Wednesday, November 10, 2010

The Clinical Importance of Patient Reported Outcome Measures

Measurement tools, such as patient reported outcome (PRO) measurement questionnaires, are essential in enabling stake holders to assess and determine if a patient’s problem is changing or not. For therapists, medical practitioners, and surgeons it is important to see that the intervention provided has enabled the individual to show improvement. You can’t just say or ask the patient, ”are you better?” They often reply, “yes” just to keep the treater happy. By recording change using PROs, it allows the practitioner to determine how the patient/client is doing both accurately and quantitatively. This is important for all parties (insurance, patients, therapists, and researchers). They can determine if different types of treatments are being effective or as effective as others. Without accurate measurement, the effectiveness of treatment and interventions cannot be established therefore, justification of treatment provision becomes ‘opinion based’.

By contrast, for patients with progressively degrading conditions such as degenerative discs, arthritis, and some oncology patients, these tools can help determine how they are doing in terms of their ability to maintain themselves and minimise their inevitable rate of regression. Outcome measures in this context enable action oriented decision supports to help decide when the step to the next stage of management should occur. It can confirm regression or worsening of symptoms and the need for change in management of their condition, be it medical, physical, or considering moving to the surgical approach. With each new stage of management the outcome measurement process is able to justify this decision and determine the effectiveness of the new strategy. Two simple examples of this can be seen within the case examples of Low Back Pain and post op shoulder management here.

Here is a great list of hundreds of PROs for you to utilize in your clinics.

If you have any questions please email me.

Philip Gabel

World Congress on Low Back and Pelvic Pain - We are Here!

PT Project contributor Luke Bongiorno is attending the 7th annual World Congress on Low Back and Pelvic Pain in Los Angeles. We are looking forward to an information packed next couple of days. If you would like to meet Luke, discuss The PT Project’s future, or are interested in becoming a member of our team please email me.

Ryan Orser

Mobile Technology and Physical Therapy - Ne'er the Twain Shall Meet

An interesting thing happens when you perform a Google search for mobile technology and physical therapy: You get one result – an advertisement for a physical therapy position in Mobile, Alabama!


Physical rehabilitation starts in the clinic and continues at home, in the office, at the gym – mobile technology is the perfect solution for this multi-location experience. Why then has the PT industry as a whole not embraced this exciting opportunity? Shouldn’t we capitalize on the prevalence of Internet connectivity and smart phone use to stay connected to our patients? Wouldn’t a patient’s mobile device be the perfect rehab aid? Our patients seem to think so. A February 2010 mobile metrics report revealed that smart phone usage had increased 193% in the last twelve months.
As a community we are resistant to change, especially when it comes to technology. Having spent most of our professional lives interacting face to face with patients and not sitting behind a computer, we aren’t particularly tech savvy. We are a sector stuck in the dark ages of information technology and somewhat intimidated by it.

The time has come to change that. With mounting pressure from insurance companies to reduce our length of stay as they cut our reimbursement, we are left with little choice but to innovate. Technology offers real and immediate solutions that could save us time, create alternative revenue streams and improve delivery of patient care.

Technology adoption in the physical therapy space is inevitable; we just have to accelerate the process from within because who understands our needs better than we do?

Bronwyn Spira

Top 10 Pieces of Advice to New PT Graduates

Top10 | Chris Johnson PT
This post goes out to all you new physical therapy graduates. I hope this advice will help guide you on your professional journey. I have been incredibly fortunate when it comes to my experiences and mentors over the years so this is a simple way to give back. Below is a list, in no particular order, of what has helped me and I am confident will help you reach your goals in the wonderful world of physical therapy. Drum roll please…



1. KNOW THY PATIENT – Arguably the most important factor when it comes to helping patients in the clinic is how well you know the person you are providing care for. Collecting a thorough and accurate history as well as knowing what each individual patient exposes their body to on a daily basis is critical. I’m talking about everything ranging from vocational demands to exercise habits to donning a tshirt to drinking a glass of water to picking one’s nose to sexual positions.

2. SPEND TIME WITH A MASTER CLINICIAN – Before I even started physical therapy school, I worked in Dr. Lynn Snyder-Mackler’s lab at the University of Delaware and gained exposure to how she conducted her clinical examinations and research data collections. Let’s just say that I was spoiled. After completing PT school, I then had the good fortune of working at the Nicholas Institute of Sports Medicine and Athletic Trauma (NISMAT), where I fell under the tutelage of Dr. Malachy McHugh and the NISMAT staff. I am forever indebted to these indviduals as they have shaped me as a clinician and researcher and I hope you have the same opportunities.

3. DEVELOP YOUR MANUAL SKILLS – Nowadays, there is a huge emphasis on good manual skills and this should come as no surprise. All of the top notch clinicians that I know and respect possess exceptional manual skills. In particular, I would encourage you to become an expert in treating myofascial trigger points as well as owning joint mobilization and spinal manipulation. Once you become savvy in these areas, watch the referrals roll in. If you are looking to learn spinal manipulation and live in the NYC area, feel free to reach out to me as well. You can also attend a seminar that Luke Bongiorno and I teach that will get you competent in resolving trigger points and performing sound mobilization/manipulation.

4. STAY CURRENT WITH THE RESEARCH – Everything in medicine comes with a date. Let’s not forget that we used to cast people after ACL reconstruction and the arthroscope was considered the “tool of the devil.” Staying up to date with the medical literature is therefore critical and has never been easier. If you don’t have the financial means to subscribe to medical journals, at least follow various PT websites and blogs. For example, Mike Reinold runs a great blog that serves to provide the reader with current information and allows you to interact with other PTs and allied health professionals. Bruce Wilk also has some great articles on his website that I would encourage you to read, especially if you take care of endurance athletes. I try to give people free information on my personal website too that I hope you take the time to check out. Let’s not forget about The PT Project too people!

5. MOVEMENT, POSTURE, & STRUCTURE – This quote by Thomas Meyers says it all… “Movement becomes habit, which becomes posture, which becomes structure.”

6. PERFORM THE EXERCISES YOU PRESCRIBE – One of the biggest pitfalls that I see in our profession is that PTs often fail to perform the exercises that they prescribe. By performing the exercises, you will become more acquainted with the details associated with each exercise as well as common mistakes that can be made. It will also help you provide a better model of performance and allow you to more clearly explain the exercise.

7. INTERACT WITH FOLKS OUTSIDE OF THE PT WORLD – I have spent time with massage therapists, chiropractors, strength and conditioning coaches, skateboarders, yogis, break dancers, martial artists, etc. I must admit that I have learned just as much if not more from these individuals about movement and performance than I would have ever thought possible.

8. KEEP A PT JOURNAL – Keeping a PT journal is one of the most important things I do in an attempt to sharpen my clinical thoughts and reasoning. Some examples of the things I jot down in this journal are patterns that I observe in various patient populations, mistakes that I have made, or exercise progressions that come to mind. Reflecting on your time in the clinic is critical!

9. CALL YOUR PATIENTS – “People don’t care how much you know until they know how much you care.” Nothing will compliment your work in the clinic more than a simple phone call to your patients. I have never had a patient get upset by me calling them. In most cases, they were thrilled (maybe that’s pushing it) to hear my voice when they were having a stressful day. It will also serve to remind them to stay consistent with their work/home exercise program outside of the clinic.

10. SHADOW AN ORTHOPEDIC SURGEON – I had the amazing experience of spending nearly 10,000 hours shadowing Dr. Michael J. Axe of First State Orthopedics as part of a graduate assistantship that I was awarded during PT school. This experience was beyond awesome. It specifically helped me understand the patient perspective and also served to bridge communication between patient, doctor, and therapist. This was particularly valuable in the case of post surgical rehabilitation. And don’t let orthopedic surgeons intimidate you because after all, we are all human!

Wishing you a career of good fortune and longevity.
Chris Johnson

Thursday, November 4, 2010

Some People Are Just Born to Run

The NY Times Online published the story of Christopher McDougall, a former retired, new back-to-running marathoner. He explains why he stopped running at first as 9 out of 10 runners have some sort of injury when training for these long distance runs. Why would anyone continue a sport that had only 10 percent chance of not injuring themselves?

After meeting with gringo protégé, “The White Horse,” (of the Tarahumara Indians of Mexico’s Copper Canyons) and Daniel Lieberman, Harvard’s “Barefoot Professor,” Christopher spend 9 months completely retraining his running style (physically, mentally, and spiritually). According to his book Born to Run, McDougall “discovered that injury-free legs aren’t such a miracle after all.”

To read the rest of the article click here. I would be interested in hearing what your best injury free running method is. . .

Ryan Orser

Why I Am Running the Marathon Against Orders

adam banks staten islandCheck out my article on why I am choosing to run the NYC Marathon despite what PTs are advising me to do.

I explore the reasons why people “must” do some things, even if it is the wrong decision or the decision that goes against medical advice. I think this is an important topic to explore – people will “do their own thing”.

For me I didn’t want to hear “don’t run the marathon” – as people were telling me that, in the back of my mind I knew that I was going to run it anyway. What I wanted from my PTs was to say, “don’t run the marathon, but if you do, here is the best way to do it to minimize further injury”.

Check out the full article on ptproductsonline.com

Adam Banks

Five Key Exercises

I recently wrote an article on my blog about five key exercises that are appropriate for most people, while taking into consideration the following factors: safety, simplicity, and efficacy.

The post generated a lot of interest, and I am working on posting videos for them – I thought it worth sharing on The PT Project.

 My Five Key Exercises are:

 1. THE DA VINCI POSTURE
  • Stand with feet shoulder width apart and equal weight between both legs.
  • Maintain a slight bend in the knees.
  • Gently tighten the abdominal wall.
  • Rotate the arms so the palms are facing forward and the arms are parallel with the torso.
  • Slide the shoulder blades back and down.
  • Look straight ahead and gently retract the chin.
  • Hold for 30 seconds and repeat at least once every waking hour.
2. SINGLE LEG STANCE

  • Position the foot so it is pointing straight ahead or just slightly toed out.
  • Maintain a slight bend in the knee.
  • Gently tighten the abdominal wall and keep the pelvis squared off and level.
  • Perform three, one minute holds on each side every day.
3. SEATED ROW (requires resistance tubing with handles)

  •  Secure the resistance tubing around an immovable object or in a door jam so it is just below chest level.
  •  Ensure that your feet are shoulder width, knees neutral, and that you are sitting upright.
  •  Grasp the handles with a neutral grip (palms facing each other) and draw them back so the arms are parallel with your torso and not breaking the plane of you body.
  •  Once your arms are in position, gently slide the shoulder blades down and back and look straight ahead. 
  •  Complete five, thirty second holds.
  •  Afford a rest period of 45 seconds between each repetition.
4. SEATED HIP RAISES(requires velcro ankle weights)

  •  Start by sitting on a kitchen countertop or table so the feet are off the floor.
  •  Secure an ankle weight around each foot (not the ankle).
  •  While holding on to the front of the table to avoid leaning back, raise the thigh off the table about six to eight inches while keeping the foot level.
  •  Complete two sets of 25 repetitions.
  •  Afford a one minute rest between each set.
5. STATIC PUSH UP HOLD
  • Assume the starting position of a standard push but with the back level.
  • Ensure the head is in line with the spine and that the elbows are slightly bent.
  • Keep the knees straight and gently tighten the abdominal wall.
  • Start with five, 30 second holds.
I am confident that you will find this group of exercises to be a game-changer when it comes to improving your strength, stability, balance, and endurance. And remember to please consult a physical therapist or fitness expert before starting this program.
Christopher Johnson

Global Upper Extremity Weakness on Side of Tennis Elbow

Tennis elbow, like many orthopedic conditions we treat, almost always has associated signs of muscular imbalance which become symptomatic for patients. A recent study looked at the effectsof tennis elbow on the rest of the upper extremity electromyographically. The results of this study showed:
  • Gross UE strength on the side of tennis elbow was consistantly weaker in a symptomatic group vs control group. Grip was 25% weaker, wrist extension and flexion were 30% weaker, MCP flexion was 36% weaker, shoulder strength (all muscles) was 25-35% weaker. No difference in MCP extension.
  • UE (forearm and shoulder) fatigability showed no statistically significant difference between symptomatic and control groups
  • Abnormal activation patterns of the extensor carpi radialis were present in the symptomatic group which demonstrated muscle dysfunction—likely due to increased activity of wrist flexors abnormally which inhibit action of antagonists
Take home message: In the treatment of tennis elbow, we must take a comprehensive approach to care when strengthening and address the entire UE vs. only the wrist/forearm. We must also focus on not just the strengthening of the ECR but also its neuromuscular control to facilitate its correct activation with wrist extension.

Alizadehkhaiyat O, Fisher AC, Kemp GJ, Vishwanathan K, et al. Upper Limb Muscle Imbalance in Tennis Elbow: A Functional and Electromyographic Assessment. J Orthop Res; 25: 1651-1657.
Jospeh Brence

Managing Functional Running Injuries Using Orthopaedic Physical Therapy

Here is an article just published in the Orthopedic Practice Vol. 22; 4:10. I believe that understanding the stage of the injury can improve the functional outcome for the patient:


While many people think that running is simply for sports participants or the marathon runner, South Florida physical therapist Bruce Wilk acknowledges that many people run as part of their recreational activities, work requirements, educational standards, and achievement of developmental motor skills.

In his newly published article in the Orthopedic Practice, Wilk and associates Annmarie Muniz, and Sokunthea Nau define running as a functional activity of dailiy living, identify risk factors for common running injuries, and propose an evidenced-based model supporting the orthopaedic physical therapy rehabilitation of running injuries.

“What we have found is that when we properly identify the stages of a patient’s running injury, we can significantly improve their functional outcomes,” says Wilk.

Simply put, a patient’s injury has five stages:

Stage 1: Pain upon exertion
Stage 2: Pain at rest
Stage 3: Pain that interferes with ADLs
Stage 4: Pain that is managed with medication
Stage 5: Pain that is crippling

Wilk says that recognizing the stages of running injuries provides insight into the severity of a particular injury, general prognosis, and a more effective rehabilitation. “As injuries present in more advanced stages, the time spent in the early phases of rehabilitation is likely to be longer,” Wilk states. “Manual therapy, proprioceptive neuromuscular facilitation, and neurodevelopmental treatment should be incorporated appropriately depending on the individual’s learning style and current standing within the proposed phases of running rehabilitation.”

Wilk cites 4 phases of rehabilitation:

1) Self-management, rest, restore ROM
2) Fix muscle imbalance and work on body awareness
3) Functional strengthening
4) Efficient return to running (the functional goal is running)

“Running is a critical requirement for participation of many activities not only for competitive athletics,” states Wilk. “Therefore, it is the therapist’s responsibility to focus on the restoration of the ability to independently and efficiently perform this ADL. By properly staging his running injury and implementing associated stage-specific rehabilitation, we were able to help our patient pass the running portion of this test and return to his work duties.”

Bruce Wilk

Questions Are the Answers

Two golden questions that will ensure client compliance, great outcomes, and promote client loyalty!


I believe that in clinical practice there exists 3 golden questions that any client undergoing a course of treatment should be asked with-out fail and with-out exception! I have trained my clinical staff that failure to ask the following 3 questions will seriously jeopardise a client’s outcome, and jeopardise the opportunity that the practice has of developing word of mouth referring and loyal clients.

The 3 golden must-ask (without fail) questions are:

1. What is your expectation of me today?

This must be asked by the practitioner at the start of the initial consultation. I recommend that it is asked after the practitioner has given the client a brief overview of what the sequence of the consultation will entail (eg. history, examination, treatment, and recommendations).

Remember that our client’s will judge us not on how well we manipulated their thoracic spine or mobilised their talo-crural joint but rather their judgement will be based on did they get what they expected? If your client has raging discogenic lower back pain and they have heard that their friend with ‘the same thing’ was ‘fixed’ with one session, than it is critical that the client’s somewhat unrealistic expectations be put in perspective.

I can think of numerous examples where clarifying my client’s expectations in practice have resulted in great clinical outcomes and compliance with the proposed treatment. Conversely I can recall my earlier days of practice where I did not ask this question or clarify what my client expected of me and I was surprised to find that the client had not rescheduled or was not ‘over the moon’ with what I believed was a great start to their care. Fortunately I learnt the above lesson early in practice and I now ensure that my physio team ask this no matter what!

If you do not ask this question and even better clarify the client’s expectation by paraphrasing it back to the client (which shows you have been listening and are attentive and engaged in their care) than you are about to start the therapeutic relationship based on your often incorrect assumptions! Remember unmet expectations are the sole cause of disappointment in clinical practice and all areas of life.

For even greater effect after you have listened to the client’s expectation (and hopefully noted it in their case notes in BOLD!) ask the following question…..

2. Why is this (the client’s expectation) important to you?

The answer to this will reveal the why behind the ‘what’ or in other words the client’s ‘buying motivation’- the reason why they drove themselves across town, and allocated an hour of their day’s valuable time to come and see you. This buying motivation is synonymous with the clients ‘goals’, however a wise clinician will make clear distinctions between the client’s goals and that of their own goals for the client.

In life people will be motivated by either pleasure or pain. In allied health (especially physiotherapy) it is normally pain that prompts a client to seek care. Discovering the client’s ‘driver’ or ‘motivation to get better’ is critical in ensuring compliance with the administered and recommended care that you prescribe.

Imagine the client who is scheduled for an international 5 hour flight next week and would like to be able to sit without back pain, and not have their lower back pain hinder their first holiday from their small business for 5 years. How compliant would you envision this client’s to be with your recommendations. Or, are the client’s grandchildren visiting form interstate next week meaning that grandma will need to repetitively bend and pick up their grandchild? No matter what the client’s ‘buying motive’ for seeking your services it is our job to discover it, record it (also in BOLD), and tattoo it on our eye-lids such that we make reference to it a every session through the episode of their care.

The recording of the client’s expectation and the reason why their expectation must be met can be recorded simply in the client’s case notes. Even better is to give the client a written copy of their expectations/goals for their own home reference. The Back In Motion Health Group ensure that every client has their goals recorded for their own take -home use by way of presentation of a personalised ROADMAPTM brochure in which the therapist in consultation with the client develops a pathway of care that will reach set goals in order to meet (and ideally exceed!) the client’s initial expectation.

Asking these two questions will ensure that you get off to a great start with the client practitioner relationship. If the client believes that you have not just a ‘good’ or ‘rough idea’ of the outcome they want from your services, but rather you have an intricate understanding and appreciation of their reason for seeking your care. Remember you can paraphrase the client’s expectation back to the client initially and then skilfully make further references to it at the time of future appointments. I caution any health practitioner from commencing an initial consultation without asking these two questions.

Next blog I will reveal the question that MUST be asked during follow –up appointments for the ongoing fostering of healthy client-practitioner relationships and the minimisation of the client dropping out of your prescribed care plan.

Jason Smith

ACL Clinical Prediction Tools and Prevention Programs for Females

ACL_hipStatistically speaking, females are at greater risk for rupturing their ACL than men playing the same sports. Why is this?

Anatomic Differences

Pelvis width, Q-Angle, size of the ACL, and size of the intercondylar notch (where the ACL crosses the knee joint)
Hormonal Differences

The ACL has hormone receptors for estrogen and progesterone, and it has been thought that hormone concentration could play a role in ACL injuries. Studies have shown some differences in rates of ACL injury during different phases of the menstrual cycle. However, there has been some conflicting data, and the effect of hormone concentration on ACL injury risk has yet to be defined.
Biomechanic Differences

Women have been found to have differences in biomechanic movements of the knee seen when pivoting, jumping, and landing — activities that often lead to an ACL injury.
The theories above are just that – theories. Unfortunately no one knows exactly what causes the increased risk of ACL tears in females. More investigation is constantly taking place to better answer this question. The below trial took place in the Cincinnati Children’s Hospital Medical Center, and investigated a tool to help identify female athletes at risk for ACL injury.

BACKGROUND: Prospective measures of high knee abduction moment (KAM) during landing identify female athletes at high risk for anterior cruciate ligament injury. Laboratory-based measurements demonstrate 90% accuracy in prediction of high KAM. Clinic-based prediction algorithms that employ correlates derived from laboratory-based measurements also demonstrate high accuracy for prediction of high KAM mechanics during landing.

HYPOTHESES: Clinic-based measures derived from highly predictive laboratory-based models are valid for the accurate prediction of high KAM status, and simultaneous measurements using laboratory-based and clinic-based techniques highly correlate. Study Design Cohort study (diagnosis); Level of evidence, 2.

METHODS: One hundred female athletes (basketball, soccer, volleyball players) were tested using laboratory-based measures to confirm the validity of identified laboratory-based correlate variables to clinic-based measures included in a prediction algorithm to determine high KAM status. To analyze selected clinic-based surrogate predictors, another cohort of 20 female athletes was simultaneously tested with both clinic-based and laboratory-based measures.

RESULTS: The prediction model (odds ratio: 95% confidence interval), derived from laboratory-based surrogates including (1) knee valgus motion (1.59: 1.17-2.16 cm), (2) knee flexion range of motion (0.94: 0.89 degrees -1.00 degrees ), (3) body mass (0.98: 0.94-1.03 kg), (4) tibia length (1.55: 1.20-2.07 cm), and (5) quadriceps-to-hamstrings ratio (1.70: 0.48%-6.0%), predicted high KAM status with 84% sensitivity and 67% specificity (P < .001). Clinic-based techniques that used a calibrated physician’s scale, a standard measuring tape, standard camcorder, ImageJ software, and an isokinetic dynamometer showed high correlation (knee valgus motion, r = .87; knee flexion range of motion, r = .95; and tibia length, r = .98) to simultaneous laboratory-based measurements. Body mass and quadriceps-to-hamstrings ratio were included in both methodologies and therefore had r values of 1.0.

CONCLUSION: Clinically obtainable measures of increased knee valgus, knee flexion range of motion, body mass, tibia length, and quadriceps-to-hamstrings ratio predict high KAM status in female athletes with high sensitivity and specificity. Female athletes who demonstrate high KAM landing mechanics are at increased risk for anterior cruciate ligament injury and are more likely to benefit from neuromuscular training targeted to this risk factor. Use of the developed clinic-based assessment tool may facilitate high-risk athletes’ entry into appropriate interventions that will have greater potential to reduce their injury risk.

This study is of great importance with regard to predicting at risk females who participate in jumping sports. The question is, so what do we do about it now?

There has been some evidence to suggest that ACL Prevention Programs, such as this one can be beneficial in preventing injury in at-risk females.

Renstrom et al (2008) in the BMJ provided a current concepts statement regarding such programs. The authors noted:

“These programmes attempt to alter dynamic loading of the tibiofemoral joint through neuromuscular and proprioceptive training. They emphasise proper landing and cutting techniques. This includes landing softly on the forefoot and rolling back to the rearfoot, engaging knee and hip flexion and, where possible, landing on two feet. Players are trained to avoid excessive dynamic valgus of the knee and to focus on the “knee over toe position” when cutting.”

At risk players can also be identified using the drop vertical jump test by Noyes et al (2005).

Does your practice perform such prevention programs?

References

Myer GD, Ford KR, Khoury J, Succop P, Hewett TE. Development and Validation of a Clinic-Based Prediction Tool to Identify Female Athletes at High Risk for Anterior Cruciate Ligament Injury. Am J Sports Med. Jul 1 2010.

Renstrom P, Ljungqvist A, Arendt E, et al. Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts Statement. Br J Sports Med. 2008;42 (6):394-412.

Noyes F, Barber-Westin F, Fleckenstein C, et al. The Drop-Jump Screening Test

Difference in Lower Limb Control By Gender and Effect of Neuromuscular Training in Female Athletes. The American Journal of Sports Medicine. 2005; 33(2): 197-207.

Griffin Y,Agel J, Albohm M, et al. Noncontact Anterior Cruciate Ligament Injuries: Risk Factors and Prevention Strategies. J Am Acad Orthop Surg. 2000; 8(3): 141-150.

Ben Gold

Identifying T4 Syndrome

While working in another facility appx. a year ago, a colleague of mine introduced me to the diagnosis of T4 syndrome. I was fascinated by this disorder and went to research databases (pubmed and google scholar) to check it out…and was extremely disappointed. While finding the earliest documentation about T4 syndrome to have occured in 1986, there has been very limited research in its differential diagnosis and management since. Below is a list of criteria which appears to be consistent in the documentation of this disorder:

1) Symptoms of stiffness in the upper thoracic spine (T2-6)
2) Paresthesias/numbness in a glove-like pattern in bilateral hands and forearms
3) Associated weakness/clumbsiness/pain of bilateral hands and forearms which follow non-segmental/non- dermatomal patterns
4) Associated sympathetic nervous system symptoms such as temperature changes (coldness) in the pattern of symptoms
5) May or may not have headaches which fluctuate with UE symptoms

I believe we must continue to investigate this disorder. The thoracic spine may be the source of pain in some of our radicular patients (vs. the cervical spine) and while many of us may be treating the thoracic spine anyway, we need to find out the most effective interventions for these patients to manage their symptoms effectively. If anyone has any literature on this diagnosis, please share. . .

Joseph Brence

ITBS Here, ITBS There, ITBS Everywhere!!

With less than 3 weeks away from the NYC marathon, our clinic is overflowing with nervous marathoners sidelined with overuse running injuries. Currently, the most prevalent of these injuries seems to be ITB syndrome. This recent influx in ITBS has got me thinking about the true causes and the best treatment strategies for this injury.

I would like to use this article as a forum for discussion on IT band issues. We all know the textbook causes and treatment strategies for this problem, but I am interested in hearing about other’s true clinic experiences in treating this problem (what seems to work for you and what doesn’t) and your thoughts on the major contributory factors.

The one thing that ALL my current runners with ITBS present with is weakness in the glut med on the affected side. Most demonstrate poor stability and form during a step down test. Other factors such as structural abnormalities, tight hip flexors, hip flexor weakness, glut max weakness, and overpronation seem to vary between this current caseload.

I find that active release techniques targeting the vastus lateralis on the ITB and TPR/ART of VL, TFL and glut med seem to work well in releasing tightness of these lateral structures.

What do you feel works best for the acute irritation at the ITB insertion site? I do not typically use modalities, but I would be interested to hear if anyone has had good outcomes with certain modalities to that area, and if so what they are. What other things do you find useful in decreasing the irritation, acute/chronic symptoms of ITBS.

I am excited to hear your thoughts, opinions, and clinic experiences and for us all to share our knowledge to help improve treatment outcomes.

Krista Simon

Wednesday, November 3, 2010

Ergonomics Part II - Measuring Work Hazards

This is the second part of a three part series of articles on ergonomics. In the first article, six ergonomic hazards were introduced by ErgoWorks through the acronym F.R.E.D.V.P. ©: Force, Repetition, Environment, Duration, Vibration, and Posture. These hazards cause fatigue and fatigue is often the beginning of the injury cycle.


Once the hazards have been identified, the second step is to quantify or measure the hazards that are contributing to a work-related musculoskeletal disorder. There are guidelines and recommendations for ergonomics from the Occupational Safety and Health Administration (OSHA) (particularly for noise, heat and cold, chemical exposures, air quality, etc…), the National Institute of Occupational Safety and Health (NIOSH), American National Standards Institute (ANSI) (ANSI B11), and the International Organization for Standardization (ISO) (ISO 9241). California and Washington have also passed state ergonomic rules and regulations.

OSHA passed an ergonomic standard under the Clinton administration, but was repealed by the Bush administration. The reasons for the controversy over this legislative rule are complicated and cause dilemmas! How can you create expensive mandates for all employers when there is ambiguity in the research data? Based on age, sex, race and anthropometrics of all individuals including handicapped, pregnant, and wheel-chaired, what criteria do you use to decide how much force is too much?…or how many repetitions are too many?…or what environmental conditions cause too much fatigue?…or how much rest and recovery does a muscle need when assessing duration of a task?…or how much exposure to vibration is too much?…or what postures cause injury? ErgoWorks’ experience is that successful companies will implement ergonomic solutions when we are able to demonstrate with reliable and valid data that the COST OF INJURY IS GREATER THAN THE COST OF ERGONOMIC SOLUTIONS.

The Center for Ergonomics at the University of Michigan has been a leading institution in the field of ergonomics for decades. They have developed models for biomechanical assessments. One of the earliest models is the Two-Dimensional Static Strength Prediction Program (2DSSPP, and recently updated 3DSSPP) which provides risk data based on configured anthropometrics. The risk data provided are back compressive force at L4-L5 and L5-S1 disc and the percent of the population that has the strength to perform the lift task on an occasional basis at the back, elbow, shoulder, hip, knee and ankle.

The University of Michigan’s guideline for back compressive force is no greater than 770 lbs. and for percent capable is not less than 75% for males. ErgoWorks has found a strong correlation between the 2DSSPP risk data and back injury. When the back compressive force approaches 700 lbs. and the percent capable is under 95%, the risk for back injury is significant. The 2DSSPP model’s ability to create what-if scenarios encourages further investigation of its benefits. For example, what if we raise the object to be lifted…or bring it closer…or reduce the weight…or change the anthropometrics? How does this change or reduce the risk data? Is the change statistically significant? There is controversy regarding most biomechanical models, but Ergoworks finds the objectiveness of the data useful in motivating companies to implement ergonomic solutions.

The revised NIOSH Lift Formula (www.cdc.gov/niosh/docs/94-110) provides a Recommended Weight Limit (RWL) based on a load constant of 51 lbs. being multiplied by six criteria: Horizontal Distance Multiplier, Vertical Distance Multiplier, Distance Multiplier (the vertical difference between the origin and destination of the lift), Angle of Asymmetry Multiplier (twisting), Coupling Mechanism Multiplier (how the item is grasped), and the lift Frequency Multiplier. The formula supports the industrial benchmark of lifting no more than 51 lbs. The criterion with the lowest fractional number reduces the RWL most significantly. Learning how to manipulate this formula will help guide to the best objective solution.

Other tools that supplement an ergonomic assessment include:

Dictionary of Occupational Titles
Checklists
Discomfort surveys
Job observations
Job cycle worksheets
Measuring tape, protractor and/or goniometer
Force gauges for gross lifting, pushing and pulling
Hand grip dynamometers with pinch measurement capabilities
Videotape to more accurately document frequency rates and ranges of motion
Rapid Upper Limb Assessment (RULA)
Borg Perceived Exertion Level

Further ergonomic analysis should consider:

Static loading
Quick, jerky and/or accelerated forces
End ranges of motion
Pushing and pulling forces
Pinch and grip forces
Energy expenditures
Asymmetric work
Restricted movements, particularly inability to maintain lumbar lordosis

A key point to remember is that no one assessment tool will lead to an optimal solution. Performing multiple risk assessments should identify primary hazards. The question that an employer will ask is, “What is causing injuries and what is the best and most inexpensive way to fix the problem?” A good analysis should objectively quantify the risk hazards that will lead toward ergonomic solutions. The next article will address implementing cost-effective solutions.

Glenn Orser

Differentiation of SLAP Lesions

Pitchers are frequently seen in orthopedic clinics for injuries to their throwing shoulder. Many of these pitchers complain of a “dead arm” or a severe decrease in the velocity at which they can pitch. It is extremely important as direct access practitioners that we correctly diagnose these injuries, especially in the presence of a Superior Labral Anterior Posterior tear (SLAP) lesion. SLAP injuries frequently present with concurrent pathologies that may mask the classic signs of the SLAP. Failure to properly diagnose these pathologies may lead to further disability for the pitcher.


There are four tests and proceedures that are commonly used to diagnose shoulder impairments, in particular SLAP lesions. These include Bicipital groove tenderness, O’Brien’s Cross Arm test, Speeds Test, and Modified Jobe Relocation Test. The O’Brien’s and Speed’s test are considered highly specific for anterior Type II SLAP lesions. The Modified Jobe Relocation Test is considered highly specific for posterior Type II SLAP lesions which is the most common SLAP lesion in pitchers.

During arthoscopic surgery on pitcher’s (+) for a posterior Type II SLAP lesion, placing the shoulder in the initial position for the Modified Jobe Relocation test resulted in a (+) peel back sign with subluxation of the posterior superior labrum. During the second portion of the test, a posterior directed force is applied to the proximal humerus which puts the biceps tendon on traction and reduces the labrum to a normal position. Given this information, the Modified Jobe Relocation Test should be performed on every pitcher that presents to the clinic with c/o “dead arm” to determine whether a posterior Type II SLAP lesion is present.

Reference:

Burkhart, Stephan. “The Disabled Throwing Shoulder: Spectrum of Pathology Part II: Evaluation and Treatment of SLAP lesions in Throwers.” Arthroscopy: The Journal of Arthroscopic and Related Surgery 19.5 (2003): 530-539. Web. 21 Oct 2010.

Adrienne Zeiler

Iontophoresis and Genital Herpes

Several research articles have been published over the years about the effectiveness of iontophoresis for inflammatory conditions. One particular condition for which iontophoresis with dexamethasone has been researched extensively is shoulder tendonitis. Studies have shown this to be an effective treatment in the presence of a true inflammatory condition. As we all know, the contraindications for iontophoresis typically include those similar to electrical stimulation. Other contraindications include prolonged erythema, tingling, burning, and pulling sensations which usually occur when the current has been turned up too quickly.


Recently, I had a patient with supraspinatus tendonitis/impingement for whom iontophoresis seemed to be a valid treatment. He had been referred by his PCP, a local internist who I have dealt with previously. I called the office and requested a prescription for dexamethasone and iontophoresis. His PA told me that she would speak with the physician and send the script over as soon as she was able. When I received the prescription it said “use only if genital herpes is not active.” I called the physician to clarify that I would be using the medication topically on the shoulder. His response was the same. He said that during treatments dexamethasone may enter the blood stream and increase the active herpes virus.

I have been unable to find any research that studies at the effects of topical dexamethasone on active genital herpes infections however, it is something to consider. Most PTs are not inclined to question their patients about their sexual history/diseases especially when they are being seen for a shoulder injury. Even if a PT is thorough in their history taking, patients may be reluctant to share this information. Until further research is done regarding the use of dexamethasone and the contraindications associated with it, perhaps we should be more careful to communicate with referring physicians regarding the patient’s overall health.

Has anyone else seen this? Please comment.

Adreienne Zeiler

Neuromuscular Electrical Stimulation of Quadriceps Femoris


Neuromuscular Electrical Stimulation of the Quadriceps Femoris from NYSportsMed & Physical Therapy on Vimeo.


Based on the work of Dr. Lynn Snyder-Mackler et al in JBJS, electrical stimulation when combined with volitional exercises yields superior quadriceps function following ACL reconstruction and should be routinely employed during rehabilitation to overcome quadriceps inhibition. It is critical to highlight the fact that the patient remains completely relaxed while the stimulation is on and the therapist should take it up to maximum patient tolerance.


Parameters:

Device: Empi PV300
Pulse Width = 400 microseconds
Frequency = 50-75 pulses/second
On/Off Time = 12/50 seconds
Ramp Time = 2 seconds
Total Treatment Time = 15 minutes

Neuromuscular Electrical Stimulation of the Quadriceps Femoris from NYSportsMed & Physical Therapy on Vimeo.

Chris Johnson

Grading Knee Effusion


Grading a Knee Effusion from NYSportsMed & Physical Therapy on Vimeo.


Oftentimes patients suffering from knee injuries present with an effusion. A simple and reliable (Sturgill et al JOSPT 2009) approach to quantify a knee effusion can be seen in this video. The corresponding effusion grade for the video demonstration is a 2+.

Grading Scale:

Zero = No wave produced on downstroke
Trace = Small wave on medial side with downstroke
1+ = Larger bulge on medial side with dowstroke
2+ = Effusion spontaneously returns to medial side after upstroke (no downstroke necessary)
3+ = So much fluid that it is not possible to move the effusion out of the medial aspect of the knee

When is Pain Being Referred?

I recently wrote a blog on Pain and if its simply more than an experience. To take this blog a step further, I wanted to get into differentially diagnosing referred pain vs. nonreferred pain. As clinicians that typically treat patients who are in pain, it is vital that we recognize when pain is from musculoskeletal origin and when its being referred from somewhere else.

To understand referred pain, we must understand how pain is referred and why it presents similar to musculoskeletal pain. When we are little, we experience pain by falling, bumping into, or doing some sort of activity that causes a traumatic stimulus to our body. This stimulus reaches cells within a sensory cortex and we have a memory of what that pain felt like. As we age, we experience this pain numerous times through similar traumas/injuries—we even can sense or experience this stimuli through memory and almost “feel” that pain again. Well on occasion, when the same cells in the sensory cortex get information from deeper structures, our brain interprets the information the same way it did from past experience. The brain misinterprets the origin and we believe it is more superficial in nature when its actually deep. Our body makes a perceptial error from the experience of pain.

Patients who experience true referred pain often compain of the following symptoms:

1) Deep burning or aching along a limb
2) Pain that radiates from the posterior aspect of the body anteriorly
3) Large, undefined boundaries of deep pain
4) The pain has no physical signs of disorder

A pain diagram is a great way of making a clinical mental note prior to even examining the patient. Often if I see a patient draw big circles, put xxxxx’s to indicate burning along a limb or draw arrows showing the radiation of pain, I will ask more systemic questions in my history. Because pain may be nothing more than experience, it is vital that we probe for its origin vs. always believing its musculoskeletal in nature. . .

Joseph Brence

Preventing Non-Traumatic Neck Pain

In the US, our current model of healthcare relies heavily upon responsive medicine. The consumer often seeks medical attention once a problem has developed but in most cases was not aware that simple preventative techniques could be performed to reduce the risk of injury. One of the most common complaints I assess is the onset of non-traumatic neck pain/ache/crik/stiffness/etc.

When assessing these patients, I almost always notice the presentation of a forward head and rounded shoulders with developement of a cervical hinge line around C6. When seeing this, I often begin treatment by educating the patient with the following analogy: Imagine your head as a bowling ball and your neck as the hand that holds that ball. Imagine letting the bowling ball sit in the palm of your hand with your arm tucked tight into the body and then slowly move your arm away from the body while continuing to palm the ball. The weight of the ball would put more and more stress on your arm as it moves away from the body until the weight causes failure or injury to occur (I will even give the patient a weighted ball and let them try this).
Postural assessment and correction is the key in the majority of non-traumatic neck pain. Research has shown that for every inch the head moves forward, 10 lbs of increased pressure is applied to the neck. So in the treatment of prevention of neck pain, always assess posture. I believe the majority of neck pain should be, and could be prevented. A few postural cues and 10 minutes of education is all a patient may need to maintain a healthy, painfree neck.

Joseph Brence

High Velocity Fastballs vs Shoulder Stability

The NY Times published a great article this weekend on the relationship between shoulder stability/strength/cuff length. Last season, several well known major league pitchers lost critical speed on their fastballs with no reports of pain or injuries. Mike Marshall, a former Dodgers relief pitcher and Cy Young Award recipient, now Ph.D. in exercise physiology says that “when baseball pitchers lose release velocity, it is always a result of the decrease in joint stability.”

If I am referred someone recovering from a shoulder injury for exercises, I ALWAYS make sure the person can maintain joint stability before progressing them to any other arm/shoulder exercises.

Mike Reinold has some great articles on shoulder strengthening.

"Tyler Twist" - Tennis Elbow Cure or Shoulder Impingement Creator?



Tyler et al. recently published a study in the Journal of Shoulder and Elbow Surgery entitled “Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial.” The authors found that patients with chronic tennis elbow enjoyed improved outcomes when a novel eccentric training exercise (AKA the “Tyler Twist”) was added to standard physical therapy. While the results of this study are beyond impressive, I have been shocked that there has been little to no mention regarding the position of the noninvolved arm while performing the Tyler Twist. It is readily apparent that the model in this video is falling in to a position of subacromial impingement that is nearly identical to the starting position of the Hawkins-Kennedy maneuver. Perhaps this eccentric training exercise may be addressing lateral epicondylosis but is it potentially creating shoulder imingement on the noninvolved arm? Since this research suggests that incorporating the Tyler Twist in to the physical therapy program of a patient presenting with chronic lateral epicondylosis will engender optimal results, proper execution is critical. So make sure to instruct your patients to keep their elbow down (below 60 degrees) to protect them while they are performing the Tyler Twist. Otherwise they may be returning to the clinic for complaints of shoulder pain. Curious to hear your thoughts on this topic. Hope everyone is having a good weekend.

Chris Johnson

Tuesday, November 2, 2010

VBI - Decision Making in the Presence of Uncertainty

http://www.theptproject.com/clinical-practice/vbi-%e2%80%93-decision-making-in-the-presence-of-uncertainty/ thumbnail imageSome estimates related to the risk of VBI when manipulating the spine range from 6 in 10 million[i] to 1 in 400,000.[ii] Although the spectrum of risk in these figures differs, the technique of performing low-amplitude high-velocity thrusts on the cervical spine is real.

It is a little disheartening to me, knowing that the tests we use to screen cervical spine patients for vertebro-basilar insufficiency (VBI) may not in fact be as accurate as I initially thought. Although our governing body supports the use of screening procedures and guidelines to indentify patients at risk for VBI, Childs et al (2005) attest that recent research does not support the idea that practitioners can assess risk in VBI patients accurately. Furthermore, Di Fabio (1999) and Halderman et al (1999) believe that there is not great evidence for ultrasound, diagnostic testing or clinical examination findings to identify patients with VBI risk.

Evidence over the past 10 or so years has confirmed cases of patients who sustained VBI after cervical manipulation. Huffnagel et al (1999) reported on 10 such patients that had no signs or symptoms predicting them for increased risk of VBI.

Despite the inaccuracy of testing, from a legal standpoint, it would still be jurisprudent for physical therapists to use the guidelines for pre-manipulative testing with appropriate patients, so that they do not place themselves at risk for litigation.

Why should we bother testing patients at all if this lack of specificity for testing exists, and there is a high likelihood that practitioners may report false negative findings when testing for VBI? Despite this being a difficult area to research, due to the occurrence of VBI being rare, we must strive to develop either safer manipulation skills or better testing measures for VBI.

Is it the manipulative procedure itself, or the position of the neck holds risk of VBI? Interestingly, Symons et al (2002) found that the strain on the vertebral arteries during thrusting is lower in some cases than range of motion testing of the cervical spine. In contrast, Kuether et al (1997) found the positions of terminal neck rotation, and neck rotation plus cervical extension reduce vertebral artery blood flow significantly.

I then ask the question, are the pre-manipulative testing positions potentially more dangerous than the high-velocity thrust performed during the manipulation? I am aware of (but not proficient in) certain cervical manipulative techniques done in supine, with the absence of any rotation performed to the neck. Perhaps these advanced techniques should be taught to physical therapy schools, rather than the current rotation/extension manipulation techniques that may be putting patients at risk.

Cleland et al (2007) and Childs et al (2005) suggest we try another approach altogether – thoracic spine manipulation to address patients with neck pain. Cleland et al (2007) reported positive preliminary results with their initial study. I will reserve judgement until the results of a validation trial are performed on their clinical prediction rule.

References:

Childs J, Flynn T, Fritz J, et al. Screening for vertebrobasilar insufficiency in patients with neck pain: manual therapy decision-making in the presence of uncertainty. The Journal Of Orthopaedic And Sports Physical Therapy. 2005;35(5):300-306.

Cleland J, Childs J, Fritz J, Whitman J, Eberhart S. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Physical Therapy. 2007;87(1):9-23.

Di Fabio, R. Manipulation of the cervical spine: risks and benefits. Physical Therapy. 1999; 79(1): 50-65

Hladerman S, Kohlbeck F, McGregor M. Unpredictibility of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation. Spine. 2002; 27:49-55.

Hufnagel A, Hammers A, Schönle P, Böhm K, Leonhardt G. Stroke following chiropractic manipulation of the cervical spine. Journal Of Neurology. 1999;246(8):683-688.

Kuether T, Nesbit G, Clark W, Barnwell S. Rotational vertebral artery occlusion: a mechanism of vertebrobasilar insufficiency. Neurosurgery. 1997;41(2):427-432.

Symons B, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. Journal of Manipulative & Physiological Therapeutics. 2002;25(8):504-510.
--------------------------------------------------------------------------------

[i] Klougart N, Leboeuf-Yde C, Rasmussen L. Safety in chiropractic practice. Part II: Treatment to the upper neck and the rate of cerebrovascular incidents. Journal Of Manipulative And Physiological Therapeutics. 1996; 19(9):563-569.
[ii] Magarey M, Rebbeck T, Coughlan B, Grimmer K, Rivett D, Refshauge K. Pre-manipulative testing of the cervical spine review, revision and new clinical guidelines. Manual Therapy. 2004;9(2):95-108.

Run the ING NYC Marathon in 3.5 Minutes. . .

Awsome time-lapse video of the NYC Marathon course on the NY Times website.



Adam Banks

Getting Old Isn's an Excuse to Give Up

Tales of “the older athlete” — Part 1

80 yr old completes 21st iron man. Defying laws of aging? Or does he just has the right attitude?

This weekend I witnessed 80 yr old scientist, Lew Hollander, from Bend Oregon, power through the finish line to complete his 16th ironman at Kona Hawaii, in a time of 15hrs 48mins, beating his time from last year by 34 minutes. Interestingly he completed his first ironman 25 years ago, at the ripe old age of 55 in a time of 15hrs 47 mins, only 1 minute faster. Hasn’t slowed down too much. What’s his secret…

“while you do lose some quickness, agility and range of motion, you NEVER lose your competitive spirit”

While most 55+ yr olds I treat couldn’t imagine doing even a part of an Ironman, when it comes to active goal setting, they’re often capable of setting the bar a little higher than they think. It’s our job as PT’s to facilitate and motivate them. When they suffer an injury, they become discouraged that “they’re getting older and slowing down”, and they will not be able to do the things they enjoy doing. The body is more than capable of building muscle and maintaining a good level of cardiovascular fitness as we get older.
Interestingly on the plane coming home, I was talking with the girl next to me and asked her how she did in the Ironman. She replied that she was here to watch her 60 yr mother complete her third Ironman. According to her daughter, she was never much of an athlete but picked up triathlons at age 50, joining a triathlon group in California. Over the past 10 years she has trained her way to be in “the best shape of her life”.
Why are triathlons good for “the mature athlete”?

Triathlons offer a good form of cross training, and often if training for a specific event, require athletes to train 6 times/week. It may sound intense, however 1-2 hrs of exercise a day can really help improve cardiovascular fitness (improving blood flow to the brain), joint nutrition and flexibility, and help slow the diminutive effects of aging. Training with a group or team provides structure, discipline and help bring out their competitive spirit, driving them to speed up and not slow down as they get older. Also the older athlete becomes more aware of their overall health, including diet and learning how to use their bodies more efficiently (part of our role is an educative one when working with them). Also structured exercise has been shown to help alleviate the symptoms of depression.

Lew Hollander demonstrates that the right attitude, focus and commitment to a goal, helps the body and mind keep going. Our role is to facilitate our patients to achieve these goals!

Check out his website:  http://www.lewhollander.com/pages/athlete.html
Luke Bongiorno

Pilates - A Patient's Perspective

A patient wrote in describing her experience during physical therapy:


As I crescendoed to the E string on my violin and turned my body to the right for emphasise, I knew that was it. A slight pinch in my lower left side and I dropped on the floor in agony. I knew the inevitable had come. It was the proverbial straw that broke the camels back. I’d been in denial about my increasing muscle stiffness and aches in my lower back and neck, which had been niggling away for the past 18months. I never thought that at 25 years of age and with my level of fitness, I might end up bedridden for 6 weeks on my back, with shooting pain down my legs and arms, debilitated. I was wrong. I had be superficially trying to fix my lower back and neck pain by attending the Physical Therapist (PT) occasionally, but wasn’t committed enough to actually learn the exercises the therapist taught me. I had been going to the PT every time I experienced discomfort: a little manipulation that always gave me some relief, however this was temporary. I thought that combining this occasional treatment with running 3 times a week was good for my body. Little did I know that every jolt was compounding the stiffness in my joints due to prolonged sitting at a desk and that visits to the PT once every 6 weeks was no panacea. The first lesson of my back pain experience was never to be arrogant about your body, no matter the level of fitness or your age. Crippling pain can strike anyone. A mixture of poor posture, bad genes and lack of core strength led to my predicament.

Unable to work or study I was forced into a life of appointments, trying every treatment to rid myself of the pain. I saw all sorts of practitioners trying to understand the cause of my back pain and more importantly learn what I could do to relieve it. I went to physicians, osteopaths, PTs and Chinese doctors. The relief these practitioners provided was often good but temporary. I decided that soon I could not afford to be making appointments 2-3 times a week in order to get a few hours of relief.

I had heard of pilates but thought it sounded pretentious and useless. I needed some relief from the stiffness and pain so I was willing to try anything. At first I was fearful of the equipment used for pilates (or neuromuscular re-education) and was worried the exercises would set me back into weeks of agonising pain again. My body had gone into protective mode and I had to work hard to fight the fear of pain so I could move again. To my relief, pilates was the only thing that gave me movement back and forced me to get over my fear. All of this was a marvellous breakthrough and left me wondering why it hadn’t been suggested by a therapist earlier. The PT I used to see had mentioned exercises that would help my condition but it was usually in a rushed manner about 5-10 minutes after the consultation.

I had never visited a PT who was into a holistic approach and whose motivation was to help me solve my problems permanently until I came to see Luke Bongiorno at NY Sports Med. I needed a therapist who was patient and willing to teach me these exercises properly, in supervised sessions, so that I could learn a whole new way to move. After a few sessions with Luke, I was relieved to see that pilates and PT (manual therapy) were so heavily integrated. I wondered why all therapists weren’t using this treatment because as I see it, you are only getting half the care you need to fully recover if you are only receiving manual treatment.

I agree that manual therapy definitely has its place but unless the patient takes responsibility for their own rehabilitation and learns proper exercises that strengthen the core muscles, recovering from back pain will usually be a prolonged process. Not only is it expensive, but it also prevents full recovery from your musculoskeletal problems and leaves you relying on medication to relieve your pain. I do not have a background in health and knew very little about how the body worked before I had my back injury. After learning pilates I have a much better understanding of movement and posture and I know how vital it is to incorporate these principles into my everyday routine.

The unfortunate thing about it all was that it took an injury that set me back for 6-12 months to realize it. I just wish more physical therapy clinics and therapists themselves encouraged pilates because this is not only a real solution to prolonged pain but a fantastic way to prevent it.

- Josephine Cincotta
* Patient’s name was changed to protect her identity

Tennis Elbow - What's the Best Approach?

Tennis elbow, lateral epicondylitis, lateral epicondylalgia or whatever you wish to call that pain on the outside of the forearm, is not easy to treat. Assuming that “tennis elbow” is not referred pain from the cervical spine, there are many treatment techniques I have encountered that aim to reduce the pain of the condition, and increase the hand and elbow function of those afflicted by it.


Some of the techniques commonly used include, but are not limited to: prolotherapy, steroid shots, lidocaine shots, Platelet Rich Plasma (PRP) shots, oral NSAIDs, oral analgesics, oral steroids, topical NSAIDS (Voltaren, Penssaid), elbow braces, immobilization of the elbow, compression bandages, ultrasound, phonophoresis, electrophoresis, trigger point release of forearm muscles, trigger point injections, cold-laser therapy, stretching, transverse frictions, joint mobilization, mobilizations with movement, mill’s manipulations, rest, postural re-education, eccentric forearm exercises, tendon transfer surgery….etc. No management strategy has had exceptional results with treating tennis elbow, even though numerous randomized trials have been performed

Bisset et al (2006) investigated whether Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow[1] had the best short and long-term results. The results of this study were not surprising, but rather, give further credence to the field of physical therapy.

The authors found that cortisone injections had the best effect at 6 weeks, even over physical therapy (except on the global improvement outcome scale), and significantly better than “wait and see.” At 6 weeks, mobilisation with movement (MWM) and exercise had a clear advantage over “wait and see.” The NNT (number needed to treat) in this example was 3, ie for every 3 patients treated with MWM and exercise, the PT would have had one more successful outcome than if they “waited to see.” At 52 weeks, physical therapy was superior to both corticosteroid shot and “wait and see.” Interestingly, those subjects that had injections had the highest reoccurrence rates of tennis elbow.

Numerous studies have shown the absence of inflammatory cells[2] histologically in tennis elbow, so why use anti-inflammatories or cortisone shots at all? I can see the benefit in the first 6 weeks of injury when inflammatory markers may be present, but I see no additional benefit for chronic cases of tennis elbow. This brings up another interesting question. Why do anti-inflammatories or NSAIDs work at all (albeit short term) in chronic cases of tennis elbow? Perhaps they work on inhibiting the pain element of the cyclooxygenase pathway (COX pathway), rather than the inflammatory element? I welcome responses regarding this phenomenon.

Some evidence suggests that tennis elbow may be related to changes in the common extensor origin, more specifically:

•neurogenic chemical mediators of pain (substance P and calcitonin gene-related peptide).[3]
•Increased level of glutamate (an amino acid)[4]
•neovascularization[5]
•muscle fiber morphology changes (ie fiber necrosis, higher percentage of fast twitch oxidative fibers, and moth eaten fibers)[6]
•Changes to sympathetic nervous system (no vasomotor response)[7]
•Presence of mechanical, but not thermal hyperalgesia[8]

With regard to manual therapy, there have been numerous studies purporting its benefit to treating tennis elbow, and proposing varied reasons why it works. In reality, there are probably many varied reasons (explained and unexplained) as to why manual therapy works on various different systems. Interestingly, Abbot et al (2001) proved that a MWM performed on the elbow in patients with tennis elbow resulted in improved external rotation ROM immediately after the procedure.[9] This certainly baffles me!

Vicenzino et al (2009) are following in the footsteps of the Childs and Cleland (2006) clinical prediction rule for treating lower back pain, in that they provided a Level IV evidence of a clinical prediction rule to treat tennis elbow[10]. Their analyses looked at age, and pain-free grip strength on the affected and unaffected sides. I will reserve judgement on this article until a further validation study has been performed.

Coombes et al (2009) in an exciting and prospective trial are following on from the work of Bisset et al (2006). In this trial, they have gathered 132 tennis elbow patients. They intend to randomize the subjects into one of four treatment groups:[11]
1) Corticosteroid injection
2) Saline injection
3) Corticosteroid injection with physiotherapy
4) Saline injection with physiotherapy.
PT will comprise 8 sessions (like in the Bisset et al trial), with follow –up assessments at 4, 8, 12, 26, 52 weeks.
I look forward to the results of this trial, especially since the authors are including cost effectiveness and cost-benefit analyses. After all, treatments must be cost-effective and have therapeutic value to be considered for use in the wider community.
--------------------------------------------------------------------------------

[1] Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939
[2] Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow): Clinical features and findings of histological. immunohistochemical, and electron microscopy studies.Bone Joint Surg Am. 1999; 81:259-278.
[3] Ljung BO, Alfredson H, Forsgren S. Neurokinin 1-receptors and sensory neuropeptides in tendon insertions at the medial and lateral epicondyies of the humerus: Studies on tennis elbow and medial epicondylalgia. J Orthop Res 2004;22:321-327.
[4] Alfredson H. Ljung BO, Thorsen K, Lorentzon R. In vivo investigation of ECRB tendons with microdialysis technique: No signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop. 2000;71:475-479.
[5] Zeisig E, Ohberg L, Alfredson H. Extensor origin vascularity related to pain in patients with tennis elbow. Knee Surg Sports Traumatol Arthroscopy. 2006;14:659-663.
[6] Ljung BO. Lieber RL, Friden J. Wrist extensor muscle pathology in lateral epicondylitis. J Hand Surg. 1999;24:177-183.
[7] Smith RW, Papadopolous E. Mani R, Cawley ML Abnormal microvascular responses in a lateral epicondylitis. Br J Rheumatol. 1994;33:1161-1168.
[8] Wright A, Thurnwaid P, Smith J. An evaluation of mechanical and thermal hyperalgesia in patients with lateral epicondylalgia. Pain Clinic. 1992;5:221-227.
[9] Abbott JH. Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia. Manual Therapy. 2001;6:170-177.
[10] Vicenzino B, Smith D, Cleland J, Bisset L. Development of a clinical prediction rule to identify initial responders to mobilisation with movement and exercise for lateral epicondylalgia. Manual Therapy. 2009;14(5):550-554.
[11] Coombes B, Bisset L, Connelly L. et al. Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: A protocol for a randomised control trial with placebo comparison. BMC Musculoskeletal Disorders. 2009; 10:76.

How Much Does That Shoe Weigh?

When helping customers at The Runner’s High, I get all kinds of questions about shoes. One of the most common being, “How much does the shoe weigh?” I could easily weigh or check the specs however, I always tell the customer that the weight should not be a major factor in running shoe selection. Here are the most important factors to remember when choosing a running shoe:


1. The purpose and function of the shoe based on the runner’s individual needs
2. The proper fit for the runner’s foot type
3. The level of protection provided by the shoe
4. The runner’s ability to run properly in the shoe selected

I almost never advise a customer to choose a shoe solely based on its weight. Understanding more about when running injuries occur can help you understand why I focus on the above factors.

Running injuries happen during the weightbearing phase (when your foot is on the ground). This weightbearing phase is where inherent weaknesses will appear, but the weight of the shoe is relatively inconsequential. In the non-weightbearing phase of running (when your leg is in the air, swinging forward) we almost never see running injuries. This is the only time where the weight of the shoe really may make a difference. The weight doesn’t truly help strengthen a running-related weakness. Instead, the runner should focus on what protective support their shoe offers so they don’t aggravate an existing deficit or cause a new injury.

Training shoes, which are generally heavier than racing flats or minimalist shoes, may assist in offering the foot resistance during the non-weightbearing or swing phase (and thereby assist in strengthening). The heavier shoes often offer more protection for the runner’s foot during the weightbearing or stance phase of running due to their greater level of protection in the shoe’s construction. On day race people often “shoe down” with a lighter racing flat which offers less resistance during the race (there will also be less protection offered to the runner’s foot). Racing flats are designed to enhance performance, but are not intended to be used throughout training. Training predominately in lighter shoes limits the benefits gained by the runner when they attempt to “shoe down” for performance on race day. Choosing the correct level of shoe protection for your foot can make your training more effective with deacreased probability of aggravating an inherent weakness.

Ultimately, your choice of proper running shoe depends on the factors I listed at the beginning of this article. I try to suggest the lightest shoe that still provides the best protection when selecting training and running shoes. Gaining a better understanding of the reasons behind why these choices make a difference can mean a more successful and enjoyable running experience for you!

Bruce Wilk

Ergonomics Part I

This is the first of a three part series of articles on ergonomics. Ergonomics is a multi-disciplined science that includes biomechanics, engineering, psychology, sociology, and economics, combined with human factors/error. It investigates all aspects of the mind, body, and soul connections, and analyzes/compares their functions to the tools, equipment, and methods used in the workplace. To put it simply, ergonomics looks at human ability versus the demands of one’s work, play, and daily activities.


ErgoWorks teaches three basic steps for performing an ergonomic analysis:

1) Identify ergonomic hazards.
2) Quantify the hazards and eliminate/reduce them through engineering, administrative, or work practice controls.
3) Demonstrate cost-effectiveness and implement solutions.

The first step is the easiest to teach and everyone can learn it. There are only six ergonomic hazards that cause injury. ErgoWorks has developed an acronym F.R.E.D. V.P. © as a way of remembering these causes of aches and pains:

FORCE – Lift, carry, push, pull, grasp, pinch, swing, strike, jerky/sudden movement, contact stress.
REPETITION – How many?
ENVIRONMENT – Hot, cold, wet, dry, humid, noise, bright, dark, slippery, outdoors, indoors, confined, hazardous, heights, dust, fumes, mist, negotiate irregular terrain.
DURATION – How long? How much recovery?
VIBRATION – Whole body or segmental.
POSTURE – Twisting, static, restricted movement, bending, reaching, poor seating, inadequate tool, squat, kneel, crawl, manipulates: slippery, bulky, sharp, awkward objects.

When the demands of these hazards are greater than human ability, they can cause fatigue; the beginning of the injury cycle. The one hazard that causes fatigue quickly is. . . Posture!

1) Carpal tunnel – stems from deviated wrist postures.
2) Rotator cuff injuries – elbow at, or higher than your shoulder.
3) Lateral and medial epicondylitis – wrist deviations of flexion and extension respectively combined with grasp force.
4) Postural back injuries – not maintaining lumbar lordosis posture and forward bending > 30 degrees.
5) Neck injuries – forward head posture.
6) Knee injuries – bending the knee > 90 degrees.

Posture is the one hazard that your patients usually have the greatest control over. Learn to identify these hazards and teach them to your patients for better compliance and reduce risk for re-injury.
Part II will discuss how to quantify these hazards and eliminate/reduce them through engineering, administrative, or work practice controls.

Glenn Orser - CEO of ErgoWorks