Evidence Based Rehab

Merry Christmas! Want to share a great performance by the Indiana University men's a cappella group "Straight No Chaser". Enjoy!

Labels: Christmas, You Tube

Ifirst want to apologize for the time between posts. I've been pretty busy at work, and have found it hard to find time to write. However, I get an "Evidence Express" email everyday from the folks over at Evidence in Motion, and today's included a link to an article from the Poughkeepsie Journal out of New York. The article was on craniosacral therapy and how proper rhythm is needed to ensure a healthy living.

Craniosacral Therapy (CST) is not new, but what is disturbing, is we know it's a bunch of hogwash, and journalist are still writing about it. For the fortunate not exposed to this lunacy, here are some of CST practitioners claims (BTW, you'll find PT's, DC's, Osteopaths and Massage therapist all using this):

1. The "founder" and his Upledger Institute states:

   "Using a soft touch generally no greater than 5 grams, or about the weight of a nickel, practitioners release restrictions in the craniosacral system to improve the functioning of the central nervous system."

2. That one can feel the craniosacral rhythms of the cerbrospinal fluid.
3. And that is is effective in treating:
• Migraine Headaches
• Chronic Neck and Back Pain
• Motor-Coordination Impairments
• Colic
• Autism
• Central Nervous System Disorders
• Orthopedic Problems
• Traumatic Brain and Spinal Cord Injuries
• Scoliosis
• Infantile Disorders
• Learning Disabilities
• Chronic Fatigue
• Emotional Difficulties
• Stress and Tension-Related Problems
• Fibromyalgia and other Connective-Tissue Disorders
• Temporomandibular Joint Syndrome (TMJ)
• Neurovascular or Immune Disorders
• Post-Traumatic Stress Disorder
• Post-Surgical Dysfunction

(Emphasis Added)
Wow! Those are some pretty broad claims. In fact, the CST claims have met all 7 of 7 of my "How to Spot Woo" post I made previously. Here are some truths:

1. Some people get better with CST. There is no doubt in this. But some people get better with magnets, with "energy manipulation", with homeopathic water, with...you get the point. The truth, though, is there is no research that shows people can get better BECAUSE of CST.
   
2. 5 grams IS NOT enough force to get movement of a cranial bone. A study by Downey and associates easily showed this.
3. Study after study shows CST providers cannot show reliability of "feeling" the craniosacral rhythm either between different providers or even within the person using repeated measures. To clarify, it's like your doctor diagnosing your heart problem by listening to your heart with a stethoscope, but at worse than chance, 2 doctors can't agree with what they hear, and worse, the same doctor hears something different when he listens a second time. Read studies done by Rogers here, and Wirth-Pattullo here.
   
4. According to a large systematic review of CST related literature, the British Columbia Office of Health Technology Assessment concluded that -
   

The benefit of craniosacral therapy has not been demonstrated using well-designed research. The available studies are of low grade evidence as rated by the Canadian Task Force on Preventive Health Care (20) ranking system, and are of poor quality when judged using standard critical appraisal criteria. Inadequacies in the studies cited above preclude any statement attesting to craniosacral therapy effectiveness.

What does John Upledger counter with? The pathetic argument that many of these snake oil salesman use:

[P]ositive patient outcomes as a result of CranioSacral Therapy should
weigh greater than data from designed research protocols involving
human subjects, as it is not possible to control all of the variables of such
studies.

Classic.

Labels: alternative medicine, cranial sacral therapy, CST, EBM, Evidence, woo

I recently came across a paper entitled "A Case of a Potential Manipulation Responder Whose Back Pain Resolved with Flexion Exercises" by Stephen May, MSc and Richard Rosedal, PT, Dip MDT. They present a single patient case study of a LBP patient that met 4 of 5 of the manipulation CPR that drastically improved with flexion exercises but did not receive spinal manipulation.

The authors conclusion(s):

We have presented a case study that was positive for 4 of 5 items of the clinical prediction rule for manipulation responders, but this patient was successfully treated with flexion exercises. The clinical prediction rule may not represent a discrete subgroup but may include patients who can be defectively managed in other ways.

I think the authors are presenting an important point. CPR's must be, for the most part, discreet from other classification, or subgroups of patients. However, this single patient case study is very weak data to lead us to abandon the Manipulation CPR.

Now there is no escaping that this single patient got better. However, one could do a case study in which a person met 4 out 5 of the manipulation CPR and the DID NOT get better at all. That's why larger randomized studies are done and then replicated.

Speaking of replication. The authors suggest that the results of the CPR studies may not work in general as all studies, including the replication study, were done on US military personnel. Specifically -

..this is why once a CPR has been derived in one population it must be validated in a different patient population with different clinicians. The manipulation CPR ahs been so validated, but both derivation and validation studies were performed by specially trained clinicians on US military personnel in military facilities, and the applicability of the results to other patient groups and clinicians is unknown.

In truth, the validation study was done 8 clinics in different regions of the US where "Most participating sites were health care facilities within the U.S. Air Force". Therefore, like in my setting near an Air Force Base, not only military servicemen, but also their families and dependents are treated. Secondly, in the US at least, spinal manipulation is a core skill and intervention taught in physical therapy schools.

In my opinion, the authors true colors about the manipulation CPR are shown with this quote:

If this patient had been treated with manipulation by itself, as she appeared to fit the CPR criteria, this management may have failed to provide the patient with her own ability to control and abolish her symptoms when they returned.

And..

Although it has been directly stated that CPRs are not meant to replace clinical judgment and should be used to complement clinical reasoning, it may also be argued that the use of CPRs minimizes the clinical reasoning process, reducing decision making to a "tick-box" activity to bypass more complex and high-level reasoning that is often required in clinical practice.

The first is a direct dogma held by many "McKenzie" therapist who usually proudly boast not needing to touch a patient to get them better. It's also a Red Herring. To imply that the use of manipulation precludes a competent PT from educating and providing the same means to "self control" their pain is almost pretentious.

The second passage is a classic "Guru" based argument. You can't be providing good results if it's easy or straight forward. One must complete expensive Con Ed after Con Ed to get additional letters after their name and finally portray to the patient the complexity of their pain.
I'm almost saddened as, I feel, McKenzie approach works very well specifically because of it's attempt to subgroup patients, which is what this CPR is striving for. Not because it has a complex model that only those with the money and time (not just access to a well done RCT) can achieve.

Finally, CPRs are used all over in medicine with great results. The Ottawa ankle rule, Canadian C-spine rules, Acute Heart failure index, Short term risk after after a PE, Deep Vein Thrombosis, etc. They are there to help us choose the most appropriate treatment for a patient, which leads to improved outcomes, lower costs, and increased patient satisfaction.

I encourage Mr.'s may and Rosedale to continue with their hypothesis and hopefully tease out what type a subgrouping is more appropriate. I know we've already got authors looking at a potential extension oriented subgroup of LBP patients.

Labels: clinical prediction rules, CPR, manipulation

Here is a follow up to the Clinical Prediction Rule for Lumbar Manipulation video I posted on a while back. Again, this video is presented by Physical Therapy Students hoping to educate the rest of us on the best treatment choices for our LBP patients. Enjoy!

Labels: clinical prediction rules, CPR, EBM, LBP, Low back pain, stabilization

While I try to stear clear of blogging on the US vs. Them, PT vs. Chiro debate (although my look at the use of the DRX9000 seems to be viewed by chiros as an assault on them), the underhanded way that profession is trying to "claim" manipulation in my state has brought this post out of me.

I want to first comment on how the Chiro profession is handling itself in Nebraska in regards to the PT profession updating our practice act (which dated back to the 1960's IIRC). Their must be respected powerful lobby was threatening to hold up this new legislation because the new act included language about the use of mobilization and manipulation (these are one in the same to the PT profession). "Oh no you don't" the Chiros exclaimed. They pulled out the old very false but effective crap about no having the training or skill to do (hmm, what was that I was learning in PT school then???) High Velocity Low Amplitude (HVLA) manual therapy. And, like PT's always do, we repented and asked the Chiros what we need to do to fix it. "We'll compromise" they offer.

So manipulation was crossed out and "Grade V mobilization" was added (again, in PT, manipulation and mobilization are one in the same). So, the bill is passed (will hold off on the commentary about Orthos objections to the use of "Physical Therapy Diagnosis"; Orthos and Chiros objections to "direct access" even though we've always had it by omission and no one has died - GASP!; and the school systems wanting to bill the government for PT despite providing care with untrained aides). Fast forward a year, and as the new practice act proceeds through it's many steps to fruition - A practice act is just a guideline, and specific rules and regulations need then to be developed from it - Chiros are back shouting "hold on!". We changed our minds, we object to "Grad V mobilization" cuz we say you can't do it. So it's back to expending money, time, energy, and sweat to again fight for what we've already attained. So, the Chiros back off with a knowing smirk of "we'll be back again".

The second item that brought me to write this was a great post by Panda Bear, MD entitled "Stealth Medicine and Other Topics" railing on Chiro's attempt at backdooring into becoming pediatric primary care providers. As Panda Bear quotes them:

“The doctor of chiropractic does not treat conditions or diseases.” Says so right in their mission statement. But then a little further down it ascribes complaints in every system to our old friend the subluxation and promises, by judicious adjustment of the pediatric spine, to allow the body to express a better state of health and well-being.

Imagine that. Promising one thing and practicing the opposite. Sounds familiar to me. Orac at Respectful Insolence and Eric at Evidence In Motion have both commented on a visited this particular post (Damn, I am slow on the uptake I guess). I'll quote Eric as a nice summary to all of this:

For those non-physical therapists reading this, it may be timely to point out that what IS in our scope of practice is all sorts of manipulative therapy. That's right, the specialization area of Orthopaedic Manual Physical Therapy is one where the physical therapist is equipped with both the tools to manipulate the spine or peripheral joints AND develop a comprehensive, integrated program of neuromuscular modalities for orthopaedic conditions.

For an excellent comprehensive look at the history of PT vs Chiro, the arguments analysed and what is most likely behind Chiro's fighting PT's over manipulation (hint: it's not really patient safety. Ok Hint #2: It starts with "M" and ends in "oney") click here.

Labels: APTA, Direct access, DRX 9000, education, manipulation

Ihave been meaning to blog on the results of a Lancet article finding neither spinal manipulation or NSAIDs are effective on low back pain. However, Eric from NPAThinktank beat me to it with a post on Evidence in Motion's blog. It is very well done and thought out.

The key point we must all understand, is that the population tested was a heterogeneous group of low back pain sufferers. Despite the mounting evidence, no sub-grouping of patient's was done. Predictably, then, to significant results were found. I don't care how many low back pain studies are done, if no treatment based classification is used, you will not find significant results.

Eric quotes Dr. K. Shepard using a great analogy for this. I post it here for your convenience:

A study that randomly assigns patients with low back pain to various conservative treatment protocols will produce the same results as a study that randomly assigns patients with abdominal pain to undergo appendectomy, cholecystectomy, or exploratory laparotomy. Neither study makes any sense.

Our hope in the rehab world is that the referral sources also have the great evidence of treatment based classification and the dramatic effects of lumbar manipulation on the right sub group of low back pain patients. Please read Eric's great post.

Labels: clinical prediction rules, EBM, Evidence, Low back pain, manipulation, physical therapy

Iseem to be on a comic kick of late. But, there sometimes isn't a better way of expressing an idea then from the pen of a comic. Dilbert has always been a favorite of mine, and Scott Adams recently published a great comic illuminating the problems with the public relying on an - often times - ignorant journalist to provide them with an understanding of research. Enjoy! I did.

Labels: ignorance, media, Research

Sorry, I just couldn't resist. The ever changing "subluxation" theory is expanded upon.

Labels: adjustment, Chiropractic, EBM, subluxation

Rising healthcare costs and the health insurance industries continuous push to maintain high profits have lead to higher and higher copays. Especially in PT where insurance companies aren't really sure what they are paying for. It's not uncommon for me to have patients come in with insurance benefits that require a $25-$35 copay per visit. Plus, there is usually some arbitrary visit limit to boot! Many patients balk at this, and our first reaction is to sympathize with them and help make excuses why they don't have to come in, or don't have to come in often. Is this the right approach, though?

A colleague and I just had a conversation today regarding this, and Larry Benz, coincidentally, posted his opinions related to copays over at Evidence in Motion. I won't cut and paste what he states, but I will express my take on the issue.

Do not make excuses for a patient's insurance copay. If you think it's too expensive, then did they really need to be in to see you in the first place? If they need your services, then don't be afraid to let them know and provide them with that service.

Another issue in the area I work in is the difference in copay for a PT owned outpatient clinic vs. a hospital run outpatient clinic. Basically, the PT owned copay is high and the hospital has none. What does one do in this situation? Refer to the hospital to "save" the patient money? If so, then what does that say about your business and your beliefs about your clinical skills when you confirm to this patient that the clinic choice doesn't matter, only the cost (so choose the cheapest?).

In the end, if you are providing quality, outcome oriented, evidence-based treatment, then you should let that prospective patient know that and then give them their moneys worth for treatment without letting that high copay rule over you.

Labels: Copays, Direct access, Healthcare, insurance, physical therapy

Many of us (physical therapists) find the overbearing control of the AMA difficult and stiffleing to what we see as professional autonomy. What most of us don't know, is that it was PT's that gave MD's the power over us. Beth Linker in the Journal of Women’s History, Vol. 17 No. 3 explains:

By 1935, the APA relinquished to the medical profession what little self-regulatory control it still maintained. In 1933, it gave the AMA’s Council on Medical Education complete power to accredit physiotherapy schools. In that same year, physiotherapists turned over the task of setting up a national registry to medical men in the Congress of Physical Therapy. As part of the agreement, the Congress required that physiotherapists be called technicians and give up their private practices to work under the direct supervision of medical doctors.

Power is like money. Once you freely give either to another person, asking them to give it up is a very thorny proposition with a bleak outlook for success.

Labels: AMA, APTA, history, physical therapist

Friday fun. Great week everyone. High fives to you all!!

Labels: Fun

Students from the University of Regis attempt to spread the knowledge regarding the Clinical Prediction Rule for SI manipulation. Fairly corny, but it gets the point across. Appears aimed at the clinician more than a prospective patient.

Are you manipulating your patients that fit the CPR? Change is difficult, but must be made to continue evolving as clinicians and providing the best care known (friggin state of Iowa and their collusion with "Palmerville")

Labels: clinical prediction rules, EBM, Low back pain, manipulation, Mobilization, physical therapy

The public has been exposed to the media over hyping (and misrepresenting) a study that finds acupuncture to be more beneficial than "western medicine". I was first exposed to this by an article on MSNBC entitled "Acupuncture - real or fake - best for back pain." Emphasis added.

Let's take a closer look. Here is a link to the full text. Luckily, this study, and the reporting of it, seems to be recieving great analysis and coverage. This includes Orac over at Respectful Insolence; Dr. Steven Novella's NeuroLogica Blog; and Dr. Ben Goldacre at Bad Science. These two are more intellingent than me, and, most importantly, are able to express themselves better. Please take the time to read their posts. Especially Orac's.

I would just like to highlight a few problems with this study. Understand, though, most studies have flaws and that does not mean they are worthless. However, these flaws must be known because they greatly effect how a study can be applied to you/me/us.

1. This study, as designed, is wholly unreproducible. Why? The "conventional treatment" group was not controlled (well). Some received all, some, one, etc of the "allowable" conventional treatments. Maybe acupuncture is a cure all, maybe not. However, another study using the same methods, cannot be done because the conventional treatment group can not be reproduced.

2. The inclusion/exclusion criteria eliminated the vast majority of patients we see (and for those reading, what you have). Therefore, cannot be applied to much of the LBP population. Orac argues this point well:

One point that leaps right off the page is that the patient population studied had had chronic low back pain for at least 6 months and, based on that duration and the patients' willingness to try acupuncture, we can reasonably infer that their pain probably wasn't responding particularly well to conventional therapy. This makes it unsurprising that the reported response rate in the standard therapy group was so low, given that it was just getting more of the same treatment.

3. There was no blinding. All the participants knew what they were receiving, and, presumably, the same practicioner was providing the "real" and "sham" acupuncture. Although is both the real and sham acupuncture did just as well...does that mean that all acupuncture is sham or that any needling is real acupuncture? Hmm..... In my opinion this opens the door to rater bias and a very large placebo effect (hmm, the 'I'm receiving a "new" treatment' group does better than the 'I'm receiving the same crap that hasn't seemed to work in the past' group).

What to make of this study then? Those with chronic LBP not linked to any known causes (sciatica, DDD, OA, Surgery, etc) that "conventional" treatment has not worked, improved with "shamish" acupuncture compared to the same old crap. Not quite the same as "Best for back pain".

Labels: acupuncture, alternative medicine, EBM, Low back pain, physical therapy

I just finished reading a guest editorial by Robert Wainner, PT, PhD and Julie Whitman, PT, DSc regarding first line interventions for hip pain in the most recent Journal of Orthopaedic & Sports Physical Therapy. Their discussion points to the trend that hip pain, especially OA, is treated in the order of 1. Drugs, 2. Surgery/invasive procedure, 3. Physical Therapy.

Why is PT last? Especially when there are known PT interventions for hip pain that work well. The authors point our that research on exercise for hip pain is not as broad as the knee; but some recent hight quality studies (which include those published by the authors) lend us the ability to form a practice guideline as to treat hip pain. This includes manual physical therapy (mobilization/manipulation) and exercise as the primary exercises.

The general public reading this should also demand (yes, demand, lol) from their primary care doctors that PT is the first line intervention for their hip pain. On our end, we (as PT's) must stay abreast the on current best evidence for treating hip pain - again, mobs and exercise as primary treatment - and APPLY this treatment. We must change and adapt as clinicians.

If you have questions about your hip pain, please as your doctor to refer you to a PT, use the APTA's "Find a PT" tool, or I can try to answer any comments you leave.

Labels: APTA, EBM, Evidence, exercise, Hip, Mobilization, OA, Osteoarthritis, physical therapy

FRiday fun again. Hope everyone had a great week. Thank you for taking the time to read my rants and ramblings. I'm planning on watching 300 for the first time tonight and thought I'd prepare by watching the trailer. Enjoyed it so much I thought I would share it with you.

Labels: Fun

I
occasionally receive comments from readers. My post on the traction machine called the DRX 9000 is a good example of many different comments left. I have recently began receiving many "Anonymous" posts that attack me directly or are far off subject. Examples being "Anonymous" drawing up arms to have me prosecuted for libel and this most current unpublished one:

Why won't you post all comments?

That is what a blog is for?

You post "under investigation" about your competition, but you won't post factual occurrences about your own profession?

Why would this be?

Please post the recent submission about the "fraud" that has been going on within the Physical Therapy profession.

Must keep an educated and unbiased look at everything :)

Until then, this is just a biased blog toward your own advancements, that is all that it is.

My reply? If you don't have the balls to not post anonymously and do so to attack me or make comments not relative to the original blog post, I will unilaterally reject the comment. I have ok'd every opposing view that stayed on subject.

Oh, and yes, this blog is for my advancement and physical therapy in general advancement. I make no hidden agendas in that right.

Conclusion, stay on subject and I have no problem publishing your comments.

Labels: Chiropractic, Direct access, DRX 9000, physical therapy

Ihate "health" products being pushed on us simply with anecdotal evidence and testimonials. One of the newest fads is 'Whole Body Vibration'. The claim is that exercising on this vibrating plate significantly increases your strength versus doing the exercises alone. There is very poor, and limited, evidence for this. For a good overview, please read Sal Merinello's excellent synopsis of the evidence over at The Healthy Skeptic. Below is a brand new journal article on this fad in regards to impact on older men over a 1 year period.

: J Gerontol A Biol Sci Med Sci. 2007 Jun;62(6):630-5. Links

Impact of whole-body vibration training versus fitness training on muscle strength and muscle mass in older men: a 1-year randomized controlled trial.

Bogaerts A, Delecluse C, Claessens AL, Coudyzer W, Boonen S, Verschueren SM.

Division of Musculoskeletal Rehabilitation, Katholieke Universiteit Leuven, Tervuursevest 101, Leuven, Belgium.

BACKGROUND: This randomized controlled study investigated the effects of 1-year whole-body vibration (WBV) training on isometric and explosive muscle strength and muscle mass in community-dwelling men older than 60 years. METHODS: Muscle characteristics of the WBV group (n = 31, 67.3 +/- 0.7 years) were compared with those of a fitness (FIT) group (n = 30, 67.4 +/- 0.8 years) and a control (CON) group (n = 36, 68.6 +/- 0.9 years). Isometric strength of the knee extensors was measured using an isokinetic dynamometer, explosive muscle strength was assessed using a counter movement jump, and muscle mass of the upper leg was determined by computed tomography. RESULTS: Isometric muscle strength, explosive muscle strength, and muscle mass increased significantly in the WBV group (9.8%, 10.9%, and 3.4%, respectively) and in the FIT group (13.1%, 9.8%, and 3.8%, respectively) with the training effects not significantly different between the groups. No significant changes in any parameter were found in the CON group. CONCLUSION: WBV training is as efficient as a fitness program to increase isometric and explosive knee extension strength and muscle mass of the upper leg in community-dwelling older men. These findings suggest that WBV training has potential to prevent or reverse the age-related loss in skeletal muscle mass, referred to as sarcopenia

The results show NO DIFFERENCE between groups; but, the authors make the conclusion that

"WBV training has potential to prevent or reverse the age-related loss in skeletal muscle mass..."

Huh? I guess that is true if general exercise does (which is true). But it doesn't do it any better and at a greater cost and inconvenience. Look for the manufacturers to post this on their websites as "evidence" that WBV training prevents muscle mass loss!

I say: Buyer beware!

Labels: alternative medicine, EBM, Evidence, exercise, fitness, outcomes

Have you taken your medicine today? Funny video poking fun at our current culture towards prescription drugs.

Labels: Fun

Found a brief PR article on lumbar stabilization by Physical Therapists. It is from ADVANCE magazine and the article can be found here. It appears directed at nurse practitioners, which is an important audience for us as more and more of family practice is being handled by "second tier" providers.

Maybe something that could be added to you "packet" of general information one could provide to your referral base.

Labels: Direct access, education, Low back pain, physical therapy, physicians

After many question from my patients and the general public regarding "alternative" treatments (e.g. magnets, craniosacral, dietary supplements, etc) I decided to sit down and write up an educational handout to summarize how to approach evaluating treatment options. This includes treatments in so called "Alternative Medicine" and main-stream medicine alike.

I am very concerned that many alternative treatments are blatant attempts to take advantage of persons in desperate situations. Such as end-stage cancer and progressive disease processes like arthritis.

Below are some ideas on how to approach decisions about "new" therapies to allow you to maximize your potential gains and to protect your money from those offering up only a big handful of woo.

---

EVALUATING INTERNET MEDICAL ADVICE

Jason Harris, PT, DPT

Our modern internet has opened the door to a vast arena of medical advice and information. With this information, it is important to critically evaluate the information and the author’s credibility. How does one pick between credible and worthless? It can be hard, but I will outline a few rules for judging the value of the information you are reading.

I suggest you look for "Red Flags" while researching medical information on the internet. In medicine "Red Flags" are signs and/or symptoms that warrant immediate attention as they indicate a potential life threatening situation. I will use the term to indicate immediate problems with information that is being evaluated.

"RED FLAGS":

1. Any site that use the terms "alternative", "holistic", "integrative", "natural", and/or "miraculous" (Barrett). The vast majority of websites using these terms should replace them with “unproven” and/or “ineffective”. They also tend to push Herbs, vitamins and supplements. Do not trust a salesman to tell you the whole and complete truth. Their job is to sell you the product.

2. Claim large effect on symptoms with out side-effects. Causing a large change in body function (or dysfunction) has a cascading effect that leads to known side-effects and occasionally adverse reactions. No side effect most often indicates such low doses as to have no real effect.

3. Claim that a treatment can cure multiple problems/pathologies. Nothing can, or ever will, cure your shoulder pain and skin melanoma.

4. Claim that everyone will experience the same positive results. Humans are not all the same. Disease processes are complex and include multiple organ systems to varying degrees. Due to this, you cannot expect all to respond the same way or to the same degree. This is why well run clinical trials are essential. Which brings us to the next point…

5. The use of testimonials as sole proof that treatment works. A positive experience one person has cannot be generalized to anyone else. This is a complex topic as we rely on recommendations and advice from our neighbors to function efficiently in society and these salesmen attempt to take advantage of this.

6. Person is touted as a “Guru” with many impressive sounding “credentials”. Often claims are made that your problems can only be cured by the seller. Often it is because of some procedure or test named after them that only they can do. In the end, only they can do it because there has been no published research to support or refute it’s ability to do what it is purported to do. Also watch for the use of “Dr.” when referring to this guru and/or unusual credentials (e.g. not common known credentials such as MD, DO, PhD). The use of the doctor title is an attempt to make the person appear more authoritative then they are.

7. Must buy to see results. Any reputable treatment/product should have peer-reviewed published literature that shows it can do what it claims. You should never have to first buy something to know or experience how it works.

Medical information from the internet must be reviewed wisely and used as a supplement to the advice a trusted healthcare professional has given you. When in doubt, bring the information you have found to your MD, DO, or PT and discuss it with them. These “red flags” are a good start to filtering out the majority of bad from the good.

Works Cited

Barrett, M.D., Stephen. " How to Spot a "Quacky" Web Site." 06 September 2006. Quackwatch. 7 July 2007 .

Labels: alternative medicine, Chiropractic, education, Fraud, Low back pain, physical therapy

Well, I'm back from my 4,000 mile drive across the US midwest and northwest. Had a great time seeing family and visiting new towns and areas of the US. Very beautiful and often time spectacular. Today I will introduce a short series on the history of post World War I Physical Therapy History. I feel it is very interesting to see our roots and understand why some aspects of our profession are the way they are.

The vast majority of the information presented comes from an article written by Beth Linker in the Journal of Women’s History, Vol. 17 No. 3. The first passage comes from 1922:

...women leaders of the American Physiotherapy Association (APA) invited Ray Lyman Wilbur, then president of the AMA, to give the keynote address at the national physiotherapy conference. APA president Dorothea Beck enthusiastically introduced Wilbur to the stage, assuring him that it was the goal of her association to “give the medical profession a band of trained women whose ideals, personality, and technical training are all that the physicians and surgeons of the American Medical
Association can wish.”
The APA’s congenial relationship with Wilbur and the elite men of the AMA complicates the typical historical narrative of professional antagonism
between the sexes during the 1920s. Physiotherapy represents a different kind of female professionalism—one that concerned itself more with achieving autonomy from other white–collar women than it did with gaining independence from white–collar men. Other female–dominated health occupations that arose alongside physiotherapy during the war, such as occupational therapy and dietetics, drew support from medical men. But as occupations steeped in the womanly spheres of arts, crafts, and home economics, these other professions also achieved legitimacy through the backing of women’s charity networks. By contrast, physiotherapists did not seek support from women’s clubs or female associations for professional uplift; rather, physiotherapists legitimized their profession almost solely by association with the medical profession.

We see early on that the PT profession banked it's success on allowing themselves to be partially "controlled" by the AMA. We have been fighting ever since. Where professions like massage therapy, ATC, DC's fought for legitimacy from public opinion, PT's have become, possibly, forever entangled with the AMA.

This has allowed for greater legitimacy in the health care world, but an inexplicable denial of autonomy by our past "parents". With this, it may be easier to "invent" a new musculoskeletal profession and become truly autonomous then ever cut the control lines from the AMA.

Labels: APTA, education, history, physical therapy

To my readers. I have been on vacation traveling by car to the west coast. I will not be back until next week. I will attempt to read and post any comments while on the road, so please be patient.

Looking forward to posting on rehab topics again soon.

Stumbled across this article from Yahoo News on a chiropractor boasting the use of "Cold Laser Therapy" or as it is often referred to as - "Low Level Laser Therapy". The article itself was what you'd expect. Mostly self promotion of the DC's practice. That's ok. Good for him in getting the article done. I had a few questions regarding some claims and comments made. Here are some examples:

For carpal tunnel syndrome especially, the treatment helps to alleviate pain associated with repetitive motion in hands and wrists.

and..

Cold laser therapy speeds up the healing process after injury to the wrists and hands.

Hmm, I thought. Is this his opinion, or is there good research to back this up. I've researched LLLT in the past and found that most studies were negative in it's use. But this was for musculoskeletal pain and balance improvement only. I don't know about carpal tunnel specifically. So I looked and here is what I found:

Archives of Physical Medicine and Rehabilitation: July 2002 83(7)

OBJECTIVE: To investigate whether real or sham low-level laser therapy (LLLT) plus microamperes transcutaneous electric nerve stimulation (TENS) applied to acupuncture points significantly reduces pain in carpal tunnel syndrome (CTS). DESIGN: Randomized, double-blind, placebo-control, crossover trial. Patients and staff administered outcome measures blinded. SETTING: Outpatient, university-affiliated Department of Veterans Affairs medical center. PARTICIPANTS: Eleven mild to moderate CTS cases (nerve conduction study, clinical examination) who failed standard medical or surgical treatment for 3 to 30 months. INTERVENTION: Patients received real and sham treatment series (each for 3-4wk), in a randomized order. Real treatments used red-beam laser (continuous wave, 15mW, 632.8nm) on shallow acupuncture points on the affected hand, infrared laser (pulsed, 9.4W, 904nm) on deeper points on upper extremity and cervical paraspinal areas, and microamps TENS on the affected wrist. Devices were painless, noninvasive, and produced no sensation whether they were real or sham. The hand was treated behind a hanging black curtain without the patient knowing if devices were on (real) or off (sham). MAIN OUTCOME MEASURES: McGill Pain Questionnaire (MPQ) score, sensory and motor latencies, and Phalen and Tinel signs. RESULTS: Significant decreases in MPQ score, median nerve sensory latency, and Phalen and Tinel signs after the real treatment series but not after the sham treatment series. Patients could perform their previous work (computer typist, handyman) and were stable for 1 to 3 years. CONCLUSIONS: This new, conservative treatment was effective in treating CTS pain; larger studies are recommended. Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Photomedicine and Laser Surgery: April 2006 Volume 24(2)

In this review, seven studies using photoradiation to treat carpal tunnel syndrome (CTS) are discussed: two controlled studies that observed real laser to have a better effect than sham laser, to treat CTS; three openprotocol studies that observed real laser to have a beneficial effect to treat CTS; and two studies that did not observe real laser to have a better effect than a control condition, to treat CTS. In the five studies that observed beneficial effect from real laser, higher laser dosages (9 Joules, 12-30 Joules, 32 J/cm(2), 225 J/cm(2)) were used at the primary treatment sites (median nerve at the wrist, or cervical neck area), than dosages in the two studies where real laser was not observed to have a better effect than a control condition (1.8 Joules or 6 J/cm(2)). The average success rate across the first five studies was 84% (SD, 8.9; total hands = 171). The average pain duration prior to successful photoradiation was 2 years. Photoradiation is a promising new, conservative treatment for mild/moderate CTS cases (motor latency <>

Photomedicine and Laser Surgery: February 2007 Volume 25(1)

OBJECTIVE: This prospective, randomized, placebo-controlled trial aimed to investigate the efficacy of laser therapy in the treatment of carpal tunnel syndrome (CTS). BACKGROUND DATA: Low-level laser therapy (LLLT) has been found to have positive effects in the treatment of CTS and various musculoskeletal conditions. METHODS:A total of 81 patients were included in this study. Diagnosis of CTS was based on both clinical examination and electromyographic (EMG) study. Patients were randomly assigned into two groups. Group 1 (n = 41) underwent laser therapy (7 joules/2 min) over the carpal tunnel area. Group 2 (n = 40) received placebo laser therapy. All patients received therapy five times per week, for a total of 10 sessions. Patients also used a wrist splint each night. Patients were assessed according to pain, hand-pinch grip strength, and functional capacity. Pain was evaluated by Visual Analog Scale (VAS; day-night). Hand grip was measured by Jamar dynometer, and pinch grip was measured by pinchmeter. Functional capacity was assessed by a self-administered questionnaire for severity of symptoms. RESULTS: The mean age of the patients (70 women, 11 Men) was 49.3 +/- 11.0 (range, 26-78). After therapy there were statistically significant improvements in VAS, pinch grip, and functional capacity measurement in both groups CONCLUSION: In using LLLT, (1) there was no difference relative to pain relief and functional capacity during the follow-up in CTS patients; (2) there were positive effects on hand and pinch grip strengths.

Australian Journal of Physiotherapy: 2004;50(3)

This study was designed to compare the efficacy of ultrasound and laser treatment for mild to moderate idiopathic carpal tunnel syndrome. Ninety hands in 50 consecutive patients with carpal tunnel syndrome confirmed by electromyography were allocated randomly in two experimental groups. One group received ultrasound therapy and the other group received low level laser therapy. Ultrasound treatment (1 MHz, 1.0 W/cm(2), pulse 1:4, 15 min/session) and low level laser therapy (9 joules, 830 nm infrared laser at five points) were applied to the carpal tunnel for 15 daily treatment sessions (5 sessions/week). Measurements were performed before and after treatment and at follow up four weeks later, and included pain assessment by visual analogue scale; electroneurographic measurement (motor and sensory latency, motor and sensory action potential amplitude); and pinch and grip strength. Improvement was significantly more pronounced in the ultrasound group than in low level laser therapy group for motor latency (mean difference 0.8 m/s, 95% CI 0.6 to 1.0), motor action potential amplitude (2.0 mV, 95% CI 0.9 to 3.1), finger pinch strength (6.7 N, 95% CI 5.0 to 8.2), and pain relief (3.1 points on a 10-point scale, 95% CI 2.5 to 3.7). Effects were sustained in the follow-up period. Ultrasound treatment was more effective than laser therapy for treatment of carpal tunnel syndrome. Further study is needed to investigate the combination therapy effects of these treatments in carpal tunnel syndrome patients.

Muscle and Nerve: August 2004 Volume 30(2)

Several studies have suggested that low-level laser therapy (LLLT) is effective in patients with carpal tunnel syndrome (CTS). In a double-blind randomized controlled trial of LLLT, 15 CTS patients, 34 to 67 years of age, were randomly assigned to either the control group (n = 8) or treatment group (n =7). Both groups were treated three times per week for 5 weeks. Those in the treatment group received 860 nm galium/aluminum/arsenide laser at a dosage of 6 J/cm2 over the carpal tunnel, whereas those in the control group were treated with sham laser. The primary outcome measure was the Levine Carpal Tunnel Syndrome Questionnaire, and the secondary outcome measures were electrophysiological data and the Purdue pegboard test. All patients completed the study without adverse effects. There was a significant symptomatic improvement in both the control (P = 0.034) and treatment (P =0.043) groups. However, there was no significant difference in any of the outcome measures between the two groups. Thus, LLLT is no more effective in the reduction of symptoms of CTS than is sham treatment.

Cochrane Database of Systematic Reviews: 2003(1)

BACKGROUND: Non-surgical treatment for carpal tunnel syndrome is frequently offered to those with mild to moderate symptoms. The effectiveness and duration of benefit from non-surgical treatment for carpal tunnel syndrome remain unknown. OBJECTIVES: To evaluate the effectiveness of non-surgical treatment (other than steroid injection) for carpal tunnel syndrome versus a placebo or other non-surgical, control interventions in improving clinical outcome. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group specialised register (searched March 2002), MEDLINE (searched January 1966 to February 7 2001), EMBASE (searched January 1980 to March 2002), CINAHL (searched January 1983 to December 2001), AMED (searched 1984 to January 2002), Current Contents (January 1993 to March 2002), PEDro and reference lists of articles. SELECTION CRITERIA: Randomised or quasi-randomised studies in any language of participants with the diagnosis of carpal tunnel syndrome who had not previously undergone surgical release. We considered all non-surgical treatments apart from local steroid injection. The primary outcome measure was improvement in clinical symptoms after at least three months following the end of treatment. DATA COLLECTION AND ANALYSIS: Three reviewers independently selected the trials to be included. Two reviewers independently extracted data. Studies were rated for their overall quality. Relative risks and weighted mean differences with 95% confidence intervals were calculated for the primary and secondary outcomes in each trial. Results of clinically and statistically homogeneous trials were pooled to provide estimates of the efficacy of non-surgical treatments. MAIN RESULTS: Twenty-one trials involving 884 people were included. A hand brace significantly improved symptoms after four weeks (weighted mean difference (WMD) -1.07; 95% confidence interval (CI) -1.29 to -0.85) and function (WMD -0.55; 95% CI -0.82 to -0.28). In an analysis of pooled data from two trials (63 participants) ultrasound treatment for two weeks was not significantly beneficial. However one trial showed significant symptom improvement after seven weeks of ultrasound (WMD -0.99; 95% CI -1.77 to - 0.21) which was maintained at six months (WMD -1.86; 95% CI -2.67 to -1.05). Four trials involving 193 people examined various oral medications (steroids, diuretics, nonsteroidal anti-inflammatory drugs) versus placebo. Compared to placebo, pooled data for two-week oral steroid treatment demonstrated a significant improvement in symptoms (WMD -7.23; 95% CI -10.31 to -4.14). One trial also showed improvement after four weeks (WMD -10.8; 95% CI -15.26 to -6.34). Compared to placebo, diuretics or nonsteroidal anti-inflammatory drugs did not demonstrate significant benefit. In two trials involving 50 people, vitamin B6 did not significantly improve overall symptoms. In one trial involving 51 people yoga significantly reduced pain after eight weeks (WMD -1.40; 95% CI -2.73 to -0.07) compared with wrist splinting. In one trial involving 21 people carpal bone mobilisation significantly improved symptoms after three weeks (WMD -1.43; 95% CI -2.19 to -0.67) compared to no treatment. In one trial involving 50 people with diabetes, steroid and insulin injections significantly improved symptoms over eight weeks compared with steroid and placebo injections. Two trials involving 105 people compared ergonomic keyboards versus control and demonstrated equivocal results for pain and function. Trials of magnet therapy, laser acupuncture, exercise or chiropractic care did not demonstrate symptom benefit when compared to placebo or control. REVIEWER'S CONCLUSIONS: Current evidence shows significant short-term benefit from oral steroids, splinting, ultrasound, yoga and carpal bone mobilisation. Other non-surgical treatments do not produce significant benefit. More trials are needed to compare treatments and ascertain the duration of benefit.

Journal of Neurology: March 2002 Volume 249(3)

Carpal tunnel syndrome (CTS) is a common disorder, for which various conservative treatment options are available. The objective of this study is to determine the efficacy of the various conservative treatment options for relieving the symptoms of CTS. Computer-aided searches of MEDLINE (1/1966 to 3/2000), EMBASE (1/1988 to 2/2000) and the Cochrane Controlled Trials Register (2000, issue 1) were conducted, together with reference checking. Included were randomised controlled trials evaluating the efficacy of conservative treatment options in a study population of CTS patients, with a full report published in English, German, French or Dutch. Two reviewers independently selected the studies. Fourteen randomised controlled trials were included in the review. Assessment of methodological quality and data-extraction was independently performed by two reviewers. A rating system, based on the number of studies and their methodological quality and findings, was used to determine the strength of the available evidence for the efficacy of the treatment. Diuretics, pyridoxine, non-steroidal anti-inflammatory drugs, yoga and laser-acupuncture seem to be ineffective in providing short-term symptom relief (varying levels of evidence) and steroid injections seem to be effective (limited evidence). There is conflicting evidence for the efficacy of ultrasound and oral steroids. For providing long-term relief from symptoms there is limited evidence that ultrasound is effective, and that splinting is less effective than surgery. In conclusion, there is still little known about the efficacy of most conservative treatment options for CTS. To establish stronger evidence more high quality trials are needed.

I was able to find these 6 peer reviewed articles on CTS and treatment with LLLT. Out of the 6, only 2 had positive results toward using LLLT. One (Arch Phys Med) included Microcurrent with the LLLT treatment. Therefore unable to tell if it was LLLT, Micro, or the interaction of the two that was beneficial. The second was a review that does not have the articles reviewed listed, making it very difficult for an individual to read the studies they feel support the use of LLLT for CTS.

My conclusion from the best literature available is that there is no evidence that LLLT is effective in treating CTS at this time. I think the DC's own statement in the Yahoo article sums up where it is being used for CTS despite evidence it doesn't help:

Cold laser therapy was accepted by the Food and Drug Administration (FDA) in 2002 and is used by athletic trainers, chiropractors and practitioners of alternative medicine.

Surprise, surprise. Although, it is easy to find many PT's making similar claims. We all love the next gadgets that can cure people without the patient or clinician having to put any effort into it.

Anyone have more compelling literature that I may have missed or not know about? Let me know. Use good peer reviewed studies to show me that my conclusion is wrong or that I am spot on.

Labels: Chiropractic, EBM, Evidence, Low Level laser therapy

A new tool in physical therapy research (and for some, PT practice) is Real Time Ultrasound Imaging (RTUSI). It has the potential to provide precise and specific feedback regarding neuromuscular control of abdominal and pelvic muscles.

As a nice article by Jackie Whittaker BSc PT, FCAMT, CGIMS, CAFCI describes the potential benefits and pitfalls that come with this new tool. Obviously, US imaging in not currently included in PT education. This can be a hurdle in scope of practice fights. Whittaker states that:

In the current environment of evidence-based practice and fiscal accountability, it is imperative that physical therapists be allowed access to the tools that will optimize the effectiveness of their interventions.

A major practical hurdle I see is reimbursement. In the US, insurance companies such as UHC are already trying to "control costs" (not to normalize costs to enrollees but to optimize profits to share holders, but that's a whole other story) by basically not paying for PT. This is done by high copays, deductibles, and arbitrary visit limits. In this world, it would be hard to convince many PT's to invest in an US imaging system, attain the education to use it, take the extra time in clinic to use it, and still get paid about $60 for a visit.

I do think Real Time US Imaging has a high potential for clinic use. We'll see how the research and willingness of payors dictates RTUSI's evolution.

Lastly, this months Journal of Orthopedic and Sports Physical Therapy is mostly devouted to RTUSI. I haven't read all the article yet, but for many of us, it will be a step in the direction of clarifying how and why RTUSI should be used in our clinic.

Labels: EBM, RTUSI, Ultrasound

From Funny or Die, Bad Doctor:

Labels: Fun

Lost a patient today to the local hospital PT. Was it because the local hospital had more convenient hours? Better PT's? Closer to home? None of the above. UHC limits her visits to 20 a year with a $30 to come to our PT owned clinic; but the pt had no copay or limits going to the hospital PT.

Where is the equity in that? ACN is horrible enough, now preference is again being given to physicians. Show me the evidence that the hospitals are providing better care at comparable costs and I'll understand. My guess is UHC will be charged more over greater number of visits than coming to a PT owned clinic that emphasizes quality care and outcomes over the bottom line of the hospital.

Labels: Direct access, Healthcare, insurance, over-use

Jason Silvernail recently posted a good perspective on the difficulties with Referral For Profit setups. The title -RFP - Get the Picture? - and the story it is refering to can be found here.

This is a serious situation that has a direct impact on PT's autonomy (or pursuit for autonomy). It is also a negative influence on patient outcomes and freedom of choice. Please read and leave you comments.

Labels: Direct access, kickbacks

Reading one of my favorite medical blogs - Respectful Insolence - Orac posted on a Homeopath in Arizona that had a patient die after performing liposuction on her. To make this even more interesting, the assisting physician had already had 2 patients die after lipo and his lisence had been put on probation.

This got me thinking, do people really know what homeopathy is? Or do they just blindly believe what these pseudo doctors are telling them?

Here is a great video of James Randi explaining Homeopathy and the "4 rules of homeopathy":



My favorite line when referring to a homeopathic medicine:

Has no side effects. That's true. My question is 'does it have any other effects'?

Absurdity, this is. I believe people should be able to choose how to treat their ailments. However, homeopathy is duping the desperate, fearful, and needy. Educate those who ask about the quackery that homeopathy medical treatment is.

Labels: EBM, education, Evidence, Fraud

A Wall Street Journal article reports old docs think new docs (residents) aren't getting the education they need because their weekly work hours are limited to 80 hours a week. That's right, 80 hours. It's actually not that good. That's an average of 80 hours over two weeks. So one could work 100 one week and 60 the next and still be compliant.

Old docs will complain about new docs not being altruistic. What seems to be their definition of altruism? Not working 150+ hours a week like they did in their training. Seems reasonable, right? You have to do it because I did! Here are the "main" findings:

Eighty-seven percent of the doctors thought continuity of care had worsened, and 75% thought the physician-patient relationship had deteriorated.

Sixty-six percent said residents’ education had gotten worse, 73% said residents were less accountable to patients and 57% said residents’ ability to place patient needs above their own had declined.

Half thought residents’ well being improved. But 56% of the teaching faculty found teaching less satisfying.

I find it interesting that in a system in which residents are paid about 20% of the staff to cover nights, weekends, holidays and everything in between, that those in charge are complaining about being able to have less of the resident.

Teaching hospitals provide a great service to our country in terms of educating our future doctors. But don't think it is altruism on their part. They get 5 residents for the price of 1 staff and used to be able to work them at their whim (and bottom line). Now that there is a 'limit' of 80 hours (ha! again I say ha!) somehow it's a detriment to patients and resident education.

Finally, the 80 hours are constantly ignored and subtly understood that that is the way the game is played. Doctors now are being paid less (don't believe big insurance), for more with less kudos than when "old docs" had their training with patients paying cash, receiving gifts and not having to answer to anyone but themselves.


UPDATE: Great response over at Over!My!Med!Body giving a first hand med student perspective on the whole "you have to because we had to" residency issue. Please read. Well written and shows the other side of the coin.

Labels: AMA, Healthcare

I am set to begin somewhat of a "series" on the APTA's vision statement on what our profession should be in the future. It is title "Vision 2020". Here is the meat and potatoes of it:

Labels: APTA, Direct access, EBM, insurance

Orac over at Respectful Insolence posted his views on chiropractor legalities in New Jersey from an MD's prospective. He also has a few nice things to say about physical therapists.

Be sure to read the comments as their are MD's, chiro pt's, chiros, and (of course) me that have chimed in on this subject.

Labels: Chiropractic, clinical prediction rules, EBM, legislation

I have recently begun using a nice new clinical test for meniscus tears. It is called the Thessaly Test (I thought we were going to quit naming things like this after ourselves, lol). It is a weight bearing test, so it's fairly functional. The Abstract can be found on the Journal of Bone and Joint surgery. The test basically requires the practitioner to hold the hands of the patient who is standing on one leg. The patient then bends to 5° and twists medially then laterally. The test is repeated at 20°. Positive test equates to reproduction of pain, catching or popping.

Here is a summary from EBM Online:

Diagnosis Sensitivity (95% CI) Specificity (CI) Accuracy +LR –LR Medial meniscal tear 89% (83 to 94) 97% (94 to 98) 94% 26.9 0.11 Lateral meniscal tear 92% (78 to 98) 96% (93 to 98) 96% 22.9 0.08 *Diagnostic terms defined in glossary; CI and LRs calculated from data in article.

In my experience, the test is easy to administer and less physical work needed by the practitioner compared to McMurray's or Apley Grind. However, like McMurray's or Apley, in the clinic, they don't quit appear as strong individually as they do when grouped.

Labels: EBM, meniscus tear, special test, Thessaly

David Colquhoun maintains a page on "Complementary and Alternative Medicine (CAM)". It is a worth while read. You can find his website here. Below is a fun argument about the dilemma of CAM treatments.

The dilemmas at the heart of 'alternative medicine'

All forms of ineffective treatment, 'alternative' or otherwise, pose real dilemmas that are usually neglected.

The definition dilemma

* Once any treatment is shown beyond doubt to be effective, it ceases to be 'alternative' and becomes just like any other part of medical knowledge. That means that 'alternative medicine' must consist entirely of unproven treatments.

The lying dilemma

* Suppose that a treatment owes all its effectiveness to the placebo effect, e,g. homeopathy (even Peter Fisher almost admitted as much). But in some people, at least, the placebo effect is quite real. It may be a genuine physical response, though one that does not depend in any activity of the drug, or other treatment.
* If the placebo effect is real, it would be wrong to deprive patients of them, if there is nothing more effective available. For example, if terminal cancer patients say they feel better after having their feet tickled by a 'reflexologist', why should they not have that small pleasure?
* If the foregoing argument is granted, then it follows that it would be our duty to maximise the placebo effect. In the absence of specific research, it seems reasonable to suppose that individuals who are susceptible to placebo effects, will get the best results if there treatment is surrounded by as much impressive mumbo jumbo as possible.
* This suggests that, in order to maximixe the placebo effect, it will be important to lie to the patient as much as possible, and certainly to disguise from them the fact that, for example, their homeopathic pill contains nothing but lactose.
* Therein lies the dilemma. The whole trend in medicine has been to be more open with the patient and to tell them the truth. To maximise the benefit of alternative medicine, it is necessary to lie to the patient as much as possible.

As if telling lies to patients were not enough, the dilemma has another aspect, which is also almost always overlooked. Who trains CAM practitioners? Are the trainers expected to tell their students the same lies? Certainly that is the normal practice at the moment. Consider some examples.
The training dilemma

* If feet tickling makes patients feel better, it might be thought necessary to hire professional feet ticklers who have been trained in 'reflexology'. But who does the training? It cannot be expected that a university will provide a course that preaches the mumbo jumbo of meridians, energy lines and so on.
* A good example is acupuncture. It is often stated that one of the best documented forms of 'alternative medicine' is acupuncture. Certainly the act of pushing needles into to your body elicits real physiological responses. But recent experiments suggest that it matters very little where the needles are inserted. There are no 'key' points: it is the pricking that does it. But its advocates try to 'explain' the effects, along these lines.
o "There are 14 major avenues of energy flowing through the body. These are known as meridians".
o The energy that moves through the meridians is called Qi.
o Think of Qi as "The Force". It is the energy that makes a clear distinction between life and death.
o Acupuncture needles are gently placed through the skin along various key points along the meridians. This helps rebalance the Qi so the body systems work harmoniously.
I suppose, to the uneducated, the language sounds a bit like that of physics. But it is not. The words have no discernable meaning whatsoever. They are pure gobbledygook. Can any serious university be expected to teach such nonsense as though the words meant something? Of course not. Well so you'd think, though a few 'universities' have fallen for this, to their eternal shame

Obviously it isn't always neccessary to wait for a treatment to be unequivocally proven before it's use. However, it's basis should at least be plausible.

Labels: CAM, EBM, Healthcare, tips

A new study from Spine concludes that there are muscle changes that, they conclude, are common in those with true low back pain. Here is the abstract:

Study Design. Prospective longitudinal study.

Objective. To investigate, using magnetic resonance imaging (MRI), the influence of bed rest on the lumbopelvic musculature.

Summary of Background Data. Reduced gravitational loading and inactivity (bed rest) are known to result in significant change in musculoskeletal function, although little is known about its effects on specific muscles of the lumbopelvic region.

Methods. Ten healthy male subjects underwent 8 weeks of bed rest with 6 months of follow-up. MRI of the lumbopelvic region was conducted at regular time-points during and after bed rest. Using uniplanar images at L4, cross-sectional areas (CSAs) of the multifidus, lumbar erector spinae, quadratus lumborum, psoas, anterolateral abdominal, and rectus abdominis muscles were measured.

Results. Multifidus CSA decreased by day 14 of bed rest (F = 7.4, P = 0.04). The lumbar erector spinae and quadratus lumborum CSA showed no statistically significant difference to baseline across the time of bed rest (P > 0.05). The anterolateral abdominal, rectus abdominis, and psoas CSA all increased over this time. Psoas CSA increased by day 14 (F = 6.9, P = 0.047) and remained so until day 56, whereas the anterolateral abdominal CSA (F = 29.4, P = 0.003) and rectus abdominis CSA (F = 8.9, P = 0.03) were not statistically larger than baseline until day 56. On reambulation after completion of the bed rest phase, multifidus, anterolateral abdominal, and rectus abdominis CSA returned to baseline levels (P > 0.05) by day 4 of follow-up, whereas psoas CSA returned to baseline level after day 28 of the follow-up period.

Conclusions. Bed rest resulted in selective atrophy of the multifidus muscle. An increased CSA of the trunk flexor musculature (increases in psoas, anterolateral abdominal, and rectus abdominis muscles) may reflect muscle shortening or possible overactivity during bed rest. Some of the changes resemble those seen in low back pain and may in part explain the negative effects of bed rest seen in low back pain sufferers.

This adds to the growing mountain of evidence against bed rest for LBP. One would hope that the current first line practitioners that LBP patients encounter (GP's and, sadly, PA's and NP's) know this; but, as Ellen Degeneres showed us even "stars" are given advice contradictory to the mounting evidence. What's worse is her large audience may also believe that bed rest is the best treatment for their low back pain.

Educate, educate, educate. Tell everyone you know about the harm of bed rest!

Labels: bed rest, EBM, Low back pain, treatment

Here is a YouTube video demonstrating Mulligan taping technique to help relieve lateral epicondylitis (tennis elbow) symptoms:



There have been a number of studies looking at Mulligan Mobilisation With Movement (MWM) technique on Tennis Elbow. I didn't find one directly related to this taping technique though.

References:

Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial
Leanne Bisset, Elaine Beller, Gwendolen Jull, Peter Brooks, Ross Darnell, Bill Vicenzino BMJ 2006;333:939, doi:10.1136/bmj.38961.584653.AE

Vicenzino B. Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Man Ther 2003;8: 66-79.

Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med 2005;39: 411-22

As the baby boomers age, we must look to a new population base for our PT practice. Enjoy!