Evidence Based Rehab

Wow, it has been a while and I apologize for that. My family and I have moved across the country, sold our house, started new jobs, and have been looking for a new home just in the last month. On top of that, I have been without internet access until just this past week. Well, I am back, and hope to again barage you all with disconnected rants and musings.

I'll take this time to try to give a peek as to what I plan to post on in the near future:

• Medicare Cap
• Round 2 of NATA vs APTA
• Because I'm forced to...the Wii in rehab
• Reviews on interesting Journal articles that others may like too

Expect a new post early next week. Thanks to those still subscribed.

Jason Harris

Labels: evidence based medicine, physical therapy, welcome

Degenerative Disc Disease. For many of those that get an unnecessary MRI and get this diagnosis, it's often taken as a death sentence for a back instead of what it is - a normal process related to aging. Although pain can be associated with DDD, it is more often just a radiologic finding. Something that was most likely present before onset of spinal pain and will remain unchanged once the spinal pain recedes.

June's issue of the Journal of Orthopedic & Sports Physical Therapy (JOSPT) includes and excellent commentary on what we know and don't know regarding intervertebral disc degeneration. I would like to summarize some critical points I found in the article.

• Although environmental factors play a role in the incidence and progression of DDD, the strongest predictors are genetically related. It is estimated that 74% of what causes DDD appears related to genetics.
• Smoking and heavy labor have not been supported as etiologic factors in developing DDD. In fact, competitive weight lifters w/o trauma have a lower than expected rate of DDD.
• Primary factor in DDD is reduction of the Intervertebral Disc's (IVD) nutritional capacity.
• "...age-related changes that occur in the composition of the IVD are similar to those observed in articular cartilage and are not necessarily related to pain."
• Vertebral endplate disruptions are being shown to have a strong relationship with DDD.
• Although similar in appearance, there are measurable differences in the diffusion capacity at the vertebral endplate of those IVD's with age-related disc degeneration and symptomatic degnerative discs. This may suggest that aging and degeneration are 2 separate processes.
• "High-Intensity Zones" represented by high intensity T2 signals near the outer margins of the annulus are correlated to pain production with discography (IMO, discography is often painful regardless of pathology) but also commonly found in asymptomatic individuals. This leads to poor specificity and the authors suggest it should not be used in isolation to make clinical decisions.
• The body's attempt to heal annular tears may lead to increasing the area of the disc that is innervated which is further increased by inflammatory byproducts which can lower the threshold needed to trigger pain. The result could be increased sensitivity to otherwise innocuous stimuli. This includes those from just standing and/or walking.
• Even if MRI shows a dramatic disc bulge, this finding is very often not associated with symptoms.
• When nuclear material breaks free and migrates into the vertebral foramen, ipsilateral pain and parasthesia may occur. This results from the chemical response to the nuclear material touching the dorsal root ganglion and not from "pinching" the nerve.

The authors then make some comments on clinical relevance. Here are a few that will lead to a change in the way I treat on Monday:

• Patients with later stage DDD - decreased disc height and hydrostatic nucleus lost - care should be taken during loading progressions, avoiding sustained loading at end range trunk motions.
• Symptoms often occur several hours after trauma to the degenerated disc (DD). Thus, exercise in the gym may go well but in the morning the patient may be too painful to even get out of bed.
• Studies have found favorable outcome in treating DDD with lumbar stabilization exercises.
• It was found that patients with DD who avoided early morning lumbar flexion had significantly less pain and disability then did those who performed lumbar flexibility exercises early in the morning.
• Patients with DD should be encouraged to avoid prolonged flexed compressive forces such as sitting in flexed position.
• Hip ROM limitation can have large effects on loads acting on the lumbar spine.
• The authors make it a point to illustrate the important role the psychological effect that the diagnosis of "degenerative disc disease" has on the patient. they state:
• "...it is important that clinicians carefully communicate with patients to reassure them that DD is a normal aging process; while it certainly can be associated with episodes of pain, only in rare exceptions do these symptoms represent serious disease, and they should not, therefore, prevent one from performing reasonable activities."

It's important to remember the fact DD is related to normal aging. And, thus, it's main treatment should most likely be non-invasive conservative care. And, as I always say, PT's are the experts in this area and well positioned to give the more efficacious care.

Jason L. Harris

Labels: DDD, Degenerative Disc Disease, DRX 9000, evidence based medicine, Low back pain, physical therapy

Anew website has been published providing information and resources on fighting chronic diseases. As we all know, the biggest impact on quality of life and health care costs are the treatment of chronic diseases. The website called "Promising Practices" comments that:

America faces an important crossroads in health care. The Partnership to Fight Chronic Disease, a diverse, national coalition of more than 100 partner organizations, is committed to raising awareness of policies and practices that save lives and reduce health costs through more effective prevention and management of chronic disease. We share common concerns about the incredible burden that chronic diseases place on families, the health care system, and the economy overall.

Though many understand the need for better ways to lower the risks of developing chronic illnesses and reduce the burden of illness on those already affected, they wonder how and where to begin. Innovators in schools, communities, workplaces, and the health care system are proving the value of addressing chronic disease in building a healthier America. Working together, we can develop innovative, common sense solutions to our current health care problems. We encourage you to use these resources to develop and support meaningful changes that will make a difference.

This appears to be a nice resource of patients and providers alike.

Jason L. Harris

Labels: education, Healthcare, Low back pain

A subject that has been eating at me for a while, but has been repressed due to it not having to do anything with PT, is "Spy Gate". Was it a shock how pervasive this taping was? Yes, but they were caught and punished. Should have been the end of it. Nope, not with our government.

We are struggling with ever decreasing reimbursement, $4 gallon gas, a war, and a slumping economy, yet Republican Arlen Specter feels this should all be ignored and the government get to the bottom of the Patriots video taping.

What a waste. I'll save the government some time. Just like stealing signs in baseball, taping-trying to get other tapes-spying-etc, is already done at every level in football. I only played at a small college, but I remember the whole team being sent running to scare off a car that seemed to be watching practice too intently; pretending to run a 3-4 defense during a walk-through at an away campus; coaches snickering at the tape they got from outside of a tape exchange agreement; and more.

I hope the good people of Pennsylvania see the light and get rid of this headline grabbing boob soon.

Jason L. Harris

Labels: Specter, spygate

More surgery, more drugs, and more injections are not what the doctor ordered.

Tallahassee, Florida, May 20, 2008 – When it comes to chronic back pain management patients should know that “less is more.” The American Pain Society at their annual meeting unveiled a current review on invasive procedures for the treatment of chronic low back. The scientific review concluded that most invasive interventions, including spinal joint injections, radiofrequency denervation, intradiscal electrothermal therapy demonstrated no evidence of effectiveness. Furthermore, surgical procedures for chronic low back pain demonstrated only small improvement in pain and disability but were accompanied by considerable risk.

"The expert panel reaffirms its previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions. "In general, non-invasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery," said Chou."

“The American Pain Society panel has acknowledged the central role of an active physical therapy program in managing low back pain patients,” noted Timothy W. Flynn PT, PhD, President of the American Academy of Orthopaedic Manual Physical Therapists. “The key in chronic low back pain is avoiding too much medicine. There is no magic bullet but a combination of hands on care and an active exercise approach is the best solution.”

Labels: AAOMPT, evidence based medicine, Healthcare, LBP, Low back pain, physical therapy, public relations