck pain in this population. Age was a consistent predictor of recovery, with younger subjects having a better prognosis in all studies. One reviewed study divided subjects into younger, middle and older age groups and those in the middle group (ages 45-59 years) were almost four times more likely to have chronic, recurrent or continuous neck pain compared with those in the younger or older age groups. Other factors including prior neck pain episodes and poor overall health predicted greater presence or intensity of neck pain at follow-up. Better psychological health and greater social support predicted better outcome in those with neck pain. Worrying, becoming angry or frustrated with neck pain were all associated with poorer prognosis, while optimism and coping strategies were associated with better prognosis. The McKenzie System of Mechanical Diagnosis and Therapy provides a framework from which to determine the presence of a cervical derangement or dysfunction, and from that point, a clearer path to recovery can be seen. The patient’s response to repeated movements can quickly provide the McKenzie clinician with a strategy on how to progress, and the patient is often able to immediately see that symptom relief is possible. Education to the patient and management strategies are essential in helping with the current episode of pain, but can also provide strategies for any future warning signs the person might experience. It is clear through the above research that many people will have recurrent episodes of neck pain, so the McKenzie System is important in enabling the patient on how to immediately help themselves when and if symptoms first recur.
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Video analysis of sagittal spinal posture in healthy young and older adults.
Kuo YL, Tully E, Galea MP
J Manipulative Physiol Ther. 2009. Vol 32(3):210-215
Reviewed by Renee Spinella, PT, DPT, Cert. MDT (6-17-2009)
Researchers used a computer video system with new, lightweight adhesive skin markers to analyze and compare the posture of 24 healthy younger (17-27 years) and 22 healthy older (60-83 years) adults. Previous studies have focused on standing posture; but not on sitting posture. Nine skin markers were placed at various points over the face, torso and pelvis of the participants. In the sitting position, their spines were unsupported with hands resting on knees. In standing, participants were asked to sustain eye contact with a target on the wall and hands resting on an object at approximately waist level. In each position, they were asked to hold still for five seconds while the right, sagittal plane view was video recorded. Researchers found several statistically significant results when comparing healthy younger versus older individuals in both the seated and standing position. First, older adults presented with increased upper cervical extension and lower cervical flexion, increased thoracic kyphosis and reduced lumbar flexion in the sitting position, as compared with the young. In standing, older adults presented with increased upper cervical extension and lower cervical flexion; the differences between thoracic kyphoses were not statistically significant. Despite a wide range in p values with these statistically significant results, researchers did not do additional testing for effect size and therefore, it is unclear how significant the differences are between the p values. Researchers also noted a correlation between spinal angles during sitting and standing postures. The results of this study support the “bottom up” theory where the body adjusts as needed to maintain erect posture over the pelvis. Despite this, the researchers found a break in the chain between the thoracic and cervical spine. They proposed a “top-down” adjustment in the chain to allow the cervical spine to break from movement patterns for sensory intake. Clinically, these researchers propose that due to the significant differences in sitting postures in the young versus the older individuals, it may not be advisable to give older adults lumbar supports for prevention or as a treatment option for low back pain. Further research is needed on young and older adults suffering from low back pain to see what postural changes occur as a result of their current ailment. This was the first study to utilize the new adhesive skin markers as opposed to exposing subjects to radiation. Results suggest their method provides a cost-effective, safer option for assessing posture in the clinic. Future researchers may also choose to use this method for analyzing movement patterns, which would be a limiting factor for radiographic methods. One potential limitation of this study is the position in which subjects were studied. In standing, individuals were asked to sustain eye contact with a target and rest their hands on an object. Both of these requests could potentially alter a normal stance or encourage a more upright posture as opposed to allowing subjects to look straight ahead and rest their arms at their side as they would under normal circumstances.
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A long way to go: practice patterns and evidence in chronic low back pain.
Carey TS, Freburger JK, Holmes GM, Castel L, Darter J, Agans R, Kalsbeek W, Jackman A
Spine. 2009. 2009;34(7):718-724
Reviewed by Julia Chevan, PT, PhD, MPH, OCS, Cert. MDT (6-8-2009)
Study Purpose: Recently, this research group from the Sheps Center at the University of North Carolina published an article documenting the increasing prevalence of chronic low back pain over the past 15 years. Using the same dataset and participants, this article delves further into health services issues in chronic low back pain (LBP) by describing the use of providers, medications, interventions and diagnostic tests. The authors take utilization one step further by examining how well the patterns of care and use relate to evidence and guidelines published by the American College of Physicians and American Pain Society and those available in active Cochrane reviews. Methods: Participants were part of a population based telephone survey conducted in North Carolina. From the 5357 households contacted, 732 adults 21 years and older with chronic LBP were identified with 706 of these persons completing the survey. These respondents were asked about their health care use, treatments and tests conducted during the previous year. Results: Among persons with chronic LBP, 84% had at least one visit to a provider in the previous year. Medication use was common among both those who saw a provider and those who did not with both groups showing a high use of over the counter pain relievers and NSAIDs (range for percent of use of OTC medications was 42%-68%). Prescription medications were also quite commonly used, especially in the group that had seen a provider. The providers from whom care was sought in the order of most frequent use were primary care providers, orthopedists, physical therapists and chiropractors. Forth-six percent of these patients had spine radiographs. Use of physical interventions ranging from traction and TENS to exercise was also common. Many of the medications, diagnostic tests and interventions used for chronic LBP were not well supported by current guidelines and evidence. Conclusions: The authors identified tests treatments that appear to be over utilized (advanced imaging studies, use of narcotics, use of muscle relaxants, traction and braces) and others that are underutilized and well supported by the evidence (treatment of depression, use of exercise). Comments: This study is a call to care providers to give more attention to published guidelines and evidence reviews as they relate to chronic low back pain. It provides substantiation of problems in the current approach to service delivery. For the McKenzie provider it reinforces a movement and mechanical basis to examination and intervention over a modalities, imaging and pharmacologic approach.
Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WD, Carey TS. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251-258.
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Physical activity and low back pain: A U-shaped relation?
Heneweer H, Vanhees L, Picavet HSJ
Pain. 2009. Vol 143(1):21-25 (May 2009)
Reviewed by Charles Sheets, Pt, OCS, Dip. MDT (6-1-2009)
Design: This study examined the association between physical activity and chronic low back pain (¡Ý3 months duration) by analyzing cross-sectional data from the Dutch population-based study of a sex¨Cage stratified sample of 25 years and older (n = 3364). This was done using a postal questionnaire, and items included the type of activity (daily routine, leisure time and sport activity), intensity of and time spent on these activities, and back exertion of sport activities. The following categories were used: sedentary, active according to recommended levels, level of activity with daily routine activities and leisure time activities, sport participation and intensity, type of back exertion in sports, and total physical activity pattern. The 12-month period prevalence of LBP was evaluated by questioning ¡®did you have low back pain during the last 12 months¡¯? The point prevalence of LBP was based on that with a current episode of pain. Current pain lasting longer than 3 months was defined as chronic low back pain (CLBP). Results: Point prevalence of LBP was 26.9%, while 21.3% of the respondents (n = 758) reported LBP complaints with a duration longer than 3 months. Being sedentary was found among 10.9% of the respondents, while activity according to the Dutch health recommendations was met by 62.6% of the respondents. Being sedentary and not being active according to the Dutch guidelines was associated with an increased prevalence of chronic low back pain (CLBP) complaints (OR¡¯s 1.41 and 1.23, respectively). Daily routine activity and leisure time activity were not associated with CLBP, neither according to intensity nor to duration. Engaging in sport activities, particularly on the level of 1¨C2.5 h/week, was associated with less CLBP complaints (OR 0.72:95% CI 0.58¨C0.90), but the intensity of sport did not matter. Benefits from sports specially counted for females (OR 0.68: 95% CI 0.54¨C0.85), whereas being sedentary yielded an OR of 1.80 (95% CI 1.32¨C2.46). When respondents were classified according to their total physical activity pattern, both extremes of low and high physical activity levels were associated with an increased risk for CLBP. Discussion: It is commonly assumed that high levels of activity (heavy or repetitive work, high-load sports activities) can lead to low back pain. While in agreement, this study also indicates that people who are inactive have nearly as high a risk of low back pain, while moderate activity has a protective effect. This study adds to most guidelines in recommending moderate levels of physical activity for general health, as there may be additional benefits of pain prevention. It is important to recognize that this study used a mailed questionnaire, using long-term recall of low back pain. Given this design, we must assume that the respondents are giving their true activity level, and that it correlates well with the pain levels described.
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The comparative prognostic value of directional preference and centralization: a useful tool for front-line clinicians?
Long A, May S, Fung T
J Manual Manip Thera. 2008. 16.248-254
Reviewed by Paul Nelson, PT, Cert. MDT (4-14-2009)
This study by Long, May and Fung demonstrates the continued importance of a mechanical assessment and specifically the centralization phenomenon. This current study utilizes data from the previous study published in 2004,“Does is Matter What Exercise?” in which the authors established the importance of establishing diagnostic subgroups prior to undergoing treatment. Currently, there is a dominant theme regarding prediction models of low back pain; namely, the prominence of psychosocial variables as prognostic signs in the treatment of low back pain. The question raised is whether centralization/noncentralization is more useful or less useful predictors of outcome than psychosocial variables. The authors took the previous data and did a multivariate analysis of prognostic variables in patients with low back pain. Three hundred twelve subjects were analyzed for the variables, 230 (74%) patients demonstrated directional preference and 82 (26%) did not. Variables collected at baseline: age, gender, marital status, Quebec Task Force(QTF) category anatomic pain location, QTF category acuity, first or recurrent episode, work status, back and leg pain rating, pain interface rating, back and leg pain bothersomeness, DP status, and whether matched or unmatched to treatment, RMDQ , medication and Beck Depression Scale. Variables with p> 0.05 were excluded from further analysis. At the end of treatment, 241 subjects were available for analysis. Eighty-four subjects (35%) met the good outcome criteria. Out of the 17 variables, only two correctly predicted a good outcome: Leg bothersomeness rating and treatment assignment. The treatment group who received matched treatment was 7.8x more likely to achieve a good result. Leg pain was negatively correlated with a good outcome. Those with a DP/Centralization who received unmatched exercises were negatively associated with a good outcome. Patients who did not demonstrate directional preference at baseline were 3.4x more likely to have a good outcome if they underwent further mechanical testing over subsequent sessions. Weaknesses of the study: 1. Secondary analysis of data, 2. Psychosocial factors not included (fear avoidance, patient expectations, distress, job satisfaction, and workplace factors.), 3. The initial study was intended to measure early responsiveness to treatment. Overall, Directional Preference/Centralization and leg bothersomeness were found to be stronger predictors of outcome than psychosocial variables. This correlates well with the previous studies by Werneke in which centralization/non-centralization was found to be more predictive than psychosocial factors. This is excellent for the mechanical therapist as DP/Centralization and leg bothersomeness are variables that we, as clinicians, recognize and use to guide our treatment on a daily basis. By applying these variables to treatment, clinicians can quickly assess whether a patient will be responsive to treatment. As always, further studies are needed to establish firmer connections, however the ground work seems to be established.
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Effects of Diagnostic Information, Per Se, on Patient Outcomes in Acute Radiculopathy and Low Back Pain
Ash LM, Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN and Grooff PN
Am J of Neuroradiol. 2008. 29:1098-103
Reviewed by Charles Sheets, PT, Dip. MDT (4-13-2009)
The purpose of this article was to address the specific benefit of providing MRI results to patients and physicians for patients with acute low back pain and/or radiculopathy. The study involved 255 patients with symptoms of less than three weeks duration, who were randomized into two groups: unblinded (doctor and patient provided with imaging information) and blinded (doctor and patient not provided the information unless a serious consequence would result if treatment was delayed). Only one blinded subject was immediately changed to unblinded, when imaging was positive for malignancy – no information was provided on whether the history should have indicated malignancy for this patient. There were two subjects in the blinded group who were changed to unblinded – for both subjects, the imaging results were requested by the doctor due to clinical presentation, and both subjects underwent surgery due to large herniations. Imaging findings, treatment (medication, referral to physical therapy, compliance with physical therapy, surgery), and standardized outcome measures (Roland Morris disability index, VAS, and SF-36) were compared between groups at various points. There were no significant differences on any of these factors, with the exception of a larger change in improvement at all points in the blinded group on the general health subscale of the SF-36. This paper supports that current literature and guidelines in indicating that there is no benefit to performing advanced imaging for patients who do not have a history or clinical presentation consistent with serious pathology (i.e. trauma, infection, malignancy, or perhaps suspected pathology indicative of surgery). Obtaining imaging did not demonstrate any additional benefit in ascribing treatment or patient adherence, and does not appear to assist with prognosis. The authors note that, given the lower levels of improvement on the general health subscale, there may actually be a negative effect when patients with acute low back symptoms are provided with their imaging results, likely due to the high prevalence of “non-normal” findings.
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After an episode of acute low back pain, recurrence is unpredictable and not as common as previously thought
Stanton TR, Henschke N, Maher CG, Refshauge KM, Latimer J, McAuley JH
Spine. 2008. 33(26):2923-2928.
Reviewed by Julia Chevan, PT, Cert. MDT (4-2-2009)
Study Purpose: The range of estimates for recurrence of an episode of acute low back pain (LBP) is quite broad (47-84%). Previous studies examining recurrence estimates committed errors in not first establishing if a person had recovered prior to asking if they had a new episode of LBP and in not standardizing the definition of an episode of LBP. The purpose of this study was to determine the 1-year incidence of recurrence of LBP and factors that predict LBP using a cohort of patient at risk of recurrence and a standardized definition of LBP. Methods: Participants were part of a cohort study underway on prognosis and diagnosis in acute LBP. There were 353 subjects eligible for the study. Eligibility was based on meeting the definition of LBP and having a true recovery by the 6 week follow up point of the study. The primary outcome measure was recurrence of LBP which was measured via 12-month recall and with pain measures taken at 3 and 12 months. Additional factors that might predict recurrence including general health status variables and health behaviors variables were collected at the baseline assessment. Results: The 1-year incidence of recurrence of LBP at 12 months based solely on recall data was 24% (95%CI= 20%, 28%). When the 3 and 12 month pain reports were analyzed the 1-year incidence of recurrence increased to 33% (95%CI=28%, 38%). The only factor that was consistently across all analyses predictive of recurrence was previous episode(s) of LBP. Conclusions: Prediction of recurrence is difficult even with knowledge of as many as 26 separate factors that have been previously examined in the literature. The rate of recurrence of LBP found in this study is lower than prior estimates and would indicate that the majority of persons with an acute episode of LBP will not have recurrence within a year of the episode. Comments: This is a useful study as it questions our current assumptions about both the rate and risk of recurrence. However, the follow up time for this study was only 12 months and it is possible that this censoring of follow-up might artificially have reduced the rate. In addition, the risk factors examined while including physical activity, smoking and health status variables did not include risk factors considered relevant to a clinician practicing with the model proposed by McKenzie including postures assumed over the course of a normal day and time spent sitting.
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Disc Prolapse: Evidence of Reversal with Repeated Extension
Scannell JP and McGill SM
Spine. 2009. Volume 14, Number 4, pp. 344-350, 2009
Reviewed by Mitchell F. Miglis, DC, Cert. MDT (3-25-2009)
Centralization is a well established phenomenon in which symptoms originating from the spine are abolished, distally to proximally, in response to therapeutic loading strategies. While the specific loading strategies which produce this response are frequently in the sagittal plane (extension), combined forces and alternative force directions are not uncommon. One possible model to explain this was proposed by R. McKenzie in 1981. McKenzie suggested that displaced nuclear material had migrated intradiscally, producing distal symptoms, which were reversed as that same material was returned to a more favorable position by therapeutic mechanical forces. This explanation has not been tested experimentally until the publication of the above paper by Scannell and McGill. This basic science study investigated whether extension or combined extension and side flexion could move a displaced portion of nuclear material from the annulus back towards the nucleus. Acknowledging that repeated flexion is a well established mechanism for disc prolapse, the authors attempted to demonstrate that repeated extension can reverse the process, as proposed by McKenzie. The C3-C4 motion segments of 18 pig cervical spines, all deemed healthy with no more than “Grade I degeneration” on the Galante scale, were dissected, prepared and mounted on a servohydraulic jig. This machine permitted repeated pure flexion or combined flexion and side flexion at a rate of 0.5 degrees/second. The authors argue that the pig cervical spine model has been shown to be anatomically, geometrically and functionally similar to human lumbar spines with similar failure mechanisms. They concluded that “repeated pure or combined extension after disc prolapse was found to redirect the displaced portions of the nucleus back to the central part in a number of discs”. This reduction was noted in 5 of 11 prolapsed discs. The remaining 6 prolapsed discs did not show signs of reduction. Interestingly, those discs that reduced had less disc height loss than the group that did not. The authors note: “The fact that not all specimens responded, seems to match clinical observation that the McKenzie approach can be effective with some patients with prolapsed discs but not others”. Those discs with greater disc height were theorized to respond better to extension loading than those with lesser disc height because “greater extension of segments could occur before the facets joints bring range to a halt and also the stress in the posterior annulus was compressive rather than tensile”. This study did not explore sustained extension loads or other force alternatives such as rotation with flexion. Future studies might explore the benefit, if any, of creative combinations of loads which mimic the actual application of Mechanical Diagnosis and Therapy (MDT) principles in cases which do not respond to purely extension loads. The authors propose future questions: Whether the returned nucleus material is able to “form a plug in the clefts between layers and splits in the collagen of the annulus” (maintain the reduction?) and: What are the optimal extension regimes, in terms of static postures or repeated dynamic motions that assist in returning the nuclear material. This study is an important basic science experiment which supports the McKenzie model of disc derangement. It proffers a biological explanation for the centralization phenomenon and hints of at least one possible mechanism for irreducible derangements. As such, it provides a platform for future studies which may, in turn, provide directions for future clinical research in MDT.
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The Twin Spine Study: Contributions to a changing view of disc degeneration.
Battie M, Videman T, Kaprio J, Gibbons L, Gill K, Manninen H, Saarela J and Peltonen L
The Spine Journal. 2009. 9 (2009) 47-59
Reviewed by Mitchell F. Miglis, DC, Cert. MDT (3-25-2009)
Although the specific pathoanatomy in most cases of back pain is unknown, there is strong scientific evidence that the intervertebral disc plays a frequent role in local and distal low back symptoms, including axial low back pain, low back related leg pain and symptomatic spinal stenosis. Up to about ten years ago, the ‘injury model’ explained disc degeneration as the result of overloading the disc, either singly or repetitively, with such forces as heavy materials handling, postural loading and vehicular vibration. However, the authors of the current study note there has been “a dramatic change in views of determinants of disc degeneration”. This substantial revision of our understanding about the causes of disc degeneration results partly from a major multidisciplinary, multinational study, The Twin Spine Study, which started in 1991 and studied individuals in, principally, Canada, Finland and the United States. The study included 600 subjects who were selected because of a major difference between the occupational exposure of one twin and that of the other. For example, one twin was a farmer, the other an accountant; one twin a plumber, the other a computer programmer. The most significant finding of this study was “the substantial influence of heredity on lumbar disc degeneration and the identification of the first gene forms associated with disc degeneration. Conversely, despite extraordinary discordance between twin siblings in occupational and leisure-time physical loading conditions throughout adulthood, surprisingly little effect on disc degeneration was observed.” The authors conclude that disc degeneration is now known to be a condition that is genetically determined “in large part”. Environmental factors, “although elusive”, play an important role as well. Interestingly, “most of the specific environmental factors once thought to be the primary risk factors for disc degeneration appear to have very modest effects, if any”. One environmental factor which clinicians may want to emphasize is “routine loading” which was found to have some benefits to the disc. The current authors note: “responses of the disc may be more in keeping with other musculoskeletal structures that benefit from adaptation to routine physical loading”. In summary, the Twin Spine Study raises questions about the adequacy of the injury model or “wear and tear” view of the disc. A major shift in understanding of disc degeneration is heralded by this study. It concludes that routine physical loading has beneficial effects on the disc. This study does not comment on or take into account the possibility that the relation between the level of activity and back pain may be a U-shaped curve: that is, both inactivity and excessive activities (back-unhealthy activity) present an increased risk for back pain with the optimal level of activity being the middle ground at the bottom of the “U”. This concept has received recent experimental support (“Physical activity and low back pain: A U-shaped Curve, Heneweer, H, Vanhees, L and Picavet, HS, in Pain, Epub ahead of print, Feb.11, 2009). As with so much of 21st century biomedical research, the role of genetics and its relations to disc degeneration is in its infancy. Hopefully, future research will better clarify the relation of underlying pathoanatomy to back pain. Interestingly, there is actually some early evidence that, once again, genetics plays a role, with some individuals being more susceptible to low back pain due to genetic variables (“Heredity of low back pain in a young population: A classical twin study.”, Hestbaek L., et. al. in 6.Twin Research, 2004;7(1):16-2 ).
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Upper limb neural tension and seated slumb tests: The false positive rate among healthy young adults without cervical or lumbar symptoms.
Davis DS, Anderson IB, Carson MG, Elkins CL, Stuckey LB
J Manual Manip Ther. 2008. 16.136-141
Reviewed by Charles Sheets, PT, OCS, Dip.MDT (3-8-2009)
This paper involves the performance of the upper limb tension test (ULTT) and seated slump test (SST) on young, symptom-free subjects, with a focus on the false-positive rate. Eighty-four subjects were involved, of whom 73 (86.9%) were found to have a positive ULTT, and 28 (33.3%) had a positive SSL. The average knee extension angle with a positive SSL was 15.1º, and average elbow extension was 49.4º - using the 75th percentile, the authors suggest that a positive test only be identified in those with symptoms reproduced before 22º of knee extension in the SSL, or 60º of elbow extension in the ULTT. While the high frequency of false positive tests in this healthy population may be surprising, the results should be interpreted with caution. In order to demonstrate a positive result, the subjects had to report decreased symptoms with release of endrange cervical spine position (flexion for the SST, contralateral bending for the ULTT). Pre-positioning the cervical spine under full tension in this manner, while helpful in increasing the sensitivity of the maneuver, is not generally the standard of examination, especially for the ULTT, in which the neck is often placed in neutral while the arm is manipulated. Adding this level of sensitization likely increased the false positive rate in this study. It is also important to note that the goal of neural provocation is to determine if the test reproduces the patient’s presenting symptoms – producing symptoms that are not consistent with the patient’s complaints should not be diagnosed as a positive test. Neural provocation testing is often used as part of the MDT evaluation to assess neurologic status, and/or establish a baseline of symptoms before performing repeated movements. Given the results of this study, we must be mindful of the high potential for finding false positive tests, especially if symptoms are provoked late in the range of motion.
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Acute low back pain and radiculopathy: MR Imaging findings and their prognostic role and effect on outcome.
Modic M, Obuchowski N, Ross J, Brant-Zawadzki M, Grooff P, Mazanec D, Benzel E
Radiology. 2005.
Reviewed by Mitchell F. Miglis, DC, Cert. MDT
(2-5-2009)
The widespread use of advanced spinal imaging is a two-edged sword. It is widely available, at least in the US, and permits the visualization of exquisite anatomic detail. But the prevalence of incidental findings is high. As Modic et al note, these incidental findings are of two types: 1) findings that are morphologically abnormal but clinically irrelevant; and 2) findings that are relevant but not related to clinical decision making or outcome. Since a significant percentage of asymptomatic individuals have abnormal MRI findings, and since the major decision confronting clinicians is conservative vs. surgical care, what, the authors ask, is the effect of spinal MRI imaging on prognosis and outcome? Two hundred forty-six patients with acute low back pain or radiculopathy were randomized to either one group told about their MRI findings within 48 hours or another group wherein both patients and physicians were blinded to MRI findings. All patients underwent six weeks of conservative care (AHCPR guidelines; non MDT). Outcomes were measured by Roland function, visual pain analog, absenteeism, Short Form 36 health status, self-efficacy scores and fear avoidance questionnaires at regular intervals up to 24 months of follow-up. The prevalence of disc herniation was the same in those with low back pain as those with radicular pain. There was no relationship between herniation type, size and behavior over time with outcome. There was no relationship between the number or extent of herniations and patient signs or symptoms. The authors conclude that MRI imaging did not have additive value over clinical assessment: “no prognostic sign that might alter treatment versus clinical assessment was identified” [by MRI]. Importantly, the authors found that patient self-measures of well-being were adversely effected by knowledge of MRI findings. This, they argue, is counter to the commonly accepted notion that MRI results may have a role in reducing patient anxiety and providing reassurance. In addition to poorer well-being, they argue, patients may be exposed to unnecessary treatments, including higher rates of surgery, and higher health care costs. In conclusion, the authors agree with the 1994 guidelines published by the Agency for Health Care Policy and Research (AHCPR) that, in the absence of signs and symptoms that suggest red flags, acute imaging does not affect patient care. This paper argues that, in fact, acute imaging may have a negative affect on patient well-being and care. MRI imaging, they indicate, should be reserved for only the minority of patients with persistent signs and symptoms who are believed to be candidates for surgery or in whom diagnostic uncertainty remains.
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Specific directional exercises for patients with low back pain: a case series.
Long A, May S, Fung T
Physio Canada. 2008. 60.307-317
Reviewed by Dave Scotton, PT, Cert. MDT, CMP (1-22-2009)
This article is a case series that studied whether outcomes could be changed after a poor response to non-specific exercises, when the prescription was changed to specific, directional-preference exercises (MDT). The case series was a continuation of a previous RCT. Patients with directional preference were randomized into exercise/advice interventions either matched with their direction of preference or to one of two unmatched protocols. The original treatment period was two weeks (six visits maximum). After the initial two weeks of treatment, 90% of the matched exercise group reported resolution or improvement of their symptoms, compared to 35% in the unmatched groups. Upon completion of the two week treatment period, patients were given a questionnaire that asked if their symptoms were: 1) resolved
2) improved but needed a few more treatments
3) have not changed
4) worse Inclusion into the case series depended on two criteria. Firstly, if the patient reported that they were unchanged or worse on the post-RCT questionnaire. Secondly, if the patient asked to change to one of the other treatment protocols. If one of these criteria were met, the patient was offered the directional preference/matched exercises if they were not intially. 121 patients met the criteria. 96 patients consented to the alternative treatment. The second phase of treatment also lasted two weeks in duration. After the change to the matched treatment, all outcomes (Back Pain rating, Leg Pain rating, Roland Morris Disability Questionnaire, number of patients taking medication, activity interference rating, and the Beck Depression inventory) were significantly improved. The amount of patients reporting resolved or improved symptoms increased from 22% to 84% after the switch. This is very close to the 90% results of the RCT matched exercise group. This may suggest that the initial delayed recovery was related to inappropriate exercise prescription. Limitations of the study were reported by the authors. These were a lack of a control group in the second phase, unblinded treatment and lack of long-term follow-up. Of interest is the author’s choice of two week treatment periods. This was reported to limit the number of treatment sessions (max six). Also, the short duration of treatments was intended to reflect accepted standards reported in MDT literature to obtain clinically meaningful changes. The study reinforces previous findings that classification-based treatment has improved outcomes, and that matched exercises to a direction of preference is a valid sub-group for classification-based treatment. It further shows that patients, who failed with unmatched exercises, can achieve substantial gains in pain and disability when switched to matched/directional preference exercises.
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Expert therapists use specific clinical reasoning processes in the assessment and management of patients with shoulder pain: a qualitative study.
May S, Greasley A, Reeve S, Withers S
Aust J Physiotherapy. 2008. 54(4):261-6
Reviewed by Charles Sheets, PT, OCS, Dip.MDT (1-19-2009)
This goal of this study was to identify the types of clinical reasoning processes and relative importance of different examination items used by expert therapists in diagnosis of shoulder pain. The study utilized the Delphi method to answer the following question: What are the key items in the clinical reasoning process which expert clinicians identify as being relevant to the assessment and management of patients with shoulder pain? The Delphi method involved contacting and sending a questionnaire to 30 different expert therapists, and going through three rounds of response to determine what elements of examination they identified as being of primary, secondary, or tertiary importance. The findings of primary importance included general history items, use of constellation of signs and symptoms of specific diagnostic categories, general physical examination items (i.e. active and passive range of motion), and certain intervention options which mostly included advice and exercise. There was a wide range of responses on the value of specific diagnostic tests such as Hawkins-Kennedy or Neer impingement, which is consistent with literature, demonstrating the failure of special tests to consistently diagnose pathoanatomical problems. This article reflects how the aspects of examination of the shoulder as instructed and performed from an MDT perspective mirror the clinical reasoning used by expert therapists. Primary importance is placed on taking a thorough patient history, and using general movements and strength tests to inform further diagnostic testing. Emphasis is also placed on the value of patient-centered care, in that careful history and discussion with the patient lead the therapist to perform appropriate tests and examination, and incorporate correct exercise and advice. This is in contrast to utilizing specific tests to determine the diagnosis, rather than using them as an adjunct to a detailed history and general physical examination. Use of these strategies is complemented by pattern recognition, which has been consistently recognized as a sign of expert therapists, and which is used to take the patient history, movements and test findings to establish a pattern (for our purposes, derangement, dysfunction, posture), determine a diagnosis and create an appropriate treatment plan and prognosis.
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Are early MRI findings correlated with long-lasting symptoms following whiplash injury? A prospective trial with 1-year follow-up.
Kongsted A, Sorensen J, Andersen H et al
Eur Spine J. 2008. 17:996-1005.
Reviewed by Paul Nelson, PT, Cert. MDT (12-28-2008)
Kongsted et al have performed a study with two objectives in mind: 1.) Evaluate the predictive value of cervical MRI after whiplash injuries and 2.) The value of repeating MRI examinations after three months including sequences with flexion and extension of the cervical spine. 178 participants were selected and had a cervical MRI on average of 13 days after the accident. Traumatic findings were observed in 7 participants. Signs of disc degeneration were common and most frequent at the C5-6 and C6-7 levels. The study population had no significant neck trouble prior to the whiplash injury and the non-traumatic findings are normal MRI findings in the population. The results of the study confirmed that traumatic findings via a standard MRI scan are rare. Having traumatic findings though, were associated with more severe neck pain and headache. It should be noted that subjects were not included in the trial if fractures or dislocations were diagnosed in the ER. The population in this trial are patients who are considered to have soft-tissue injuries. This trial also showed that the scan performed at 3-month follow up showed very little additional information. Study limitations: 1.) Time between accident and MRI were, on average, 11 days, 2.) A large portion of the study did not present for the 3-month follow-up MRI (108/203), 3.) MRI was performed using a low-field system. 4.) Not focusing more on the upper cervical spine,and 5.) Flexion and extension x-rays were carried out in the supine position and not to end-range. This study is significant as the aetiology behind the lasting pain seen in the chronic population is largely unknown. It seems that MRI is not the answer to a diagnosis in the vast majority of patients developing long-lasting pain. The value of repeating the MRI is very suspect to predict prognosis.
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A Clinical Review: Evidence Based Diagnosis and Treatment of the Painful Sacroiliac Joint.
Laslett, Mark.
JMMT. 2008. 16(3):142-154
Reviewed by Dave Scotton, PT, Cert. MDT (12-3-2008)
This review is of a commentary article by Mr. Laslett on the diagnosis and treatment of the Sacroiliac joint. It includes an invited commentary by Peter Huijbregts, DPT, OCS, FAAOMPT, FCAMT. Its purpose is to clarify the distinction between SIJ dysfunction and pain arising from the SIJ. It also discusses possible future research into investigating SIJ treatments.
Over the past approximate ten years, Mr. Laslett has reviewed the literature concerning SIJ diagnosis and treatment. He has found it lacking in validity. This prompted him to perform his own research on developing valid diagnostic examination techniques (1,2,3,4,5,6,7,8).
This commentary serves as an excellent primer for the basics of statistical analysis in research. On this basis alone, it is a must read for all therapists.
The main points of this commentary are:
1.Palpation tests for SIJ movement, position, and symmetry are NOT reliable in regards to specificity and
sensitivity in predicting SIJ problems.
2.SIJ pain provocation tests (distraction, compression, thigh thrust, Gaenslen’s, and sacral thrust), when combined with the absence of centralization, are valid for predicting SIJ pain (77% probability). In those with pregnancy related pelvic girdle pain, this increases to 90% probability.
3.Despite their short comings, controlled blocks under flouroscopic guidance ARE the best available
reference standard for identifying intra-articular SIJ pain.
4.At the present time, there are NO studies that have examined the efficacy, efficiency, and therapeutic value of treatments applied to patients CONFIRMED as having SIJ pain.
5.The author suggests that there MAY BE a subgroup of patients likely to have SIJ-mediated pain that is
treatable by specific movement/loading (mechanical SIJ pain).
6.The author suggests that lumbopelvic stability exercises and intra-articular steroid injections offer the MOST POTENTIAL reducing SIJ pain and it’s disability.
The invited commentary by Mr. Huijbregts was in agreement with Mr. Laslett’s research and suggestions. He agreed that the combination of a McKenzie evaluation and the cluster of SIJ pain provocation tests are a good SIJ clinical prediction rule (CPR) for the diagnosis of SIJ pain. He also agrees that this CPR should next be tested with various interventions to see if patients consistently respond favorably to matched interventions, and to determine which interventions are most effective. References:
1.Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine 1994:19:1243-1249.
2.Laslett m, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: Validity of individual provocation tests and composites of tests. Man Ther 2005:10:207- 218.
3.Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac joint provocation tests. Aust J Physiother 2003:49: 89-97.
4.Laslett M, Oberg B, Aprill CN, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J
2005:5:370-380.
5.Laslett M, McDonald B, Aprill CN, Tropp H, Oberg B. Clinical predicators of screening lumbar Zygapophysial joint blocks. Development of clinical prediction rules. Spine J 2006:6:370-379.
6.Laslett M, Oberg B, Aprill CN, McDonald B. A Study of clinical predictors of lumbar discogenic pain as determined by provocation discography. Eur Spine J 2006: 15: 1473-1484.
7.Young SB, Aprill CN, Laslett M. Correlation of clinical examination characteristics with three sources of
chronic low back pain. Spine J 2003:3:460-465.
8.Laslett M, van der Wurff P, Buijs EJ, Aprill C. Comments on Berthelot et al review “Provocative
Sacroiliac joint maneuvers and sacroiliac joint blocks are unreliable for diagnosing sacroiliac joint pain.” Joint Bone Surg 2007:74:306-307.
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A Clinical Review: Classifying Subgroups of Chronic Low Back Pain Patients based on lifting patterns
Slaboda JC, Boston JR, Rudy TE, Leiber SJ
Arch Phys Med Rehabil. 2008. Vol. 89:1542-1549
Reviewed by Dave Scotton, PT, Cert. MDT (12-3-2008)
The following article investigates whether back pain patients can be classified into subgroups based on their lifting patterns. The study obtained the subjects from a database at the University of Pittsburgh Medical Center Pain Evaluation Treatment Institute. The subjects completed a medical evaluation, a psychological evaluation, and a repetitive lifting task. The lifting task data was then used to define the hidden Markov models. They were then used to classify the patients into two subgroups. The measures from the evaluations were compared between Chronic LBP (CLBP) subgroups to see if there were any differences between the groups on measures other than lifting patterns and compared to controls.
The study was broken down into eight different protocol domains consisting of: medical, task self efficacy, pychosocial, cognitive, disability, spinal mobility, and the repetitive lifting task. Most of the items used were questionnaire type measures.
From a MDT stand point, the key areas of interest were the lifting task and the patient’s self efficacy. For the lifting task, the patients were required to lift against a force gauge attached to a handle. The patients pulled for four seconds. The process was three trials with 15 seconds rest between each attempt. The investigators then used 40% of the mean of the three trials as the resisted force for the repetitive lift task. The 40% mark was selected because it is the minimum amount of resistance necessary to show fatigue on EMG recordings and because it would enable the subjects to perform for a sustained period of time. The task itself required the subjects to lift the load from 33 cm from the floor to waist height. The BTE Work Simulator provided the resisted load during the upward phase of the lift. It also gave the subjects signals when the lift started and at the end of each lift. Reflective markers on the subject’s bodies were tracked to define changes in body angles as functions of time during each lift. This was achieved via a motion analysis model 110. Subjects performed lifts for a maximum of 20 minutes with 15 second rest intervals. Subjects were instructed to lift until they felt physically unable to continue or until the time limit was reached. They received no visual or verbal feedback during the task. They reported their pain (via 0 – 10 scale) before the task, after the static strength task, and at the end of the dynamic lifting task. The parameters were calculated for each lift and from them a multi-dimensional time series of lifting parameters was obtained for each subject. A data reduction procedure applied to the parameters allowed for five different lifting patterns to be found. The patterns were: 1) slow, low jerk lift, 2) squat starting posture lift, 3) fast, high jerk lift, 4) torso starting posture lift, and 5) two segment lift where the lower body moves faster than the upper body. The 81 CLBP subjects in the study were classified into two groups: guarded CLBP lifters and high-performing LBP lifters. The guarded group was defined as performing slow, low jerk lifting pattern most frequent (76% of the lifts performed). The high-performing group was defined as frequently using all of the lifting patterns except the slow, low jerk lifting pattern. The results indicated that the high performing CLBP group lifted more similarly to control subjects than the guarded CLBP group. They completed more lifts, and reported lower pain severity, lower pain intensity, and higher self-efficacy. The guarded CLBP group lifted very differently from control subjects, completed fewer lifts, and reported higher pain intensity, higher pain severity, and lower self efficacy.
This exhibited a relationship between self-reported measures and physical performance. It showed the need for examining function in classifying pain patients.
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Cyclic tensile stress exerts a protective effect on intervertebral disc cells
Sowa G, Agarwal, S
Am J Phys Med Rehabil . 2008. 87.537-544
Reviewed by Mitch Miglis, DC, Cert. MDT (11-18-2008)
Citing the beneficial effects of motion-based therapies in the clinical research literature, the authors hypothesize that physical levels of tensile stress have a beneficial effect on the intervertebral disc. They note that bone, tendon and articular cartridge as well as disc respond positively to controlled forces with increased cellular proliferation, matrix production and improved biochemical profiles. Using in vitro rat discs as a model, they demonstrate that moderate levels of tensile stress act on the disc as a protective signal by increasing the expression of anti-inflammatory agents while at the same time decreasing the expression of catabolic agents within the disc. They conclude that motion-based therapies that create tensile stress on the annulus may exert their beneficial effects through these anti-inflammatory and anti-catabolic mechanisms. This paper underscores the protective effect of controlled physical loads on the intervertebral disc. Interestingly, the authors suggest that low levels of tensile stress actually act as a potent anti-inflammatory and anti-catabolic signal because of changes in gene expression which occur in response to these physical loads: "These data represent initial building blocks to lead to an improved understanding of how mechanical forces can be explored to initiate repair". While this in vitro study is preliminary and has limited generalizability, it is consistent with the disk model as commonly used in MDT with reference to the repetition or sustained use of end range loading forces. In this paper, in contrast, beneficial effects are seen to arise, at least partially, from the anti-inflammatory and anti-catabolic effects of mechanical, tensile loading forces applied repetitively. In the model frequently used in MDT, physical reduction of internal or external disk derangement is purported to occur with the application of end range loading. While the latter model requires an intact hydrostatic mechanism, this paper’s anti-inflammatory model apparently does not. The degree to which either of these hypotheses applies to the observed clinical results in MDT patients requires further research. In addition, the role of other models, such as neurophysiologic pain mechanisms like central pain modulation, remain to be clarified. In the end, it may be possible that all the models, and others as yet unknown, are valid and may interact in complex ways. While MDT is not dependent on underlying pathoanatomy (relying instead on a symptomatic and mechanical patient response to loading strategies) it is nevertheless interesting to see another model, an "anti-inflammatory model", consistent with repetitive mechanical loading as done in MDT. Further research into this hypothesis may lead to a better understanding of the optimal loading parameters such as frequency, intensity and duration in addition to the well established mechanically determined directional preference. This work is consistent with the extensive body of literature supporting the benefits of motion-based therapies for both the spine and extremities. With additional research, MDT may continue to refine its use of mechanical forces to further enhance the efficacy of "movement in the right direction".
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North American Spine Society Evidence-Based Clinical Guidelines for Multi-Disciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis
. 2007.
Reviewed by Mitch Miglis, DC, Cert. MDT (11-4-2008)
North American Spine Society Evidence-Based Clinical Guidelines for Multi-Disciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis, available free online as PDF download at http://tinyurl.com/6p8dtz or, in condensed form from the National Guideline Clearinghouse (www.guideline.gov) at http://tinyurl.com/6rtyem. This extensive clinical guideline is prepared following rigorous literature review standards and is an update of the original guideline from 2002. The current guideline, published in January 2007, is 264 pages in length and cites 394 references. As such, it serves as a comprehensive reference work for busy clinicians who may, following an initial read, prefer the summary data of the document as noted above. Diagnostic and treatment methods are rated using a clearly defined hierarchical system, allowing clinicians to assess the current clinical strength of the evidence. Among the most appropriate historical and physical findings in cases of symptomatic degenerative lumbar spinal stenosis, this document lists the following: older patients, decreased symptoms with sitting, postural abnormalities such as a wide-based gait, positive balance disturbance (positive Romberg test), increased thigh pain with extension for more than 30 seconds and neuromuscular deficits. Patients whose pain is not made worse with walking have a low likelihood of stenosis. MRI is recommended; electrodiagnostic studies are not. The Oswestry Disability Questionnaire is a useful and reliable outcome measure. Evidence supporting one form of intervention over another is weak; nevertheless, “a limited course of physical therapy is reasonable in patients with degenerative lumbar spinal stenosis” is recommended. Use of a brace or corset may increase walking distance but there is no evidence for sustained benefit. This document offers an extensive overview of the literature relevant to degenerative lumbar spinal stenosis through a cutoff date of April, 2006. Its value to the MDT practitioner is as an aid to better understanding the natural history of this disorder as well as several historical clues to consider in individual cases. More research is clearly needed regarding conservative, non-invasive treatment of lumbar spinal stenosis. An excellent paradigm for the diagnosis, if not management, of symptomatic degenerative spinal stenosis is contained in a paper published in the International Journal of Mechanical Diagnosis and Therapy, Vol. 2, No. 1, March, 2007: Lumbar Spinal Stenosis: A Proposed Algorithm for Mechanical Evaluation, by Martin Melbye, PT, Dip. MDT.
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Lumbar disc prolapse: Response to mechanical physiotherapy in the absence of changes in magnetic resonance imaging. Report of 11 cases.
Broetz D, Hahn U, Maschke E, Wick W, Kueker W and Weller M
NeuroRehabilitation. 2008. 23(3): 289-294
Reviewed by Charles Sheets, PT, Dip.MDT (9-8-2008)
This case series described the effect of mechanical diagnosis and therapy on symptoms and MRI findings in 11 consecutive patients – 8 acute and 3 chronic - with clinical and MRI evidence of lumbar inververtebral disc prolapse. The authors note that regression of extruded discs is a common finding over time, but this has not been assessed over a shorter period of time, nor has it been correlated to the effects of a specific treatment. All patients underwent MRI before evaluation, and were tested for multiple clinical signs (weakness, pain intensity, sensory loss, SLR, Roland Morris score, distance of referred pain, and analgesic use) before undergoing evaluation and treatment through MDT methods. Patients were followed up after 5 treatment sessions and after an average of 51 days, with an average indication of improvement in all symptoms in 10 of 11 patients (one had surgery at 4 weeks). On MRI, ten of eleven prolapses were sequestrated – one occupied more than 2/3 of the canal, 3 occupied more than 1/3, and 7 occupied less than 1/3. None of the patients showed changes in prolapse on days 3-7 after study entry. Even for a case series, it is somewhat difficult to get much strong evidence from this study – the operational definitions are poorly described, and there is no mathematical data to describe the lack of change in the prolapsed disc, or any statistical calculations (i.e. p values, confidence intervals) to show the meaningfulness of the clinical changes seen. This is in contrast to the presentation give by Dr. Eric Parent at the Conference of the Americas 2008, who used precise and reliable measurements on a similar population (although not specifically prolapsed) to arrive at very similar findings – that of no change in MRI appearance of the disc in those who respond to MDT. The most powerful idea to take from this paper is that even in patients with evidence of sequestrated discs (not defined in the paper), which are often thought not to be amenable to treatment by repeated loading, there was rapid clinical improvement in the majority of patients, with full centralization of pain in at least half of the patients by the one-month follow-up. This helps to lend further support to the value of a mechanical evaluation before spending the money on expensive diagnostic imaging, as even patients with the least favorable findings on MRI, including those with chronic symptoms, may rapidly respond to treatment.
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Lateral Hip Pain: Findings From Magnetic Resonance Imaging and Clinical Examination
Woodley S, Nicholson H, Livinstone V, Doyle TC, Meikle GR, Macintosh JE, Mercer SR
JOSPT. 2008. 38(6):313-328
Reviewed by Mitch Miglis, DC, Cert. MDT (7-21-2008)
Lateral hip pain is a diagnostic conundrum. Symptoms may arise from a number of pain generators: locally (intra-articular or peri-articular structures) or distally (lumbar or sacroiliac structures). Diagnosis is based on history and physical examination. The former is often unhelpful in localizing the pain generator and the latter unreliable. The end result, more often than not, is labeled ‘trochanteric bursitis’. Efforts to clarify the underlying pathology by means of advanced imaging have been disappointing. As in other areas of musculoskeletal imaging, both the symptomatic and asymptomatic hip frequently reveal abnormal findings whose clinical relevance is uncertain. In the current study, Woodley, Nicholson et al attempt to address these uncertainties by determining if a “gold standard” can be established radiologically. They reason that the validity of physical tests can then be assessed by comparison to this gold standard. What they find is that the degree of interexaminer agreement was moderate for bursitis (kappa = 0.45), slight for tendon pathology (kappa = 0.02) and osteoarthritis (kappa = 0.08) and substantial for muscle atrophy (kappa = 0.61). 22 out of 40 asymptomatic hips were found to have radiological abnormalities: “In general, the agreement between the radiologists and physical therapists was low. The strength of agreement for diagnoses of bursitis was classified as poor (kappa = -0.04), and for gluteal tendon pathology (kappa = 0.17) and osteoarthritis (kappa = 0.21) it was fair.” They conclude that gluteus medius tendon pathology, bursitis, osteoarthritis and gluteal muscle atrophy are all implicated in lateral hip pain but that further refinement is needed before MRI can be considered a valid reference standard. Consequently, no definite conclusions could be made about the physical tests commonly used to diagnose lateral hip pain. While this study points to the current limitations of imaging and conventional orthopedic approaches to lateral hip pain, it may further encourage classification of lateral hip pain into non-specific syndromes, such as MDT’s derangement or dysfunction syndromes, with mechanical loading strategies formulated in response to directional, end-range loading. In this regard, as with the contents of this study, the author’s conclusion that further study is needed is certainly relevant.
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A novel approach to managing graduated return to spinal loading in patients with low back pain using the Spineangel® device: a case series report
Horton SJ, Haxby Abbott J
NZ J Physio. 2008. 36:22-28
Reviewed by Dave Scotton, PT, Cert.MDT, CMP (7-10-2008)
This article is a case study of 3 patients using a new device called the “Spineangel”. The device is a small unit that is worn on the waist of your pants or on the belt just superior to the greater trochanter. It monitors and helps measure graduated spinal loading (in either flexion or extension). It also can give reminders for exercise performance throughout the day. Thus, it gives the patient feedback when they are placing their spine in sustained or repeated flexion. It also can do the opposite if extension needs to be avoided. It can be adjusted to give varying degrees of flexion (or extension) before and alarm gives the patient immediate feedback. Therefore, it assists with recovery of function by allowing a graduated increase in loading forces. The article gives 3 case studies that demonstrate the device’s application towards reinforcing patients’ behavior modification to avoid flexion and to perform their exercises. All 3 patients commented on how the device was helpful in doing this. The cases demonstrated how the unit was an adjunct to the McKenzie method. It essentially teaches good postural habit. I see its immediate use with those difficult patients that just “don’t get it” or can’t self monitor their body throughout the day to avoid flexion motions and postures. Cost may be this devices ultimate demise. I see possible issues with payers for the device. It may be more practical to get a rental of the unit via a one-time initial charge from the payers.
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Mechanical or inflammatory low back pain. What are the potential signs and symptoms?
Walker B.F., Williamson O.D
Manual Therapy. 2008. 2008; 1-7
Reviewed by Charles Sheets, PT, Dip.MDT (7-5-2008)
This article involves the creation and implementation of a questionnaire designed to determine whether practitioners from a variety of disciplines agree on the objective and subjective signs that identify low back pain of chemical (ILBP) or mechanical (MLBP) origin. The authors note that patients with mechanical pain traditionally benefit from treatments such as mobilization, manipulation, traction and exercise, while those with inflammation benefit from treatments like non-steroidal anti-inflammatory medications and corticosteroid injections; if differentiation is possible, the number of inappropriate therapy decisions could be decreased. The aims of this study were to identify whether it is possible to discriminate between ILBP and MLBP and determine whether the different groups involved in the management of LBP interpret these signs and symptoms in a similar manner. The questionnaire consisted of 27 items, decided on by the authors. It was sent to equal numbers of spine surgeons, rheumatologists, musculoskeletal medical practitioners, chiropractors and manipulative physiotherapists. In this study the low back was defined as the area between the costal margins and inferior gluteal folds. Responses were assessed on an 11-point semantic differential scale with the participants indicating the degree, from strongly disagree (0) to strongly agree (10), with which they associated each symptom or sign with ILBP and/or MLBP. Morning pain on waking demonstrated high levels of agreement as an indicator of ILBP. Pain when lifting demonstrated high levels of agreement as an indicator of MLBP. Constant pain, pain that wakes, and stiffness after resting were generally considered as moderate indicators of ILBP, while intermittent pain during the day, pain that develops later in the day, pain on standing for a while, with lifting, bending forward a little, on trunk flexion or extension, doing a sit up, when driving long distances, getting out of a chair, and pain on repetitive bending, running, coughing or sneezing were all generally considered as moderate indicators of MLBP. While this study identified two groups of factors that were generally considered as indicators of ILBP or MLBP, none of these factors were identified to strongly discriminate between ILBP and MLBP. The indicators of ILBP found in this study are consistent with those found in a previous study using markers on ankylosing spondylitis: morning stiffness greater than 30 min, improvement with exercise but not with rest, awakening because of back pain in the second half of the night and alternating buttock pain. The limitation of this study is that it relies on professional opinion, rather than determination of signs and symptoms consistent with specific inflammatory markers. The lack of agreement on these signs, especially between professions, highlights the challenge of providing consistent, appropriate care for patients with low back pain. The findings of this study are unlikely to have a significant effect on the evaluation and classification of low back pain by therapists utilizing the McKenzie method, aside from increased awareness that a history of pain with prolonged rest, in combination with no pain on mechanical loading, is less likely to be of mechanical origin. The signs and symptoms that would likely be seen in ILBP are consistent with those defined by Peterson et al. (2003) as non-mechanical disc: mechanical loading strategies in any direction increase the symptoms, which may get no worse or worse as a result; no decrease and/or abolishment of symptoms; range of movement remains unaffected. Objective response to mechanical loading will make these findings clear, and will likely yield far more valuable information than any specific subjective questions. Peterson T., Laslett M., Thorsen H., Manniche C., Ekdahl C., and Jacobsen H Diagnostic classification of non-specific low back pain. A new system integrating patho-anatomic and clinical categories. Physiotherapy Theory and Practice 19: 213-237, 2003
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Inclusion of Mechanical Diagnosis and Therapy (MDT) in the Management of Cervical Radiculopathy: A Case Report
Schenk R, Bhaidani T, Boswell M, Kelley J, Kruchowsky T
J Man & Manip Ther. 2008. 16(1) E2-E8
Reviewed by Dave Scotton PT, Cert. MDT, CMP (6-10-2008)
This is a case study of a cervical radiculopathy patient treated with a combination of MDT and other approaches. This is significant just in the fact that it is a cervical patient. There is only a fraction of cervical reports/studies in the literature compared to the lumbar spine. This is true within MDT also. The article demonstrates how MDT can be applied in the cervical spine and the application of MDT principles and reasoning dominates this case. It shows how a patient with a cervical derangement with a relevant lateral compartment responded to repeated movements and postural correction. It is a great example of how having fully exhausted the sagittal plane we need to explore laterally to find a directional preference. There was a little “fiddling around” as it initially took putting the UE in a non-tension position to allow for reduction to occur. It would have been nice to see this case study using just the MDT assessment, classification and treatment. Whilst mixing different approaches is a common practice and does reflect the eclectic nature of the North American approach to orthopedics, in any study, as with clinical practice, it has the obvious effect of limiting the conclusions for any one of those particular interventions. Additionally, this multi-faceted treatment approach may give the impression that the McKenzie System cannot be used as a stand–alone, comprehensive approach. Most McKenzie therapists would argue that this would be a false impression. Any study that stimulates discussion regarding the use of MDT in relation to other approaches may be controversial, but is always valuable. These controversial topics do need to be raised with the MDT and Manual Therapy communities; however, I will leave their discussion to another forum.
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Three-Dimensional Movements of the Sacroiliac Joint: A Systematic Review of the Literature and Assessment of Clinical Utility
Goode, A, Hegedus, EJ, Sizer Jr, P, Brismee, J-M, Linberg, A, Cook, CE
JMMT. 2008. 16(1) 25-38
Reviewed by Lynda McClatchie, Cert. MDT (5-18-2008)
The sacroiliac joints (SIJ) move through both rotational and translational motion along three axes, the origin of which lies between the left and right posterior superior iliac spines. The SIJ is thought to have six degrees of freedom due to the three angular and three linear motions occurring at each joint. The amount of translation and rotation reported during motion shows great variability in the literature, and several techniques have been applied to quantify these movements. In reviewing the published literature, the authors omitted any study that did not utilize the Roetgen Stereophotogrammetric Analysis (RSA) technique, which is considered the gold standard to calculate movement in three dimensions (3-D). The RSA procedure to detect SIJ motion involves percutaneously inserting titanium balls into the motion segments of the pelvis, followed by an RSA exam within two weeks. Direct 3-D digitizing enables the position of the pelvic landmarks to be recorded. Seven studies meeting the inclusion criteria were reviewed. Both in vitro and in vivo studies using RSA methodology were examined. The table below outlines the rotational and translational motion about the three axes based on positions or movements with selected leg positioning such as supine to standing, supine to sitting, standing to prone, and various hip positions. SIJ Rotation(o) X-Axis: -1.1 to 2.2 Y-Axis: -0.8 to 4.0 Z-Axis:-0.5 to 8.0 SIJ Translation(mm) X-Axis: -0.3 to 8.0 Y-Axis: -0.2 to 7.0 Z-Axis:-0.3 to 6.0 The quality of the reviewed studies ranged from 13/13 to 10/13, with the most common deficit being the failure to report reliability measures. The findings of this study suggest only minute rotational and translational movement of the SIJ, and it is unknown if these movements are clinically significant. Although all studies in this review used RSA, significant variability was present in the movements detected in all three axes. These differences could be attributed to the wide range of positions and movements used for determining the SIJ motions. For example, one study used long levers of the cadaversf lower extremities to apply stress to the SIJ, and they reported almost five times as much motion as other studies. Using cadavers in this method could have eliminated the effect of active pelvic stabilizers on the SIJ and possibly decreased the clinical applicability of the findings. Dysfunctional SIJ were included in four of the seven studies, suggesting that only minimal movements are detectable even in the presence of SIJ pathology. The limited movements evaluated may not be enough to allow a clinician to palpate the relative position and motion of the SIJ. For MDT therapists this study adds more weight to the justification for not using kinetic testing when assessing the SIJ especially when we have a battery of reliable and valid pain provocation tests as the best evidence-based alternative.
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Expert Opinion and Controversies in Musculoskeletal and Sports Medicine: Core Stabilization as a Treatment for Low Back Pain
Standaert C, Herring S
Physical Medicine and Rehab. 2007. 88(4): 537-540
Reviewed by Paul Nelson, PT, Cert.MDT (5-13-2008)
In this commentary on core stabilization, Standaert and Herring have examined several aspects of using exercise to enhance lumbar stability. Along the way they raise several points concerning core stabilization as a treatment for low back pain: 1. Few prospective studies on patients with low back pain, 2. Patient selection, 3. Dose response, 4. Long term response, and 5. Lack of standard protocol and accepted definition of core stability. Even though there is wide spread acceptance in the lay community as well as the medical and physical therapy arena there appears to be a significant lack of quality research to support the use of specific stabilizing exercises. Importance to MDT? The importance lies once again in the assessment process. There is no clear-cut answer as to who is most appropriate for these exercises; and which one, if any, will work. If there is no standardized assessment as to who is appropriate for these exercises, clinicians are relegated to delivering random exercise. There is minimal evidence to suggest the proper way to assess lack of “core strength”, pick the most appropriate exercises for the specific patient, give the proper volume and intensity of exercises, and to instruct the patient in home exercises to decrease recurrence rate as well as restore function. As Standaert and Herring report; “Should I prescribe lumbar stabilization exercises to all my patients with LBP? Again, the short answer is ‘No.’The data clearly do not support the universal application of specific stabilizing exercises for all patients with LBP.” As a whole core stabilization needs to be better defined. There needs to be a standardized assessment process to identify who will respond to these strengthening exercises as well as a progression of forces to include a functional return to life and to prevent recurrences. This will be best accomplished with further research to address these issues.
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Is treatment in extension contraindicated in the presence of cervical spinal cord compression without myelopathy? A case report
Murphy DR, Beres JL
Man Ther. 2008. 1-5
Reviewed by Mitchell F. Miglis, DC, Cert.MDT (5-8-2008)
Extension of the cervical spine is said to decrease the diameters of both the central and lateral canals with the potential of producing spinal cord and nerve root compression, respectively. It is often assumed that patients with compromised spinal or lateral canals are not, therefore, candidates for treatments involving extension of the cervical spine. In this paper, the authors present a patient with cervical radiculopathy with motor loss in whom four disc protrusions were shown by MRI, two of which compressed the spinal cord. While carefully monitoring symptomatic response, treatment consisted of end-range extension loading strategies. Symptoms centralized and abolished within three treatments and motor strength normalized. The authors conclude that, in this case, extension not only failed to exacerbate the problem, it actually hastened its resolution. They conclude that extension procedures may not be contraindicated in such a case if a mechanically determined directional preference suggests their use, symptomatic and mechanical responses are carefully monitored and the patient does not exhibit clinical signs of myelopathy. The weak points of this study include the fact that, as a case study, no conclusion can be drawn regarding the effect of the treatment compared to the natural history of the disorder. This is relevant in this study because the first follow up visit was four weeks after the initial assessment. In addition, treatment was multimodal, including end-range exercises, but also another exercise which the authors refer to as the “cervical brace exercise”. Regarding the biomechanical effects of extension of the cervical spine, the authors’ review of the relevant literature leads them to conclude that extension narrows the lateral canal but does not narrow the central canal. This case study sounds a cautionary note, once more, to avoid treating MRI findings and focus on patient response. While the MRI findings in this case indicated significant morphologic abnormalities, the patient’s symptomatic and mechanical response to appropriate end-range loading were positive. The MRI findings in this case should have alerted the clinician to proceed with caution, monitoring for signs of clinical myelopathy, but served little purpose beyond that, and could easily have halted an apparently effective treatment based upon a false-positive MR-“lie”.
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Subclassification of low back pain: a cross-country comparison.
Billis EV, McCarthy CJ, Oldham JA
Eur Spine J. 2007. 16:865-879
Reviewed by Julia Chevan, PT, PhD, MPH, OCS (4-21-2008)
Study Purpose: Many different systems exist for classifying and identifying patients with non-specific low back pain. These classifications share the common aim of creating homogenous subgroups but the purpose of these subgroups differ within the classifications. Some classifications are treatment based while others are diagnostic, few take into account differences by culture or country although low back pain is a “culturally driven disorder.” The purpose of this critical literature appraisal was to conduct a cross-country comparison of classification systems and to investigate whether any classification systems have incorporated cultural factors. Methods: The authors conducted a systemic search of electronic databases (Medline, Cinahl, AMED and PEDro) for articles that contain classification systems for low back pain. The types of articles included theory, clinimetrics and outcomes based studies. Each article was then classified according to methodological criteria detailed by the authors. Results: Classification systems from 9 countries were identified. These systems encompassed 3 paradigms of classification: biomedical, psychosocial and biopsychosocial. The biomedical paradigm incorporated pathoanatomic and/or clinical features. The psychosocial paradigm incorporated psychological and social features. The biopsychosocial paradigm included a mixed approach of both biomedical and psychosocial features. The majority of the studies (28/39) were classified as being from the biomedical paradigm. Conclusions: Country based differences were evident in the classification systems. These differences included the profession involved in developing the classification system and the purposes of the classification system. No singular system has, as yet, been universally adopted. Furthermore, the authors criticize that most classification studies are based on the opinions of experts and are developed using a “judgemental approach.” Few of these systems have undergone critical review in an empirical fashion. Rarely are cultural considerations incorporated into classification systems. The authors recommend that psychosocial and biomedical profiles need to be considered simultaneously in systems; that systems with some degree of established external validity and reliability be used more widely (Quebec Task Force and McKenzie identified); that cultural factors be more widely incorporated. Comments: For the McKenzie practitioner this article offers a unique perspective on future directions for the classification system and some of the limitations of all classification systems. That the McKenzie system of classification has undergone work towards its external validity and reliability is a credit and therapists who are trained in MDT should continue this effort with clinical prediction rule studies and randomized trials.
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Associated sagittal spinal movements in performance of head pro- and retraction in healthy women: a kinematic analysis.
Persson PR, Hirschfeld H, Nilsson-Wikmar L
Manual Therapy. 2007. 12:119-125
Reviewed by Charles Sheets, PT, OCS, Dip.MDT (4-20-2008)
Objective To assess differences in motion and areas of motion when performing cervical retraction in two different sitting positions. Design Biomechanical analysis Setting University Hospital Patients Fourteen healthy adult women aged 30-48 years, without pain and without history of treatment for pain in the past year. Intervention The subjects performed seven trials of full active protraction and retraction in two sitting positions, one with a specific lumbar support, and one without. In the less restrained position, the subjects were instructed to ‘‘sit in a self-selected comfortable position with contact only against the thoracic back rest’’. In the more restrained position, the subjects were instructed to ‘‘strictly keep contact with the thoracic and lumbar back rests of the chair’’. Main Outcome Measures 14 reflective markers were used to measure total anterior/posterior and vertical displacement during active protraction and retraction, as well as the amount of motion at four different levels: cervical (neck to C7), cervicothoracic (C7 to T4), middle thoracic (C4 to apex of thoracic kyphosis), and lower thoracic (apex of thoracic kyphosis to T12). Main Results The difference in total head excursion anterior–posterior direction between the two sitting positions was statistically significant (p = 0.005). There were no statistically significant differences between the sitting positions for anterior–posterior spinal unit displacements. The cervical unit contributed to anterior–posterior total head excursion with 62% in the more restrained and 58% in the less restrained position, the cervicothoracic unit with 28% and 29%, the middle thoracic unit with 7% and 8% and the lower thoracic with 3% and 5%, respectively. Protraction was significantly smaller in absolute values in the more restrained position compared with the less restrained position (p = 0.003). The lower thoracic unit protraction was significantly smaller in relative values in the more restrained position as compared with the less restrained position (p = 0.009). There were no statistically significant differences in retraction amplitude between the different sitting positions. Resting head posture, i.e. retraction, was 45% of total head excursion in the more restrained and 44% in the less restrained position. Conclusion In this study, a large proportion of total head excursion in the sagittal plane was shown to arise from the thoracic region, in healthy women aged between 30 and 48 years.A high correlation between total head excursion and cervicothoracic unitdisplacements was demonstrated, as well as spinal alignment in the sitting position determining the range of active sagittal head excursions. Furthermore, thoracic end range positions influenced sagittal head excursion and limited total head excursion. Comments This study demonstrates the extensive involvement of nearly the entire spine when performing seated cervical sagittal plane motions, as even the lower thoracic spine contributed up to 5% of the motion. When subjects were restrained in an attempt to prevent thoracic motion this resulted in a significant decrease in the total cervical movement. Thus, the present McKenzie procedure of performing protrusion and retraction which allows the thoracic spine to freely contribute appears to be the best way of achieving end range. Patients often demonstrate some concern about feeling symptoms distal to the neck when performing retraction, often in the scapular region. This may be referred pain from the cervical spine, or due to motion in that specific area. This paper also demonstrates the decrease in end range protrusion range of motion with use of lumbar support. This finding supports the common use of a lumbar roll in sitting for patients with posterior derangement or postural syndrome, with a goal of avoiding sustained end range protraction. We must be careful not to extrapolate these results to all of our patients, as the subjects included only middle-aged, asymptomatic women with no significant history of pain. Testing of a symptomatic population might show different results.
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Reconceptualising pain according to modern pain science
Moseley GL
Physical Therapy Reviews. 2007. 12(3): 169-178
Reviewed by Charles Sheets, PT, Dip.MDT (4-20-2008)
This article present a summary of several decades of progress in our understanding of pain and its treatment, moving from the well-known gate-control theory to the current description of the pain neuromatrix. The neuromatrix theory views pain as one of multiple outputs of the central nervous system that occur when tissues are seen to be under threat; it can be accompanied by changes in the immune system, as well as changes in muscle activity. This pain response, however, is related to the perceived threat of damage to the tissues, not to the actual level of tissue damage, especially in patients with more chronic pain. This helps to explain the significant impact that psychosocial factors have in establishing and maintaining chronic pain states. This paper makes four primary points: pain does not provide a direct measure of the state of the tissues, pain is modulated by many factors from across somatic, psychological and social domains, that the relationship between pain and the state of the tissues becomes less predictable as pain persists, and that pain can be conceptualized as a conscious correlate of the implicit perception that tissue is in danger. Given this understanding, the author emphasizes the need for diagnosis and treatment skills beyond anatomy and biomechanics as emphasized in such systems as Mechanical Diagnosis and Therapy. The clinician must recognize that peripheral and central sensitization, as well as psychological and social factors will all have an influence on the patient’s perception of the threat to their tissues. Given the wide and rapidly growing literature on this topic, however, it would be impossible for all but the most dedicated to be current in all aspects of pain understanding. The clinician is emphasized, rather than knowing all of the evidence, to consider different psychological and social factors in terms of what effect they might have on the patient’s perception of threat. Patient education about pain biology has been shown to have immediate and lasting effects on pain and disability. The goal of education is to understand the different factors affecting pain, and encourage patients to ask “’how does this [factor] affect the answer to this question, how dangerous is this really?” In addition to addressing these factors, physical treatment is designed to encourage a return to normal movement, without provoking excessive protective responses. This involves setting a safe baseline, and then exposing the tissue gradually to threat while avoiding unwanted symptom response. This is consistent with the general treatment outline for “chronic pain syndrome” patients in the McKenzie and May lumbar text, which discusses graded exposure and general movement, without a focus on direction-specific treatment. The book discusses that the priority for MDT therapists is a thorough mechanical evaluation and re-evaluations, recognizing that a general worsening of symptoms with all movements likely indicates a non responder due to a chronic pain state. Length of time since onset, while an aspect of the diagnostic reasoning, is not sufficient in isolation to justify this classification. Since reading and incorporating into my practice the ideas presented in Lorimer Moseley’s “Explain Pain” and “Painful Yarns” books, as well as “The Back Book”, I have seen a marked change in my relationships and outcomes with patient with chronic pain. Those who have never had the opportunity to learn this information before will often immediately “get it”, with rapid and occasionally instantaneous changes in pain level. They are frequently relieved to finally understand why this pain remains, and on multiple occasions patients who did not appear to fit any specific category will, with a greater understanding, be able to better describe their pain response and subsequently fit a mechanical classification. The ideas presented in these books and related research have had the greatest impact on my treatment over the past several years.
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McKenzie classification of mechanical spinal pain: profile of syndromes and directions of preference.
Hefford C
Manual Therapy. 2008. 13.75-81
Reviewed by Dave Scotton, PT, Cert. MDT, CMP (4-10-2008)
This is a review of a study performed in New Zealand. Its primary goal was to establish how many patients with mechanical cervical, thoracic, and lumbar pain could be classified into each of the MDT syndromes by credentialed therapists. The secondary goal was to determine, for the reducible derangement syndrome, the proportion of patients in each symptom distribution and their respective direction of preference. They then compared their results with previous studies with the hope of validation. The participating therapists came from a group of 50 McKenzie credentialed therapists that were surveyed by the New Zealand branch of Institute. This group was eventually narrowed down to 34 that actively participated in the study. The study consisted of 321 spinal patients that were treated at the clinics of the participating therapists. Each therapist evaluated and classified 10 consecutive spinal patients presenting in their clinics. They were also given the appropriate initial treatment based on the subgroup they were classified into. Reducible derangement was found to be by far the largest group from all 3 spinal areas, accounting for 81% of the cervical patients, 75% of the lumbar patients and 87% of the thoracic patients. Extension was the most common treatment principle prescribed across all 3 spinal areas regardless of the location of symptoms. This study reinforces some great principles of MDT. 1) That spinal pain patients can be classified into subgroups with appropriate and distinct treatments for each. 2) That reducible derangement is the classification that accounts for the vast majority of spinal patients in all spinal areas. 3) With these derangement patients the directional preference found in the evaluation becomes the treatment principle. These three points make this study particularly relevant. The study was limited in that it only accounts for classifications from the first evaluation. As MDT therapists, we know that in some cases it takes several sessions to gain proper classification. Also, the outcomes of the treatments were not included in the study. It would have been interesting to see them. One final interesting aspect is that it includes cervical and thoracic spinal patients. There are not many studies that include these populations.
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Intertester Reliability and Validity of Motion Assessments During Lumbar Spine Accessory Motion Testing
Landel R, Kulig K, Fredericson M, Li B, Powers CM
Physical Therapy. 2008. 88:1, 43-49
Reviewed by Paul Nelson, PT, Cert. MDT (3-16-2008)
Landel and colleagues have provided a study to assess the intertester reliability of the PA examination in determining intersegmental spine motion and to evaluate validity in vivo with dynamic magnetic resonance imaging. The study was made up of 29 subjects with central low back pain. Two therapists were used for the assessments, one with 15 years and one with 16 years of manual therapy experience. Participants underwent 2 separate assessments of PA mobility of the lumbar spine: within the MRI environment and outside of it. Overall, the study showed good intertester reliability for judging the least mobile segment, but poor intertester reliability for judging the most mobile segment. Most telling, the PA assessments of lumbar mobility did not agree with sagittal plane intersegmental motion as measured by MRI. This study is important to MDT because it serves to illustrate why an MDT evaluation does not incorporate palpation and to try and delineate intersegmental motion of the lumbar spine. It seems that to try and make a treatment plan based solely on palpation would be basing your diagnosis on a poor scientific basis. MDT is a well structured evaluation process using mechanics and the patient’s own pain response as a guide. Using palpation in our assessment process might further confuse the information versus adding valuable information to our assessment. We do nothing to add to the value of an MDT assessment by including palpation. Due to the poor correlation with actual movement based on an MRI, basing a judgment on poorly supported assessment technique would seem to lead us down a slippery slope.
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The internal mechanical properties of cervical intervertebral discs as revealed by stress profilometry.
Skrzypiec D, Pollinyine P, Przybyla A, Dolan P, Adams M
Eur Spine J. 2007. 16(10):1701-1709
Reviewed by Renee Spinella, PT, DPT, Cert. MDT (2-27-2008)
Researchers used stress profilometry to gauge the compressive loading force along the antero-posterior diameter of cadaveric cervical discs. The goal of the study was to determine functional qualities that were unique to the cervical discs as well as those that were similar to the lumbar spine. Specimens were created by mounting two vertebrae and their intervertebral disc (a "motion segment") to a dental plaster mold superior and inferiorly. In total, researchers collected 46 motion segments from 25 cadavers, ageing 48-90 years old; all cervical spine levels were represented (C2-3 through C7-T1.) Discs were classified according to their level of degeneration, 1 (non-degenerated) to 4 (severely degenerated.) Following a two hour "creep" compressive loading force, pressures were measured with the specimens in three postures: neutral, 2-5 degrees flexion and 2-5 degrees extension. This was the first study to focus on the cervical spine; previous studies examined thoracic and lumbar discs, and helps demonstrate several instances where cervical discs function in parallel with lumbar discs. For instance, both exhibit the presence of a hydrostatic nucleus and all discs showed differences in stress concentrations that vary with age, degeneration, posture and creep, however the postural effects were inclined to be greater in degenerated discs. Despite these similarities, the cervical spine displayed two distinct qualities. First, stress concentrations in the posterior annulus usually were smaller than those in the anterior annulus, especially at the lower levels. Next, several displayed a stress gradient across the central regions, even though vertical and horizontal "stresses" were equal. These mechanical differences, however, were not discussed in the study as having clinical implications for function, evaluation or treatment of the cervical spine. Strengths of this study included carefully controlled conditions for retrieval and testing of specimens; a wide range of specimens studies across age, spinal level, and degree of disc degeneration; and repeated tests on each specimen that demonstrated replicable results. Other findings of note were that, similarly to the lumbar spine, discs that were rated more degenerated had little to no hydrostatic nuclear material. Also, posture had significant effects on the tissue. For example, high levels of stress were found throughout the disc in flexed postures, especially in the anterior annulus. Extension demonstrated the opposite, decreased levels of stress in the anterior annulus an elevated levels in the posterior annulus. For McKenzie therapists this research goes some way to explaining why we see a very similar clinical effect in the cervical spine as we do in the lumbar spine. In the lumbar spine we have always looked to the hydrostatic nucleus to explain the symptomatic and mechanical changes, as well as the phenomena of centralization. With the release of previous anatomical work on the cervical spine, when its architecture was shown to be dissimilar to the lumbar spine, arguments were put forward that the McKenzie system in the cervical spine had been undermined and thus its utility in the cervical spine should be questioned. Meanwhile, MDT practitioners refused to allow potentially confounding information regarding the "disc model" to cloud the clear and dramatic clinical effects they saw. This study reaffirms that the use of the "disc model" in the cervical spine is justified, with the disc's hydrostatic nucleus potentially able to play a very similar role as it is documented to in the lumbar spine. Of course, this does not preclude other physiological and pathological reasons for what we observe clinically, but for now the disc model serves its purpose in the cervical as well as the lumbar spine.
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Prognosis of subacute low back pain patients according to pain response.
Schmidt I, Rechter L, Hansen VK, Andreasen J, Overvad K
Eur Spine J. 2008. 17:57-63
Reviewed by Mitchell F. Miglis, DC, Cert. MDT (2-20-2008)
Centralization or failure to centralize have both been shown to be predictors of low back pain prognosis. The aim of this study was to evaluate the prognostic value of the pain response at the first consultation and the possible influence of gender for low back patients seen in a specialty spine clinic in Denmark. Inclusion criteria were “neck or low back pain with radiating symptoms, with a duration of 4-26 weeks, and without satisfactory improvement after treatment in the Primary Care system”. The published study included only low back patients and, although describing the cohort as “sub-acute”, the patient sample ranged from acute (4 weeks) to chronic (26 weeks). 793 patients were categorized by means of MDT into four subgroups. This was based on the findings of a single, initial consultation. The four subgroups were: Centralization, non-lasting centralization, peripheralization and no effect. Assessment was by two therapists “trained and experienced in Mechanical Diagnosis and Therapy method of assessment”. After assessment, patients were given an individualized exercise program emphasizing their directional preference, when such was present. Otherwise, patients were given a general exercise program and some (where all movements worsened leg pain) were instructed in rest and relief from work. A follow up questionnaire was mailed for one-year follow up. No systematic or statistically significant differences in prognosis were found for the four patient subgroups after one year. Several aspects of this study limit its generalizability to MDT practitioners. After the initial assessment, the patients had their first follow up visit “after two to four weeks to evaluate their status and adjust their exercise program”. This is problematic in two respects. Centralization itself may take more than one visit to establish. In addition, prompt and attentive follow-up is critical to evaluate diagnostic classification, exercise technique, results and compliance in order to confirm, reject or modify the management strategy. In the MDT approach, the first follow up is recommended within one to two days, by phone if not physically, and not two to four weeks later, as in the current study. Rather than a single assessment, MDT emphasizes an ongoing and dynamic assessment process at each visit, with initial visits scheduled in a timely manner as needed. The dynamic nature of this process is believed to optimize outcomes. In addition, the patients in this study ranged from acute to chronic patients all of whom had failed a trial of (undefined) primary care and were seen in a specialty spine clinic. These patients had complex presentations: 96% had leg pain, 11% had prior lumbar surgery, 56% were on sick leave, and 69% had one or more neurologic deficits. These patient characteristics suggest caution in generalizing the results of this study to general contact practice while at the same time suggesting an explanation for the reported lower prevalence of centralization after a single assessment in reference to previous studies. Finally, the episodic and recurring nature of low back and leg pain may confound use of a single one-year outcome questionnaire.
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Classroom postures of 8-12 year old children
Geldhof E, De Clercq D, De Bourdeaudhuij I, Cardon G
Ergonomics. 2007. 50(10):1571-1581
Reviewed by Andrew Marsh, PT, Cert. MDT (2-18-2008)
Back pain is a huge cost for health care, and people have been trying to figure out prevention for years with limited, if any success. Recent literature indicates that back pain is more prevelant among school aged children than previously documented. This study is trying to see how strong the relationship is, if any, between school posture and reports of back and neck pain in 8-12 year olds. This is important to consider as activity management in the schools could play a role in how we manage the biomechanical forces that affect the spine throughout a day at school. The study was made up of 54 boys and 51 girls, ages 8-12 years old, across 41 fourth and fifth grade classes. Postures were recorded via videotape with a portable ergonomic observation device during normal classroom lessons. Two separate researchers reviewed the video tape. Questionnaires on self reported neck and back pain were used 1 month after the recordings under the supervision of their class teachers. This study reinforces some previous studies which note children sit with a poor posture (trunk and neck flexion) for the vast majority of time in the classroom and only move occasionally. There was one significant finding on the relationship between posture and pain: Children who spent more time sitting with the trunk flexed over 45 degrees reported more thoraco-lumbar pain compared to pain free children and those with neck pain. No other significant difference of posture activity was noted among the children who self reported pain in either the neck or back. The other noteworthy finding was that children who did report to have more pain were all older children and the fit of the school furniture was noted of a point of concern. Physical therapists treat kids with back pain and neck pain. Posture is a large part of many treatment paradigms, and school postures are no exception. Knowing school postures are poor overall, a new track of thought may be to focus more on the fit of the furniture to the child as well as the actual posture it self, but further study on this would be required to make a true statement of the reality of this issue. This study also confirms that it is not just adults who spend the majority of their day in a flexed posture, the same applies to children. It is therefore not surprising that clinically we find extension to be a common directional preference in children as well as in adults.
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Evidence-informed management of chronic low back pain with the McKenzie method.
May S, Donelson R
Spine J. 2008. 8.134-141
Reviewed by Dave Scotton PT, Cert. MDT, CMP (2-15-2008)
This commentary covers a review article of McKenzie Mechanical Diagnosis and Therapy. MDT practitioners are well acquainted with the authors. They have been at the forefront of MDT research and publication of MDT, as well as being very active in the Institute. This review is essentially a “state of the union” concerning MDT and the evidence base behind it. It reaffirms that MDT reliably classifies patients into subgroups with distinctly different treatments. This is the direction our profession is moving to. It also clearly demonstrates that MDT is the most researched/evidence based approach for spinal therapy. For MDT trained therapists, it offers an excellent marketing tool to present to referral sources. It very clearly and concisely describes the MDT method and the research behind it. This also would be an excellent article to share with non-MDT trained therapists. It offers interesting conversation to get them involved in using this method.
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An in vivo assessment of the low back response to prolonged flexion: Interplay between active and passive tissues.
Clinical Biomechanics. 2007. 22(9):965-971
Reviewed by Paul Hodges, PT, Cert. MDT (2-10-2008)
This study looks at full lumbar flexion postures maintained over prolonged periods of time and the resultant amount of increased lumbar flexion that is produced. It also looks at the amount of lumbar extensor muscle firing that is required to lift an object at regular intervals and how that changes as the person remains in the flexed posture over time. The study consisted of 10 healthy participants without low back pain who performed a regimen of a 10 minute full lumbar flexion posture. During this 10 minutes, a slow speed isokinetic lift was performed every 2.5 min. The next phase immediately after was a 10 minute full upright standing posture during which a slow speed isokinetic lift was again performed every 2.5 min. The second trial performed on a separate day was identical to the first except a 30 sec. rest was taken after the second lift in both the full flexion phase and the upright standing phase. Measures of the angles of full lumbar flexion and the EMG activities of the lumbar extensors were measured throughout both trials and evaluated. The results showed significant increases in the full flexion lumbar spine angle over time in full flexion phase of the study and it also showed significant increases in the EMG activity of the lumbar extensors. During the upright stance phase, the lumbar flexion angles decreased over time as did the EMG activity of the lumbar extensors. The 30 sec. rest in trial 2 did not produce significantly decreased force of the extensors in the following 2 lifts but did significantly decrease the overall lumbar flexion angles. For the MDT clinician this study adds to the body of evidence implicating sustained flexion as a risk factor in LBP and reflects what we hear with regularity from our patients. It shows particularly that heavy lifting or high force exertion of lumbar muscles immediately after prolonged flexion could be a risk factor for low back pain as passively increasing lumbar flexion causes the extensors to exert more effort over time. Especially when the muscles may ultimately lose force generating capacity as their demand is increased over time. The study also shows that 30 sec of rest is not enough to alter the increased demands of the lumbar extensor muscles over time. Combine this information with what we already know of the increased intradiscal pressure in flexion, the posterior disc migration and weak posterior-lateral annulus and we have the perfect recipe for LBP. Luckily, moving patients in the opposite direction is commonly the perfect remedy!
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Is there a subgroup of patients with low back pain likely to benefit from mechanical traction?
Fritz JM, Lindsay W, Matheson JW, Brennan GP, Hunter SJ, Moffit SD, Swalberg A, Rodriquez B
Spine. 2007. 2007;32:E793-E800
Reviewed by Julia Chevan, PT, PhD, MPH, OCS (1-30-2008)
Study Purpose: Although mechanical traction is not well supported in the empirical literature, it is still an intervention used by clinicians for patients who have back and leg symptoms that are not responsive to other interventions. This study examined if it is possible through a clinical trial to identify a subgroup of patients who have low back pain that respond in a favorable manner to an intervention that includes mechanical traction. Methods: This was a single-blind randomized clinical trial. The inclusion criteria stipulated that subjects were 18-60 years of age with symptoms of pain and/or numbness that extended distal to the buttock, an Oswestry score ¡Ý30% and signs of nerve root deficit. There were two treatment groups into which subjects were randomized. The 33 subjects in the extension group received a maximum of 9 sessions over a 6 week period consisting of an ¡°extension oriented treatment approach¡± that included sustained and repeated lumbar extension, PA mobilization all with the goal of increasing extension range of motion without peripheralizing symptoms. The 31 subjects in the extension and traction group received a maximum of 12 sessions during the 6 weeks that included the same extension oriented interventions as well as mechanical traction during the first 2 weeks of the program. Outcome measures taken at baseline, 2 weeks and 6 weeks included ROM measures, Oswestry, pain rating, FABQ and a patient global rating of change questionnaire. Results: The group that received both extension and traction had greater improvement in Oswestry and FABQ scores at the 2 week follow-up. At the 6 week follow-up there were no differences between the two groups on the outcomes measured. Conclusions: The results may indicate that either traction does not appear to provide a lasting benefit or alternatively, the results suggest that the traction intervention may have been needed to extend beyond the first two weeks of treatment. More interestingly through a covariate analysis the authors identified that the presence of symptoms that peripheralize with extension movement and a positive crossed SLR test may both be indicators of the subgroup that is more responsive to traction whereas centralization indicated a subgroup that was responsive to any intervention either extension or traction. Comments: This was a nicely conceived clinical trial that was unfortunately too short in duration, too small in sample size and too short on follow up to be clinically meaningful. The authors conducted a power analysis for change between groups on the Oswestry but not for the covariate analysis they conducted that was meant to help identify subgroups. This rendered the samples generated as adequate only to detect change between groups but possibly not for the more complex multivariate analysis conducted to identify responsive subgroups. The authors did acknowledge that the six week follow up was far too short and the elimination of traction at 2 weeks from the program seemed too early. From the standpoint of a MDT practitioner the finding that peripheralization of symptoms with extension might identify those who would benefit from traction is certainly interesting but an MDT practitioner would first explore response to lateral movement and this was not done in this trial. Ultimately, if a trial similar to this was conducted again with the exploration of lateral movement for those who peripheralize with extension and the addition of traction for those who do not respond to lateral movement a homogenous group of potential responders to traction might better be identified. Despite the lack of consideration of lateral movements in the treatment, it was encouraging to see the use of a more extensive repeated movement assessment during the examination (including lateral movements) than had been evident in previous trials. Hopefully, this may reflect a trend towards using a more comprehensive MDT assessment in these subgrouping studies.
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Mechanical diagnosis and therapy in back pain: Compliance and social cognitive theory
Hammer C, Degerfeldt L, Denison E
Advances in Physiotherapy. 2007. 9:190-197
Reviewed by Mitchell F. Miglis, DC, Cert. MDT (1-23-2008)
This is a descriptive and correlational design study conducted in Sweden. The stated purpose was to describe certain constructs from social cognitive theory (SCT) in relation to therapeutic exercise compliance using patients with a lumbar derangement syndrome. Social cognitive theory holds that personal factors interact with environmental factors to shape behaviors. While incorporating principles of behavioral psychology, SCT also acknowledges the role of self-reflection, cognition, self-efficacy, etc. in determining ultimate behavior. 58 patients completed the study. 38 McKenzie-certified Swedish physiotherapists performed the assessments and treatments. Of interest to MDT practitioners are the following conclusions from this study: 1) All subjects but one stated that they found the hypothetical explanation of the derangement syndrome satisfactory; 2) 90% of the subjects reported that they were willing to do the exercises several times per day; 3) Subjects reported confidence to perform the repeated movements as very high; 4) Subjects reported confidence to correct posture as somewhat lower, but still high; 5) Actual posture correction behavior was observed to be consistently lower than for correct exercise behavior; 6) Overall exercise compliance appeared to be quite high compared to other studies but differences in measurement methods limits this conclusion. This study has some methodological weaknesses but seems to point toward the following relevant conclusions. Patients perform therapeutic exercises when these are simple, do not require special equipment and do not take much time and when there is a clear cause-and-effect relationship between the exercises and rapid or progressive clinical improvement. MDT exercises are individualized to the patient and often fulfill these criteria. One take-away point from this study may be that patients need a little more attention, monitoring and education in relation to the importance of posture correction.
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Effectiveness of a lumbar support continuous passive motion device in the prevention of low back pain during prolonged sitting.
Aota Y, Iizuka H, Ishige Y, Mochida T, Yoshihisa T, Uesugi M, Saito T
Spine. 2007. 32(23):674-677
Reviewed by Dave Scotton, PT, Cert. MDT, CMP (1-21-2008)
This commentary covers an interesting study performed to establish the effects of a Continuous Passive Motion CPM) lumbar support device vs. a fixed support in decreasing LBP during prolonged sitting. It consisted of 31 male subjects without LBP for at least 6 months. A pneumatic lumbar support device was used. All subjects sat in the same chair that was adjustable to allow a 90 degrees flexed knee and 110 degrees back rest angle. The CPM device used a 60 sec. on/off cycle. Each subject sat in the chair for 2 hours on 3 consecutive days. One day no support, one day fixed lumbar support, and one day CPM support. The order of the 3 was randomized. Subjects were to try to remain motionless. Immediately after each trial the subjects rated LBP, stiffness, and buttock numbness on a 10 - cm VAS. The researchers also studied whole body motion and pressure distribution of the human - seat interface. The results of the study were significant in that both the fixed and CPM supports had significant reduction in self reported LBP, stiffness, and fatigue when compared to no support. The CPM device also had a significant reduction in the buttock numbness. For MDT trained therapists, this was significant in that it reaffirms previous studies that show maintenance of the neutral lordotic curve with a simple device decreases discomfort in patients. This study does not support the cost of a pneumatic device over a simple fixed device. Remember, that this was a non-symptomatic population. It would be interesting to repeat the study in symptomatic population as has been done previously with a simple fixed device (Williams, et al, Spine, 1991).
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Effect of neck exercise on sitting posture in patients with chronic neck pain
Falla D, Jull G, Russell T, Vicenzino B, Hodges P
Phys Ther. 2007. 87:408-417
Reviewed by Troy McGill, MPT, Dip. MDT (1-18-2008)
Study Purpose: Poor sitting posture has been implicated in the development and perpetuation of neck pain. This paper examined 2 situations: 1) compare change in cervical and thoracic posture during a distraction task between patients with chronic neck pain and a control group and 2) compare the effect of 2 different neck exercise programs on persons with neck pain to maintain correct sitting posture during a distracted task. Methods: The authors measured change in cervical and thoracic upright posture every 2-minutes during a 10-minute computer task. The subjects were then randomized into one of 2 exercise groups. The first group received a 6-week exercise training program of the craniocervical flexor muscles; the second group received a 6-week training program focused on endurance-strength of the cervical flexor muscles. Change of cervical and thoracic sitting posture angle served as the outcomes measure. Results: Subjects with neck pain demonstrated a change in the cervical angle across the duration of the task (mean angle change was 4.4º). No significant difference was observed with the control group (mean change = 2.2º). Following the exercise program, the craniocervical flexor training group demonstrated a significant reduction in the change in cervical angle across the duration of the computer task. Conclusions: The authors state that this paper showed that people with chronic neck pain demonstrate a reduced ability to maintain an upright posture when distracted. They go on to note that after training the craniocervical flexor muscles, subjects with neck pain demonstrated an improved ability to maintain a neutral cervical posture during prolong sitting. Comments: The authors in the introduction section go into great depth to explain cervical muscular function. They list the importance of these muscle groups in maintenance of cervical posture and that recent studies have identified impaired activation of the deep cervical flexor muscle groups in people with neck pain. Patients were aware that their posture was being monitored, so bias to actively correct posture could have been a factor. No group of patients received posture education/correction only. It would have been interesting to see what strength changes occurred with purely functional exercises i.e. postural education/changes. The authors mention “retraining the deep cervical flexor muscles, which has been shown to decrease neck symptoms and increase activation of the deep cervical flexor muscles during performance of craniocervical flexion which may improve the ability to maintain an upright sitting posture”. By sitting tall, both groups demonstrated a reduction in pain, irrespective of the exercise program they received. This study underscores the proverbial argument, which came first the chicken or the egg. So the question would be; were patients that received exercises for their cervical musculature now more aware that they should sit tall and did so; or was it the fact that they strengthened cervical musculature with exercises that they now were able to sit with improved posture. I would argue the former, the paper argues the latter. If you argue the latter then you would have to say that posture is an involuntary action, similar to gastrointestinal function. Maintaining posture is a voluntary action. One can have “strong” cervical musculature and still have a forward head position or poor cervical alignment. The implications for the MDT clinician would be to ensure patients are properly educated on correct postural alignment and the reasons why correct alignment is important. Patients can and should expect short-term “new pains” while they functionally strengthen and acclimate the muscles to a proper postural alignment.
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A case of a potential manipulation responder whose back pain resolved with flexion exercises.
May S, Rosedale R
J Manipulative Physiol Ther. 2007. 30:539-542
Reviewed by Albert Couperus, BPhty, Cert. MDT (1-7-2008)
This article looks at the issue of a clinical prediction rule (CPR) for manipulation of patients with back pain and whether or not clinically assessed manipulation responders are an exclusive subgroup compared to a mechanically assessed directional preference (DP) subgroup. The article is a case study, looking at one patient with low back pain. This patient displayed 4 out of 5 clinical characteristics of a CPR for a manipulation responder. This patient then underwent a mechanical assessment. On assessment it was found that the client demonstrated a DP for flexion. She was given self-management flexion exercises to perform. She was followed up on a number of occasions: 4 days later, 6 days later, 1 month and 6 months. She demonstrated a consistent improvement on various validated outcome measurement scales, and displayed the ability to self-manage any exacerbations over this period of time. The authors go on to discuss the implications of this finding and provide a critique of CPR, as well as their own findings. The main point of this article is that the authors raise the possibility that patients that fit a CPR for manipulation may also respond to self-management as a result of a mechanical assessment finding a directional preference. There are a number of implications for the MDT clinician. Firstly, this case study suggests that there are patients that respond to DP exercises even though they may be classified as an exclusive manipulation responder. Secondly, it suggests the possibility that MDT is an appropriate alternative to manipulation. The implications in terms of self-management are obvious. It also emphasises the benefit of applying a mechanical assessment to all patients that come across the clinician’s path.
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Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain
Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N
Eur Spine J. 2007. 16:1539-1550
Reviewed by Julia Chevan, PT, PhD, MPH, OCS (12-20-2007)
Study purpose: To assess the accuracy of clinical diagnostic tests in identifying the disc, facet joint or sacroiliac joint (SIJ) as the source of a patient’s non-specific low back pain (NSLBP). Methods: The authors performed a systematic review of the literature. Criteria for the literature search algorithm and study inclusion were provided; 41 studies fulfilled the inclusion criteria. Methodological quality of each study was assessed using QUADAS. Overall quality of the studies was “moderate.” 28 of the studies investigated the disc as the source of pain, 8 investigated the facet joint and 7 the SIJ. Results: Discogenic studies included MRI findings, the centralization phenomenon and response to vibration testing. Centralization studies indicated informative +LR (2.8) and uninformative –LR (.66). Spinous process vibration indicated uninformative +LR and –LR. Facet joint studies were inconclusive providing mixed results for Revel’s criteria. SIJ studies indicated informative +LR (3.2) and uninformative –LR for combinations of tests. Conclusions: Based on this review the authors provided conclusions about each clinical entity. For discogenic problems, there are no available clinical tests that can be used to both increase and decrease the likelihood of the disc as the source of NSLBP. MRI high intensity zone, MRI disc degeneration, MRI endplate changes and centralization all have informative +LR which would indicate that a positive test result increases the likelihood of the disc as the source of symptoms. For the facet joint there are currently available tests have limited diagnostic validity. For the SIJ a combination of pain provocation tests both increases and decreases the likelihood of SIJ as the source of symptoms. Comments: Systematic reviews are reliant on the studies previously published and the methodology including the subject population and the reference standards used by these same studies. The authors of this systematic review rightfully point out that these are major limitations of their conclusions. This review does not contribute substantially to information already known to clinicians. The most relevant component for the MDT practitioner pertains to the value of centralization. However, clinicians are most interested in its value in confirming the diagnosis of derangement, determining directional preference and predicting outcome. For the broader medical/surgical community and spine researchers for whom the relevance of being tissue specific may be greater, the confirmation of centralization’s ability to predict discogenic pain will hopefully make more of an impression. In this regard the study adds to the body of literature supporting centralization as an important diagnostic tool.
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Randomized trial of two physiotherapy interventions for primary care back and neck pain patients: cost-effectiveness analysis.
Manca A, Dumville JC, Torgerson DJ, Klaber Moffett JA, Mooney MP, Jackson DA, Eaton S
Rheumatology. 2007. 46:1495-15010
Reviewed by Julia Chevan, PT, PhD, MPH, OCS (12-18-2007)
Study purpose: To assess the cost effectiveness of two theoretically different intervention approaches for non-specific musculoskeletal back and neck conditions. The intervention approaches studied were the Solution Finding Approach, a cognitive behavioral intervention and the McKenzie approach. Methods: Subjects were recruited from primary care practices in two areas of the UK. Inclusion criteria required subjects to be over age 18, have back or neck pain that was of non-systemic origin and score either 4 or greater on the Roland Morris Disability Questionnaire or 10 or greater on the Neck Pain Questionnaire. Subjects were randomized into the two intervention groups. The McKenzie Approach subjects (n=161) were assessed using repeated movements and based on the findings prescribed specific exercises to work on repeatedly on their own with follow up at the physiotherapists’ discretion. The Solution Finding Approach subjects (n=154) worked with a physiotherapist on identifying problems related to the pain, developing solutions and setting goals. These subjects interaction with the physiotherapist included an interview, physical exam, explanation about the condition, reassurance and goal setting, 1-2 follow up sessions were offered for guidance. Outcome measures included number of physiotherapy visits, additional resource use, unit costs and the Euro-Qol-5D Questionnaire which was completed at baseline, 6 weeks, 6 months and 12 months. Cost effectiveness analysis was carried out using incremental costs for intervention and Quality Adjusted Life Years. Results: Subjects in both intervention groups had improvements over time with no significant difference between groups. The McKenzie Approach required on average 4 visits while the Solution Finding Approach required 3. The incremental mean cost for the McKenzie Approach subjects was £177 higher when all resource use was considered. Subjects who received the McKenzie approach had slightly greater utility (QALYs) compared to the other group. Thus with the Solution Finding Approach slightly cheaper and the McKenzie Approach conferring greater benefit/utility, the cost effectiveness analysis favored the McKenzie Approach. Conclusions: Both approaches provide benefit for subjects. The Solution Finding Approach is lower in cost but the McKenzie approach has better health outcomes as measured by QALYs. Policy analysts would need to consider each outcome in deciding which approach to advocate. Comments: This study presents an economic analysis of potential benefits derived from the McKenzie approach. The analysis may be unfamiliar to most practitioners of MDT. Especially unusual but typical of cost effectiveness studies is the use of QALY, a health benefit measure that accounts for both health related quality of life and risk of mortality. The measure itself may be called into question since the risk in most mechanical conditions is actually morbidity and disability rather than mortality. Still, this study did demonstrate that the cost of providing care with the McKenzie Approach as opposed to a cognitive behavioral approach is worthwhile due to the additional benefit gained. Whether these two approaches are real choice options for most patients seeking care was never explored in the article and is worth consideration.
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A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy.
Rubinstein SM, Pool JJ, van Tulder MW, Riphagen II, de Vet HC.
Eur Spine J.. 2006. Sep 30
Reviewed by Julia Chevan, PT, PhD, MPH, OCS (12-18-2007)
Study purpose: To assess the diagnostic accuracy of six provocative clinical tests (the upper limb tension test [ULTT], shoulder abduction test, Spurling’s test with neck extension, Spurling’s test without neck extension, traction/distraction and Valsalva’s maneuver) for cervical radiculopathy. Methods: The authors performed a systematic review of the literature. Criteria for the literature search algorithm and study inclusion were provided; six studies fulfilled the inclusion criteria. Methodological quality of each study was assessed using QUADAS. Results: None of the studies included use the optimal reference standard of both electrodiagnostic testing and advanced imaging. A number of additional threats to internal validity were identified in each study. External validity generally scored well across all studies. There was great variability in the results of the studies on the diagnostic accuracy of the tests. The studies which investigated Spurling’s tests, neck traction/distraction and Valsalva’s maneuver demonstrated low to moderate sensitivity and high specificity. The studies which investigated the ULTT demonstrated high sensitivity and low specificity. The studies for the shoulder abduction test demonstrated low to moderate sensitivity and moderate to high specificity. Conclusions: Based on these results a practitioner could use these clinical tests in conjunction with a history to determine the presence of a cervical radiculopathy. A positive Spurling’s test, neck traction/distraction test and Valsalva’s maneuver may be indicative of the presence of a cervical radiculopathy. A negative ULTT may be indicative of the absence of a cervical radiculopathy. Comments: The authors while conducting a methodologically sound ultimately had to make conclusions based on a small number of studies that used a number of different and not necessarily optimal reference standards. These limitations prevent any “firm conclusions” about the diagnostic value of the provocative tests under study. Nonetheless, implications for the MDT practitioner come from the tests with the highest specificity (i.e. the lowest false positive rate) and those with the highest sensitivity (i.e. the lowest false negative rate). In the least, when discussing findings with medical practitioners who diagnose radiculopathy using electrodiagnostic testing or imaging the MDT practitioner should select an array of tests to rule in (Spurling’s, neck traction/distraction and Valsalva’s maneuver) and rule out (ULTT) rather than relying on any one single test or technique.
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Unloaded movement facilitation exercise compared to no exercise or alternative therapy on outcomes for people with non-specific chronic low back pain: a systematic review.
Slade SC, Keating J
J Manipulative Physiol Ther. 2007. 30:301-311
Reviewed by Myra V. Hufnagel, PT, DPT, Cert. MDT (11-1-2007)
Exercise is proven effective in treating nonspecific chronic low back pain (NSCLBP). However, there is a wide variety of interventional exercises intended to treat NSCLBP. Identification of the specific effects of these exercises can aid with prediction of outcomes. The investigators conducted a systematic review of published randomized controlled trials. Six high quality researches were selected based on inclusion-exclusion criteria. Four studies used the McKenzie method of unloaded movement facilitation (McKenzie method) compared with: (1) chiropractic care, general stretching and strengthening exercises; (2) educational booklet ;( 3) trunk strengthening exercises; and (4) general practitioner care. Two studies compared yoga postures compared with: (1) PT designed general conditioning and strengthening exercises; (2) self-care; and (3) patient education. The effects of each intervention were measured using the Standard Mean Difference at 95% confidence interval. Pooled effects were analyzed using the Cochrane Collaboration Review Manager 4.2.3 software. Outcome measures include pain and function. The results are: (1) McKenzie method is better than intensive trunk strengthening for short and long term pain; and short term function. Their effect to medium term function is comparable. (2) McKenzie method is comparable to trunk stabilization exercises for short term pain and function. (3) Yoga is comparable to trunk strengthening for short and medium term pain and function. (4) Pooled effects favored the McKenzie method over other exercises for short term pain; and comparable for short term function. (5) Pooled effects favored yoga over education for medium term pain and function. (6) The effects of the McKenzie method are comparable to yoga. Conclusion: Strong evidence supports the favorable effects of unloaded facilitation exercises on pain and function compared to no exercise; the effects are comparable to effort- intensive exercises and stabilization. Although MDTers may not be over the moon at coming out of this study being “comparable to yoga” at least this study does not ignore the McKenzie literature and on the whole the results are relatively favorable. This review can certainly be seen as adding another contribution to the evidence base of MDT.
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Psychosocial variables in patients with (sub)acute low back pain: an inception cohort in primary care physical therapy in The Netherlands.
Heneweer H, Aufdemkampe G, van Tulder MW, Kiers H, Stappaerts KH, Vanhees L.
Spine. 2007. Mar 1;32(5):586-92
Reviewed by Susanne Schaars, PT, Dip. MDT (11-1-2007)
The article “Psychosocial Variables in Patients with (Sub) Acute Low Back Pain by Heneweer et al examined a variety of indicators to try to predict which person would progress from acute to chronic pain. They looked at the demographic, psychosocial and psychological information of 66 people. The information was gathered at 2, 4, 8 and 12 weeks. The study showed that the status of the person at 8 weeks, as measured on the Acute Low Back Pain Screening Questionnaire, indicated whether or not the person developed chronic pain. The total score being 81 for those that had not recovered and 67 for those that had. This shows the usefulness of this tool for showing a difference between the two groups. The other tests did not show significant differences that measured fear-avoidance, fear of pain, and pain-coping. This information gives the McKenzie practitioner time to work on the mechanical loading of the person, since 8 weeks was when the difference in numbers was noted. The limitation in the study is that it only included 66 people and 15% dropped out. They stated that those that dropped out did not differ significantly on baseline demographic characteristics. The 62% of the population had had 1 -3 episodes of LBP in the past 5 years with 5% having none and 7% having more than 10. The other limitation is that therapy was not controlled and it was at the discretion of the therapist. The authors felt that it mostly included manual therapy, manipulation or exercise therapy. The success of the therapist needs to be questioned since the 45% of the patients were not better at 12 weeks and they had not continued to improve much from eight to twelve weeks. So for this study, the first 8 weeks appeared to be critical. This study contradicts much of the recent literature in regards to it finding a lack of predictive value of many psychosocial factors (including fear avoidance). Pain related factors showed a greater predictive strength. This intuitively makes sense to most mechanical therapists and may be a sign that the pendulum has swung a little too far towards the psychosocial and may be due to swing back!
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A comparison of fatigue failure responses of old versus middle-aged lumbar motion segments in simulated flexed lifting.
Gallagher S, Marras WS, Litsky AS, Burr D, Landoll J, Matkovic V
Spine. 2007. 32:1832-1839
Reviewed by Lynda McClatchie, Cert. MDT (11-1-2007)
Hoops et al (2007) investigated the effects of shorter rest periods on repetitive loading into flexion of feline lumbar spinal motion segments. The repeated movements into flexion allowed creep and micro-damage in the viscoelastic tissues in all samples. Interestingly, the group with the shortest rest period demonstrated similar creep values to the group with the longest rest period, but the two mechanisms were very different. With a work to rest ratio of 2:1, multifidus spasms and evidence of damage to neuromuscular tissues acted to stiffen the joint in an attempt to limit further injury, which served to minimize the creep of the viscoelastic tissues. With a rest period of four times the duration (1:2), there were decreased frequency and intensity of multifidus spasms, allowing larger amounts of creep to recover. With medium work to rest period (1:1), it allowed only moderate creep recovery and spasms were not very frequent or large, so neither protective joint stiffness nor creep recovery was effective. Allowing work to rest ratios of 1:1 or higher into repeated lumbar flexion induced an acute neuromuscular disorder, as measured by cumulative creep in the viscoelastic tissues and EMG in the multifidus muscle. A work to rest ratio of 1:2 appeared not to lead to an acute disorder. Gallagher et al (2007) examined repeated flexion to failure in lumbar motion segments of adult and elderly spines. Repeated manual lifting of even a moderate load in a flexed position is enough to cause endplate fractures, leading to internal disc derangement and fissuring of the disc. Older vertebral segments demonstrating significantly decreased bone mineral content and bone mineral density experienced tissue failure with repeated flexion much more rapidly than the younger vertebral segments. Lifting a load from a flexed lumbar spine position would likely cause more rapid tissue failure than lifting the same load with an upright position. McKenzie (1981) reports that when lifting a load with the lumbar spine flexed and knees straight, the intradiscal pressure can increase up to five times of that from an upright position. Robin McKenzie purports that the frequency of lumbar flexion is a predisposing factor to low back pain (McKenzie, 1981). These studies have shown that too short rest periods between repetitive loading into flexion, and older lumbar segments with decreased bone mineral content are risk factors for lumbar spine derangements.
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Short rest between cyclic flexion periods is a risk factor for a lumbar disorder
Hoops H, Zhou BH, Lu Y, Solomonow M, Patel V
Clinical Biomechanics. 2007. 22:745-757
Reviewed by Lynda McClatchie, Cert. MDT (11-1-2007)
Hoops et al (2007) investigated the effects of shorter rest periods on repetitive loading into flexion of feline lumbar spinal motion segments. The repeated movements into flexion allowed creep and micro-damage in the viscoelastic tissues in all samples. Interestingly, the group with the shortest rest period demonstrated similar creep values to the group with the longest rest period, but the two mechanisms were very different. With a work to rest ratio of 2:1, multifidus spasms and evidence of damage to neuromuscular tissues acted to stiffen the joint in an attempt to limit further injury, which served to minimize the creep of the viscoelastic tissues. With a rest period of four times the duration (1:2), there were decreased frequency and intensity of multifidus spasms, allowing larger amounts of creep to recover. With medium work to rest period (1:1), it allowed only moderate creep recovery and spasms were not very frequent or large, so neither protective joint stiffness nor creep recovery was effective. Allowing work to rest ratios of 1:1 or higher into repeated lumbar flexion induced an acute neuromuscular disorder, as measured by cumulative creep in the viscoelastic tissues and EMG in the multifidus muscle. A work to rest ratio of 1:2 appeared not to lead to an acute disorder. Gallagher et al (2007) examined repeated flexion to failure in lumbar motion segments of adult and elderly spines. Repeated manual lifting of even a moderate load in a flexed position is enough to cause endplate fractures, leading to internal disc derangement and fissuring of the disc. Older vertebral segments demonstrating significantly decreased bone mineral content and bone mineral density experienced tissue failure with repeated flexion much more rapidly than the younger vertebral segments. Lifting a load from a flexed lumbar spine position would likely cause more rapid tissue failure than lifting the same load with an upright position. McKenzie (1981) reports that when lifting a load with the lumbar spine flexed and knees straight, the intradiscal pressure can increase up to five times of that from an upright position. Robin McKenzie purports that the frequency of lumbar flexion is a predisposing factor to low back pain (McKenzie, 1981). These studies have shown that too short rest periods between repetitive loading into flexion, and older lumbar segments with decreased bone mineral content are risk factors for lumbar spine derangements.
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Measurement of range of movement in the lumbar spine—what methods are valid? A systematic review
Littlewood C, May S
Physiotherapy. 2007. 93:201-211
Reviewed by Paul Stackhouse, PT, Cert. MDT (11-1-2007)
Physiotherapists are well aware of the difficulty of clinical measurements, particularly as it relates to measurement of spinal joint motion. This systematic review examines two widely used clinical methods, the double inclinometer and the modified modified Schober’s test compared to the gold standard of radiographic analysis of spinal motion. This is a very useful paper for clinical physiotherapists to read for several reasons. Firstly the authors give a straightforward description of their methods of choosing the studies to review and the criteria for assessing the quality of the studies. The QUADAS(quality assessment of studies of diagnostic accuracy) is a set of 14 questions which can be applied to any such research. This helps the reader decide if it is worthwhile persisting to the statistical analysis section of a particular research study. Secondly, Littlewood and May discuss the problems in the use of the Intra-class correlation coefficient to determine the amount of agreement between a gold standard test and a clinical reference test. They make a strong case that the ICC will show a linear relation between the gold standard and the reference test, but this does not clearly describe the extent to which the measures agree. Their suggestion is to use the 95% level of agreement which requires the use of the actual units of measurement. The LOA 95% is useful to show the range within which the observed values can be expected to be found. Refer to their paper for the details of this. Finally this systematic review demonstrates the double inclinometer method and the MMST are not valid tests to use in the clinic to measure lumbar spine active range of motion. The MDT terms of minimal, moderate and major loss for lumbar active range of motion remain in my clinical vocabulary. The test is simple, time efficient, and a useful baseline even if it is not demonstrated to be a valid measure of active lumbar ROM.
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Full symptomatic recovery does not ensure full recovery of muscle-tendon function in patients with Achilles tendinopathy
Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J
Br J Sports Med. 2007. 41:276-280
Reviewed by Paul Nelson, PT, Cert. MDT (10-31-2007)
Silbernagel et. al. have provided a clinically relevant study that deals with not only symptomatic recovery of tendon injuries, but functional recovery as well. The results show that of the 67% of patients who achieved symptomatic recovery only 25% had achieved acceptable level of muscle function. When symptoms abate, patients are likely to stop therapy and go back to normal activities. Unless educated that symptoms can abate before functional recovery ensues, the patient can wrongly assume that their injury has healed fully. If the patient returns to an activity that exceeds the tissue capabilities, the injury cycle is re-visited. By assessing the patient with a clinically relevant questionnaire and functional testing, the clinician has a valuable tool readily accessible to ensure full recovery. Patients must be reminded that the tissue is still injured and must go through the healing process to recover full function. It also underscores the importance of setting functional baselines and functional goals that are meaningful to the patient, allowing them to judge progress and provide a realistic end-point. This study fits into MDT philosophy for two reasons; It provides the framework for the clinician to develop an optimal treatment plan for the patient, and it equips the patient with the tools necessary for self-assessment. Therapists trained in Mechanical Diagnosis and Therapy are well equipped to handle such patients, as they are skilled at establishing meaningful baselines, progressing forces, re-assessing status and educating the patient. Most importantly MDT emphasizes both recovery of function and self-assessment to ensure that the patient is not only safe during formal therapy, but he/she is prepared to leave therapy with the appropriate tools to avoid re-injury.
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Mechanical Diagnosis and Therapy approach to assessment and treatment of derangement of the sacro-iliac joint.
Horton SJ, Franz A
Manual Therapy. 2007. 12:126-132
Reviewed by Andrew Marsh, PT, Cert. MDT (10-30-2007)
Anyone who has spent any time treating lower back pain will come across the discussion of the role of the sacro-iliac (SI) joint as it relates as a causative factor for back pain. This is not a new discussion, and will most likely rage on for years to come. Although good research has supported the use of the McKenzie evaluation to clear the lumbar spine and then use a series of provocation tests to include or exclude the SI joint (Huijbregts, 2004), the PT community as a whole does not follow this paradigm instead follows minimally support processes which have been used for many years, such as palpation as a primary basis for sacral dysfunction. This paper is a single case report on just how one is to proceed with the use of the McKenzie evaluation and use of repeated motions to further evaluate and treat the SI joint using symptoms classification based on symptom behavior rather then traditional palpation techniques. The case itself is not uncommon to patients we all treat everyday. The rationale for techniques and procedures chosen were well explained throughout the paper. Pictures also depicted treatments to alleviate any questions of the actual technique. A clear visit to visit report starting from relevant history, to physical examination and treatment provides an easy read. Evaluation starts with repeated flexion in sitting, due to the inconclusive nature of the initial physical evaluation, progressing to using a seatbelt to fix the pelvis with standing flexion and extension, moving onto provocation testing for the SI joint and anterior or posterior pelvic motion. In conclusion this is a well done case report with thorough explanations and research to support them. This case also provides a great road map on how to use the McKenzie system to evaluate the SI joint, and more importantly when to do so.
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The response of the nucleus pulposus of the lumbar intervertebral discs to functionally loaded positions.
Alexander LA, Hancock E, Agouris I, Smith FW, MacSween A
Spine. 2007. 32:1508-1512
Reviewed by Renee Spinella, PT, Cert. MDT (10-30-2007)
The investigators used the new upright positional MRI scanner to image the spine in six functional positions to determine the effect on the position of the nucleus pulposus (NP.) Eleven healthy volunteers were placed into each of six positions (standing; sitting upright, flexed and extended; supine; and prone extension); scanning took approximately five minutes per position. The midsagittal slice was then analyzed for each position to determine significant differences between the Cobb angle which equates to the lumbar lordosis. Results suggest a significantly reduced lumbar lordosis in the upright and flexed sitting postures as compared with the other four positions and significantly greater lordosis in the prone extension position as compared with all positions except standing. This is the first study to provide evidence for the longstanding belief that functional positions impact the position of the NP of the lower lumbar spine and therefore, the study has important implications for physical therapist practice. The results confirmed that, for these subjects, flexed seated postures caused a significant posterior migration of the L4-5 NP as compared with sitting in extension. These findings provide evidence that supports the recommendation to maintain the lumbar lordosis while in the sitting position in order to preserve proper positioning of the NP. Likewise, results indicate significantly less posterior migration of the L4-5 NP with standing as compared with sitting upright or flexed as well as prone extension and supine lying as compared with any of the three sitting positions. Since no significant difference was found between prone extension versus supine lying, this study does not support the common practice of utilizing a prone on forearms position more than simply lying down to decrease posterior disc derangement. However, as MDT therapists, the therapeutic value of positions and movements are determined by the symptomatic and mechanical response. So while correlation with disc position is interesting, it cannot be used to dictate the usefulness or not of any particular loading strategy. Unfortunately, the researchers lacked the ability to scan the subjects during active movement or in an end-range extended position, both of which are more commonly used as treatment techniques for individuals with low back pain. All in all this study does add some weight to previous literature for the justification of using the disc mechanics model to explain clinical and daily responses to movements and loading strategies.
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The effects of common anti-inflammatory drugs on the healing rat patellar tendon
Ferry S, Dahners L, Afshari H, Weinhold P
The American Journal of Sports Medicine. 2007. 35:1326-1333
Reviewed by Frank Filice, PT, Cert. MDT (10-23-2007)
Although there is a large amount of animal studies on the effect of nonselective and cox-2 selective NSAIDs on bony healing (decreased biomechanical strength, slower radiographic healing and delayed fracture healing), the data on tendon healing is more limited and unclear. The purpose of this study was to compare the effects of a number of commonly used analgesic agents on the properties of a healing tendon at the osteotendinous junction. The authors hypothesized that the acute inflammatory response seen after injury or surgery is important to the healing process and that a detrimental effect will result from the use of NSAIDs immediately post injury or post surgery as compared to a control group and one that received acetaminophen(no anti-inflammatory properties). This was an animal study using 215 rats whose patella tendon was transected at the inferior pole of the patella and then repaired using sutures. The animals were then randomly divided into one of seven treatment groups: one control and one of each receiving acetaminophen, ibuprofen, piroxicam, naproxen, celecoxib and valdecoxib. The drugs were administered for fourteen (14) days at which time the animals were sacrificed and the extensor mechanisms isolated. The specimens were then loaded to failure and a biomechanical analysis of the repair site was undertaken. All of the animals that received NSAIDs, with the exception of ibuprofen, displayed detrimental effects on healing strength as demonstrated by decreased failure loads and increased failures at the repair site. Biomechanical analysis showed a significant relationship between the strength of the repair and the total collagen content of the repaired tissue. The ibuprofen group most closely resembled the control and acetaminophen groups. No reason could be clearly identified for this. The exact mechanisms by which NSAIDs inhibit tendon repair remains unclear but may have to do with the suppression of bone morphogenic proteins (BMPs) and tendon cell proliferation. The former have been shown to facilitate tendon repair and may be involved in the normal tendon healing process and the later could lead to decreased collagen production. The authors cite studies that have shown that these effects do not seem to occur if NSAIDs are administered after the acute stage. They therefore conclude that anti-inflammatory drugs with the exception of ibuprofen, should be used judiciously in the acute period after the injury or surgical repair at the bone-tendon junction.In applying Mechanical Diagnosis and Therapy principles to the extremities we often use repeated movements with the intention of remodeling tissue. By demonstrating that the repair process immediately post surgery (and by implication immediately post injury) can be compromised by the use of anti-inflammatories, this study alerts us to the possibility that the response to mechanical treatment during this phase could also be compromised in the presence of anti-inflammatories. Moreover, a mechanical approach to treatment during this phase would make more sense than one that was focused on suppression of the inflammatory response.
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A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain.
Murphy DR, Hurwitz EL
BMC Musculoskel Dis. 2007. 8.75
Reviewed by Mitchell F. Miglis, DC, Cert. MDT (10-4-2007)
Spinal pain and disability are common problems. Their treatment is determined more by the type of healthcare practitioner seen than by the needs of the individual patient. In this paper, Drs. Murphy and Hurwitz acknowledge the need for clinicians to be better able to base treatment decisions on reliable and valid diagnostic strategies and thus to achieve better outcomes in terms of pain relief and functional improvement. To this end, they review a broad array of diagnostic and prognostic factors in a systematic and orderly way which creates a cohesive and testable hypothesis regarding appropriate management strategies for back pain patients. The framework of their hypothesis is built around the answers to three key questions: 1) “Are the patient’s symptoms reflective of a visceral disorder or a serious or potentially life-threatening illness?” 2) “From where is the patient’s pain arising?” Precise tissue of pain origin is not the intended answer. Rather, probabilistic assessments are encouraged regarding a set of possible underlying pain generators. Centralization, pain provocation signs, neurodynamic signs and muscle palpation signs are all proposed for evaluation. And, finally, 3) “What has gone wrong with this person as a whole that would cause the pain experience to develop and persist?” This question targets other factors than the pain generating tissue (for example, yellow flags and chronic pain states) which may maintain or perpetuate the pain experience. The value of this paper to the MDT practitioner is the rich perspective it provides regarding a very complex issue: “None of the important factors that may be present in any given spinal pain patient occurs in isolation. Pain generators and perpetuating factors interact in producing the clinical picture that practitioners see”. Centralization is recognized in this paper as an important component of an evaluation, however, similarly to other papers by non-MDT trained individuals; its full potential is understated. Those trained in MDT recognize the potential of the system to clarify many of these apparently complicated and multidimensional issues. This ultimately reduces the potentially large subset of non-responders into a much smaller group. The authors promise a follow up paper to systematically review the evidence regarding their hypothesis as well as proposed research to test their model.
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Sub grouping patients with LBP: Evolution of a classification
Fritz JM, Cleland JA, and Childs JD
JOSPT. 2007. 6(6):290-302, 2007
Reviewed by Dave Scotton, PT, Cert. MDT, CMP (10-2-2007)
This commentary covers a series of research efforts to develop a valid classification system aimed at assisting therapists in the management of patients with LBP. The authors have been actively involved in this body of work since the late 1990’s. It represents the current evolution of the classification system. The original system was developed by Delitto et al in 1995. It classified LBP patients into one of 4 categories: manipulation, stabilization, traction, and specific exercise (flexion, extension, and lateral shift). The subsequent research over the past decade or so has required some modification of the classification criteria. Modifications are evidence based from this research. Overall, the classification system is concise and easy to use. It is a manual therapy based system. There are some challenges for MDT trained therapists in using the system. First of all, in the extension sub-group it states that it is only for patients with symptoms distal to the buttock. We, as MDT therapists, have all had many patients with central or asymmetrical LBP that responded well to directional preference (DP) based exercises. There also is and assumption that you can only use flexion and extension exercises for a derangement or stenosis population. There are other pathoanatomical reasons for their use. Secondly, the manipulation and stabilization groups have clinical prediction rules (CPR) for classification. The classification criteria for the manipulation group represents patients that MDT therapists successfully treat every day without manipulation. This point was made clear in the recently published case study by May and Rosedale (J. Manip. & Physio. Therapeutics, Sept. 2007). They report of a patient that had 4 of the 5 criteria for the manipulation CPR. This patient also demonstrated a DP for flexion. The patient was successfully treated with flexion DP exercises. The patient remained pain free at 6 months follow-up. One interesting question that should be looked at is: Do patients that receive manipulation respond faster compared to directional preference based exercises? Also, do they have less reoccurrence if manipulated? These are questions for other studies. In closing, the classification system reported poses some challenges for use by MDT trained therapists secondary to the differences in classification criteria.
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A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs
Fishbain DA, Cole B, Cutler RB, Lewis J, Roseomoff HL, Rosomoff RS
Pain Medicine. 2003. 4(2):141-81
Reviewed by Mitchell F. Miglis, DC, Cert. MDT (9-29-2007)
During the 1980’s, orthopedic surgeon Gordon Waddell studied a group of physical signs often found in chronic pain patients. Although these signs were later shown to occur in acute pain patients as well, they were initially thought to represent primarily “non-organic” findings, suggesting either malingering or hysteria. Dr. Waddell defined 8 discrete signs and placed them into 5 general categories (tenderness, simulation, distraction, regional and overreaction). Using this format, Dr. Waddell proposed that if 3 or more categories were positive, the patient should be investigated for psychological problems. Since this initial work, the use and interpretation of the so-called “Waddell signs” has been both widespread and controversial. In the above paper, Drs. Fishbain, Cole, et. al. perform a structured evidence-based review of the literature relating to the meaning of Waddell signs. They examine the reliability and validity of classic Waddell signs across 15 categories. They conclude that the evidence does not support an association between Waddell’s signs and psychological distress, illness behavior or secondary gain. Further, they argue that test-retest reliability and inter-tester reliability have not been demonstrated. On the other hand, their review supports the validity of using Waddell signs to predict poorer outcomes. Despite the historical use of Waddell’s signs as indicators of psychological distress, signs of non-organic involvement, abnormal illness behavior, somatic amplification, or worse (malingering, secondary gain signs), the authors argue that there is very little scientific evidence presented to support these interpretations. They advance a number of theoretical explanations to explain Waddell signs, based upon a review of additional pain literature. At least 5 of the Waddell signs, they argue, may have organic explanations according to current knowledge of pain mechanisms. The clinical value of this paper to the MDT practitioner can be summarized as follows. Waddell signs may represent organic, more than non-organic, pain signs. Their most reliable clinical use is prognosis: they have been shown to be inversely related to clinical outcomes and likely have an umbrella effect across all back pain subgroups. They can occur in any stage of pain: acute, sub-acute or chronic. They often worsen with failed and improve with successful treatment, as Dr. Waddell himself later acknowledged. And, finally, their use and interpretation as signs of psychological distress, malingering or for diagnostic purposes is to be questioned.
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