Web-based academic discussions could well be the way forward for cost-effective and tailored continuing education for health professionals. China’s interactive Orthochina.org wiki project for orthopaedic surgeons is an example of the potential of such internet training for continuing medical education. Zhen-Sheng Ma of the Fourth Military Medical University in Xi’an, China, and his colleagues thoroughly evaluated this online tool and will publish their results¹ in the October issue of Springer’s journal Clinical Orthopaedics and Related Research.

Until recently, the primary vehicle for continuing medical education has been the more traditional conferences and training courses. However, the content of these sorts of courses is not necessarily tailored to meet the individual or immediate needs of professionals and their cost-effectiveness has yet to be established. Created in 1998, Orthochina.org uses an interactive case-based format and is structured using the wiki concept, where the content of the website is created collaboratively by users through an Internet browser. Information in Chinese and English is posted, edited, deleted and updated by carefully screened participants and is academically monitored by its orthopaedic users. Ten years on, the site boasts nearly 34,000 users and counts over 6,000 visits and over 2,000 posts every month.

Real patient cases are submitted for discussion by orthopaedic surgeons. They include the patient’s complaint, findings from physical examinations and relevant images. Professional discussions between participants take place anywhere, anytime, giving suggestions for diagnosis and treatment. Multiple opinions can help the surgeon who has posted his complex case, and is seeking advice on how to treat it, to make an informed decision about his treatment plan.

The authors firmly believe that “surgeon-to-surgeon communication is the most important, the easiest, most closely related to clinical practice, and cost-effective method of patient-problem-orientated continuing medical education.” By using the Internet, orthopaedic surgeons from different backgrounds and geographic locations can work together to enhance their quality of care, something workshops and meetings cannot provide in such a tailored and timely manner.

As a profession that is hampered by practice variation and difficulty adapting (changing) to more evidence based treatemt, I feel physical therapy could really fourish with a similar approach. While we do have great sites to share ideas (EIM, Rehabedge, SomaSimple), often time the forum type format can be disonjointed and hard to follow or return to in the future.

Jason L. Harris

Labels: EBM, physical therapy, Wiki

A press release from the American Association of Oral & Maxillofacial Surgeons discusses a bill that would allow them to refer patients to physical therapy. Currently only osteopathic (DO's) and allopathic (MD's) doctors may "oversee" (read: sign the ok for) physical therapy.

Oral & Maxillofacial surgeons and other dentist make the case that they routinely treat patients that would benefit from PT, therefore having the ability to do so would be beneficial:

As Congressmen Pascrell and Cantor noted in sponsoring the bill, because a dentist or OMS cannot directly refer patients for physical therapy, they must refer patients to an allopathic or osteopathic physician to establish a therapy plan. In his statement of introduction on the floor of the House of Representatives, Pascrell stated, Such consultation has proven to be inefficient, unnecessary and cumbersome, and it ultimately delays patient treatment and the continuum of care.

I agree. But I'll take it one step further. It is just as "inefficient, unnecessary and cumbersome" for patients to have to go to their MD, DO, DDS in the first place for neuromusculoskeletal rehab. True full direct access to physical therapist - the experts in neuromusculoskeletal conservative care - would greatly decrease time to recovery and the extraneous costs of medications and excessive imaging associated with going to multiple physicians before getting to see a physical therapist.

Jason L. Harris

Labels: Direct access, EBM, education, evidence based medicine, Medicare

Wow, I thought I'd found a candidate I could back. Not what am I going to do? I know this is not physical therapy related, but it is a prominent figure backing pseudoscience over evidence based medicine.

Here is McCain's statement from The Wall Street Journals Health Blog:

Going against the opinion of America’s top public health agencies, John McCain has suggested that autism may be linked to thimerosal, a preservative containing mercury that used to be common in children’s vaccines.

“It’s indisputable that autism is on the rise among children,” McCain (pictured) reportedly said while campaigning recently in Texas. “The question is, What’s causing it? And we go back and forth, and there’s strong evidence that indicates that it’s got to do with a preservative in vaccines.”

This despite every credible expert/scientist/clinical study that shows the opposite: NO LINK BETWEEN AUTISM AND THIMEROSAL

Jason L. Harris

Labels: Autism, EBM, evidence based medicine, Healthcare, McCain, Vaccine

Rich-Mar announces the first FDA approved combination Laser/TENS unit. Because if separately one is questionable in it's effectiveness, together they must be able to cure the blind.

Somewhere Chiropractors are lining up to buy these units by the dozen.

From the release:

One of the biggest challenges physical therapists and chiropractors faced, up until now, is the fact that laser treatments were not reimbursable by health insurance,” said Douglas Johnson, ATC, EES, CLS, and medical consultant to Multi Radiance Medical. “These professionals knew that therapeutic lasers worked, but struggled with both the initial purchase of the unit and determining what to charge patients for the treatment without reimbursement. The LaserStim accessory and its unique design changes all of that. Time spent administering light therapy with LaserStim is now being reimbursed by insurance. Most physical therapists and chiropractors will see the unit pay for itself in less than one month of treatments.”

Ahh, the truth comes out. Insurance companies (rightfully, for now) won't reimburse for Laser treatment, but they do for E-stim. Well, hell, strap a couple of electrodes to the laser and call it "LaserStim" and you can now charge for it!

Labels: EBM, evidence based medicine, Fraud, Low Level laser therapy, woo

Irecently read an article regarding a great Firefox extension called Zotero. I'll get to what it is in just a minute; but, this find got me thinking about Evidence Based Medicine (EBM) and how to keep up to date easier and with better organization.

For me, the big barriers to practicing EBM are keeping up-to-date with information from a multitude of sources and then trying to effectively organize that information once received. Fortunately, the internet and free software can help me/us with both of those barriers.

First, a great way to keep current on new information from multiple sources is taking advantage of a technology called RSS that is a web feed format that automatically updates information from it's source. How do you use RSS? Feeds can be 'subscribed' to and kept in one place such as your Google Homepage, My Yahoo page, aggregators, or RSS readers. I'm not an expert on the pro's on con's of each, so some trial and error will need to be done on your part. However, I did find a nice explanatory article on many of these.

For those of us that are technologically inept (you should work on that), EvidenceInMotion has a service called Evidence Express that does the work of aggregating all the information for you then sends it to you in daily Email right to your in box.

For those who want to collect the RSS feeds themselves, a previous payware reader called FeeDemon is now Freeware. I currently use FeedReader because it is free, updated regularly, and is straight forward to use. Take a look at them both and choose for yourself.

So, now you've got the latest update on new research from, say JOSPT, now what do you do? I would download the PDF, put in a folder with a name I'd hope I'd remember down the line, and then either never find it again or take hours to do so. Now this problem can be solved. Zotero is an extension (aka - an add in the works inside firefox) for Firefox that automatically sites, stores and allows you to make notes, attach items, and more for all of our evidence we find. There is a slight learning curve, but it is well worth it. You can then search key words to find the exact article you are looking for.

The tools are available for us to be efficient with how we find and store evidence for our clinical practices. We just need to take advantage of them, and not be afraid for flail a little when learning to use them.

Looking forward to any comment regarding other great EBM tools out there.

Labels: EBM, evidence based medicine, physical therapy, RSS

Arelease from the APTA states the NATA (athletic trainers association) has filed a lawsuit against them for "anticompetitive" activities. The main point relates to MANUAL THERAPY, specifically rib and spinal manipulation. Now, as the few of you that read my posts know, I'm a big believer you don't need 4 years of hot air and philosophy to manipulate the spine, but you do need to have an excellent background in systems review, examination skills, and a wide knowledge of differential diagnoses. Chiros have this and PT's have this, but I don't see this with ATC education. And I choose a "masters" level education, which is the "new and improved" ATC degree, to highlight this.

I make no claim that I could effectively manage the day to day sports injury needs of a sports team or walk the sidelines of a game and provide the triage care that an athletic trainer can. However, ATC's are beginning to push their limited rehabilitation education into the realm of PT, and I guess DC. This is just another example of people wanting more than they are willing to go to school and get the education for. Heck, internally we even exclude PTA's from MT courses because IT IS OUTSIDE OF THEIR educated abilities. Here is the statement from the APTA:

APTA Responds to NATA Lawsuit

The National Athletic Trainers' Association (NATA) on February 1, 2008, filed a lawsuit against APTA and the Orthopaedic Section, APTA, Inc. in the U.S. District Court in Dallas. The complaint alleges that the APTA and the Section have violated the antitrust laws by seeking to deny athletic trainers (ATCs) access to the market for manual therapy and by coercing physical therapists to refrain from educating ATCs in certain techniques. APTA's counsel is currently reviewing the complaint. APTA believes that the NATA lawsuit is wholly without merit.

Physical Therapy can ONLY be provided by lisenced PHYSICAL THERAPISTS. Not by ATC's who wish themselves physical therapists.

For more fun reading, here are some additional links:

• NATA's Letter to the APTA - laughable
• Addendum to the above letter
• APTA's letter to NATA
• NATA's Injunction Filing

What is sad, is that we NEED ATC's. They are an integral part in the healthcare field. However, they are not physical therapists and yet they not only want to act like PT's their informational pamphlets boast about how ATC can be abused for economic gains being used as PT's by physicians and hospitals:

The value of certified athletic trainers isn’t limited to the
sports field. While ATCs have worked with orthopedists and in
rehabilitation clinics for the past 40 years, they can provide
a great deal of assistance – and additional revenue – to a
hospital, physician office or clinic, whether it be a large,
university-run complex or a small, private practice.

Then from a "FACT SHEET":

1. FACT: All athletic trainers have a bachelor’s degree from an accredited college
or university. Athletic trainers are health care professionals similar to physical,
occupational, speech, language and other therapists.

Sure, and I have a Doctorate degree similar to medical doctors then. What? It's not? Somebody better tell the NATA then.

To me, it seems the NATA may be trying to convince the lay public that they are in fact physical therapists with out having to go to physical therapy school. I hope you don't make the mistake of taking your grandfather s/p CVA or your mother with a diabetic ulcer, or your uncle who is trying to recover from a heart attack to a professional with out the educational background to effectively, and possibly, safely treat them.

It one thing to wave the magic wand (ultrasound) over someone and educate them in therapeutic exercise (which I believe ATC's surely do well) it's another thing to claim to be on par with THE experts in neuromusculoskeletal evaluation and rehabilitation.

Labels: APTA, Direct access, EBM, Healthcare, NATA, woo

Iontophoresis is a means of administering an ionic medication transdermally using a low electrical current to "push" it along. There is research out there that show it actually occurs and that "long wear", ultra low current, iontophoresis may deliver the medication to a greater depth; but using a skin model (pig skin to be exact). However, the general consensus in the literature tends to be that it doesn't make much of difference in musculoskeletal pain. Anecdotally, though, I have found success when very selectively applying it to areas where the intended tissue is plausibly close to the surface such as the lateral epicondyle, MCL (in thinner pt's), and tendons of the hand. Unfortunately, this practice has not been supported by the literature.

This is clearly shown by the multitude of insurance companies that won't reimburse it's use due to "lack of efficacy" (yet they gladly pay for the cheaper ultrasound). Now there is a new study recently published in the American Journal of Sports Medicine by A. Burke Gurney, PT and Daniel C. Wascher, MD that was very cleverly done. Here is the abstract:

Absorption of Dexamethasone Sodium Phosphate in Human Connective Tissue Using Iontophoresis

Background: Iontophoresis ostensibly facilitates the delivery of medications through the skin to underlying tissues using a direct electrical current. Dexamethasone is the most commonly used medication with iontophoresis to treat a variety of connective tissue disorders.

Hypothesis: Iontophoresis will facilitate the absorption of dexamethasone into connective tissue compared with diffusion.

Study Design: Controlled laboratory study.

Methods: Twenty-nine adults undergoing anterior cruciate ligament reconstructive surgery using the semitendinosus/gracilis autograft were randomly assigned to either a true iontophoresis (TI) or sham iontophoresis (SI). In the TI group, a 40-mA/min dose of iontophoresis using a 0.4% (4 mg/mL) solution of dexamethasone was used targeting the semitendinosus tendon just before surgery. The SI group underwent the same treatment, but the machine was not turned on. Tissue was extracted within 4 hours of treatment and analyzed for dexamethasone. In addition, 2 control samples were sent to the laboratory for analysis.

Results: There was a statistically significant difference in dexamethasone concentrations between the groups (P = .0216). Of the 16 samples in the TI group, 8 had measurable amounts of dexamethasone, with an average concentration of 2.906 ng/g of tendon tissue. In the SI group, 1 of the 13 samples had measurable amounts of dexamethasone with an average concentration of 0.205 ng/g of tendon tissue. The control samples contained no dexamethasone.

Conclusion: Iontophoresis facilitates the transmission of dexamethasone to connective tissues in humans.

Clinical Relevance: Iontophoresis can deliver dexamethasone to connective tissues in humans.

Now, we next have to show that that dexamethasone has a significant impact on tissue inflammation, but this a step in a good direction for iontophoresis as used by physical therapists.

Labels: dexamethasone, EBM, evidence based medicine, iontophoresis, physical therapy

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

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

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

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

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

Labels: adjustment, Chiropractic, EBM, subluxation

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

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

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

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