Patellofemoral pain (aka EMM, patellar chondromalacia, PFPS, anterior knee pain, etc) is a common diagnosis that I see in the clinic. The problem is, we are not exactly sure what causes it (or if there or many causes) and what is best for remedying it (strengthening, stretching, neuromuscular re-education, bracing, even spinal mobilizations). In the past, PFP was attributed to lateral patellar tracking caused by poor VMO strength/activation and tight lateral structures such as the IT Band. While it is still commonly believed that PFP is from excessive lateral patellar tracking, it is thought that this is caused by poor lower extremity pronation/valgus control by the hip musculature. Specifically the hip abductors and external rotators. This has been preliminarily supported by research that shows, in weight bearing, in those with PFP the femur tends to internally rotate under the patella rather the the patella being pulled laterally (Salsich, GB - JOSPT Sept 2007).

The following article done by Lori Bolgla, PT, PhD, ATC et al looked at hip strength and lower extremity kinematics in those with PFP vs. those with out. Here is the abstract:

Hip Strength and Hip and Knee Kinematics During Stair Descent in Females With and Without Patellofemoral Pain Syndrome

Lori A. Bolgla, Terry R. Malone, Brian R. Umberger, Timothy L. Uhl

STUDY DESIGN: Cross-sectional. OBJECTIVE: To determine if females presenting with patellofemoral pain syndrome (PFPS) from no discernable cause other than overuse demonstrate hip weakness and increased hip internal rotation, hip adduction, and knee valgus during stair descent. BACKGROUND: Historically, PFPS has been viewed exclusively as a knee problem. Recent findings have indicated an association between hip weakness and PFPS. Researchers have hypothesized that patients who demonstrate hip weakness would exhibit increased hip internal rotation, hip adduction, and knee valgus during functional activities. To date, researchers have not simultaneously examined hip and knee strength and kinematics in subjects with PFPS to make this determination. METHODS AND MEASURES: Eighteen females diagnosed with PFPS and 18 matched controls participated. Strength measures were taken for the hip external rotators and hip abductors. Hip and knee kinematics were collected as subjects completed a standardized stair-stepping task. Independent t tests were used to determine between-group differences in strength and kinematics during stair descent. RESULTS: Subjects with PFPS generated 24% less hip external rotator (P = .002) and 26% less hip abductor (P =. 006) torque. No between-group differences (P > .05) were found for average hip and knee transverse and frontal plane angles during stair descent. CONCLUSION: Subjects with PFPS had significant hip weakness but did not demonstrate altered hip and knee kinematics as previously theorized. Additional investigations are needed to better understand the association between hip weakness and PFPS etiology. LEVEL OF EVIDENCE: Symptom Prevalence, Level 4.

J Orthop Sports Phys Ther. 2008;38(1):12-18, published online 21 November 2007, doi:10.2519/jospt.2008.2462

I commend the authors for doing this study. Treatment in the clinic is dependent on clinical theories and basic science being "put to the test" in RTC with actual patients. It is important to note that hip muscle weakness was found in the symptomatic group; however, significantly altered lower extremity mechanics were not. An admitted limitation is that they only looked at stair stepping (a common pain provoking activity with those with PFP) and this specific activity may not have been challenging enough.

I treat most of my patients with PFP using hip strengthening, lower extremity stretching, and proprioceptive exercises in general. But this study reminds us that we were wrong before about the cause of PFP and most certainly could be wrong about the hip weakness leading to increased pronation/valgus theory most of us currently abide by.

Labels: EBM, evidence based medicine, patellofemoral pain, PFP

The most savage controversies are those about matters as to which there is no good evidence either way.
- Bertrand Russell

Labels: EBM, Evidence, physical therapy

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