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Research Reviews
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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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
Geldof E, DeClercq 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 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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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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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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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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Research
