[Michael McMurray]

Laura-
Have you followed up with her? Wondering how the second visit went. It sounds like there is a mechanical issue at her knee that needs addressed to return her to her PLOF, especially running, and while talking about how she’s feeling may help some i don’t think it is going to significantly reduce her symptoms.

Taping to unload may help reduce the stress through the irritated tissue. Improving hamstring and quad length, improving quad and hip abductor strength and gradually loading the tissue are what i would think about as progressions for her. Unless she has a current SIJ or low back history i wouldn’t worry about SLS.

Graduated therex and progressively loading her system will most likely help curb some of her fear and apprehension without ever having to talk about how she is feeling.

Thanks for posting-

[Michael McMurray]

Laura – I have concerns with this statement:

“In terms of quad strengthening, I don’t want to stress her SIJ or knee joint so no quadruped or unilateral weight-bearing activities. Do you guys have any other suggestions for quad/LE strengthening?”

I think the demand she puts on her system just walking, living in a world of gravity is less than what we consider “too much stress” on those tissues.

She has low irritability, so I sure would try to progress her tissue tolerance – improve strength/stability in a progressively loaded (pregnant), hypermobile system.

Taping may be a way to unload some of the irritated tissues (Jenny’s article is helpful with some techniques) for short term pain relief, increased function.

[Michael McMurray]

CDC Says Nondrug Approaches ‘Preferred’ to Treat Chronic Pain; APTA Adds its Support

The US Centers for Disease Control and Prevention’s (CDC’s) draft clinical guidelines on the use of opioids for chronic pain make it clear: nondrug approaches such as physical therapy are the “preferred” treatment path for chronic pain.

APTA couldn’t agree more.

This week, APTA submitted comments to a new CDC document aimed at primary providers who may prescribe opioids to treat chronic pain. The guidelines attempt to rein in growing rates of opioid use disorder and opioid overdose, and to help reduce the prevalence of opioid prescriptions, which topped 259 million in 2012—”enough for every adult in the United States to have a bottle of pills,” according to the CDC.

The guidelines were developed after expert review of evidence around not only the effectiveness of opioids (and their dangers), but also the ways in which nondrug approaches can be used in treatment. After evaluating the evidence, the CDC drafted recommendations around determining when to initiate or continue opioids for chronic pain, as well as guidelines for drug selection and dosage, and risk assessment.

Its first recommendation: “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.”

“Based on contextual evidence, many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, complementary and alternative therapies (e.g., manipulation, massage, and acupuncture), psychological therapies such as CBT, and certain interventional procedures can ameliorate chronic pain,” the draft states. “In particular, there is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip … or knee … osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2–6 months.”

In its comments to the draft, APTA applauds the recommendations, stating that approaches such as physical therapy “have been underutilized, and, therefore, can serve as a primary strategy to reducing prescription pain medication abuse and improving the lives of individuals with chronic pain.”

APTA’s comments also note that referral to exercised-based interventions “is essential prior to the initiation of opioid-based therapy,” and that exercise interventions “have the potential to improve health outcomes, reduce costs, and decrease the risks associated with opioid prescriptions.”

The association goes on to recommend that the CDC provide clear guidance on the patient populations that would benefit from nondrug approaches, and that more extensive patient education resources should be developed on the benefits of exercise-based interventions over opioid prescriptions. This education needs to be aimed at both the public and primary care providers, ATPA writes.

APTA also added its support to CDC recommendations around the use of multidisciplinary approaches to management of chronic pain, such as a combination of physical therapy and cognitive-based interventions. The problem, the association points out, is that although supported by evidence, the approaches “have been challenged by reimbursement policies.” APTA recommends that the use of multimodal approaches to treat chronic pain be part of a broader effort to change payment policies in ways that make them more amenable to nondrug approaches to chronic pain.

The CDC guidelines—and APTA’s comments—come at a time when the fight against opioid abuse and heroin use has gained attention at a national level. The issue was a part of President Barack Obama’s final State of the Union address on January 12, and the epidemic is the subject of a White House initiative that includes APTA and other health care and corporate partners. At the state level, West Virginia—one of the states hardest hit by the opioid abuse problem—has announced the formation of a new House committee on substance abuse. That committee includes Rep Mick Bates, PT.

[Michael McMurray]

I agree Laura – Highly entertaining (mainly Nick) – love the introspective, thoughts, patient applicability, and need to make some practice changing adjustments.

We all have biases, practice patterns that we fall in to – so do many MDs (even the good ones).

Remember this JAMA conclusion :”It takes an estimated average of 17 years for only 14% of new scientific discoveries to enter day-to-day clinical practice.”

The Aussies have been doing a much better job of educating the public regarding some of these practicing changing conclusions in the evidence through the National Public Health resources. Public service campaigns to distribute this/and similar information to the general public.

Maybe we as US Physios need to continue to do a better job on a national scale educating and distributing information that eventually decreases the expenditure for the most expensive health care consumers – chronic non specific low back pain with high fear/disability.

Thanks everyone for your thoughts/efforts – keep it up

Cheers – Happy pending Snowpocalypse

[Michael McMurray]

Great job Laura and Nick – still waiting for others to post.

The more familiar you are with “tips and tricks” for the main database (PubMed usually) that you search, the more efficient you will continue to be.

Let’s continue this string throughout the year with additional successes/failures in literature searching to help each other become efficient and critical consumers of the evidence.

Happy New Year

[Michael McMurray]

The article is attached

[Michael McMurray]

Great take home points here.

We are typically part of the problem versus the solution with these folks.

“Weak core”, unstable spine”, “Hypermobility”, “Hypomobility”.

Patient with high fear/anxiety become more hyper vigilant with everything that we say, waiting for the most fearful phase to twist into a pain memory which requires challenging efforts to change.

Some great things I read – were: Showing her, not telling her that she can control her pain by moving better (transitional movements); getting cognitive change through her own awareness; especially relaxation and movement to decrease her fear of pain/re injury.

Manual Therapy in these cases – think neurophysiological effects more that anything bio mechanical you think you may be doing; and definitely how you explain Manual Therapy rationale.

Our language probably more important than the specific technique

Great post – more discussion hopefully with similar cases – more next OMPTS Weekend as well

[Michael McMurray]

Here are some cervical CPR development studies: (I think Nick pulled most of these in his literature review, before being encouraged to choose the Dunning article he reviewed.

Again these “Rules” have not been validated, so maybe “clinical decision assisting tools” .

Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine.
Puentedura EJ, Cleland JA, Landers MR, Mintken PE, Louw A, Fernández-de-Las-Peñas C.J Orthop Sports Phys Ther. 2012 Jul;42(7):577-92. doi: 10.2519/jospt.2012.4243.
PMID: 22585595

Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise.
Raney NH, Petersen EJ, Smith TA, Cowan JE, Rendeiro DG, Deyle GD, Childs JD.
Eur Spine J. 2009 Mar;18(3):382-91.
PMID: 19142674

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.
Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL.
Phys Ther. 2007 Jan;87(1):9-23.

[Michael McMurray]

Great discussion, so far.

Oksana – just wanted to clarify that those are CPR guidelines for LUMBAR manipulation, not spinal manipulation.

Also – Try using some strategies that we discussed this weekend to search the evidence like MESH terms and post your findings in trying to find specific information – formulate a searchable PICO question, and use some of the suggestions/resources to see if you can get more clinically relevant evidence for decision making.

[Michael McMurray]

Full text for the journal club article is attached

[Michael McMurray]

Thanks for the post Nick, not a common diagnosis, but definitely should be on the differential with sensory changes > motor especially in a very specific distribution. Good review article to have in your library.

Anyone else treated this or had a presentation with this as a differential?

Have to post this article as well: Jim Beazell’s first article published: Classic_ JOSPT 1988:

http://www.jospt.org/doi/abs/10.2519/jospt.1988.10.3.85#.Vg0ZnX2Ps2o

Article in Shared Dropbox

[Michael McMurray]

Relationship between Hip Strength and Trunk Motion in College Cross-Country Runners
KEVIN R. FORD1,2,3, JEFFERY A. TAYLOR-HAAS2,4, KATLIN GENTHE2,5, and JASON HUGENTOBLER2,4

MEDICINE & SCIENCE IN SPORTS & EXERCISE DECEMBER 2012

[Michael McMurray]

Great thoughts/posts/discussion.

I agree; we should not be having everyone do TA activation with LBP; so intrinsic foot muscle activation exercises are not appropriate for every foot/ankle patient either.

Just like having various ways to teach/educate TA activation; experiment with various ways to educate patients on how to activate intrinsics.

“Toe Yoga” is just a stupid name for : alternating First Ray stabilization, lift lateral 4 digits; lift first ray, stabilize lateral digits. Focus of exercise typically should be stabilize base of first MTP with lifting lateral 4 digits, keeping STJ/mid foot in neutral position – think terminal stance for push off when 60% of weight should be on 1st ray with adequate rear/mid foot stabilization, for 1st MTP DF without varus/valgus loading.

Who would be those “classification category” patients to use “intrinsic foot muscle activation” exercises with?

[Michael McMurray]

thanks for all of the great discussion, hopefully this has been beneficial to everyone. I think this is an area that further research needs to be done because the opinions vary so widely depending on the clinician. Personally i am a firm believer in the fact that there is a huge proprioceptive input from the lumbar spine and i believe that may be a component of what affects the APA. I try to retrain proprioception with most, if not all, of my lumbar patients, and i think MET is a great system to address stabilization, motor control and proprioception (i may be a little biased:) ) I also agree that functional is the way to go, based on the patients goals. What it comes down to with lumbar patients, especially chronic, is that i try get them up weightbearing as soon as possible, and as their control improves i incorporate uneven surfaces, diagonals, single leg, etc…all things that i think address balance/proprioception as well as trunk control.
hope that sheds some light on things, at least somewhat on my thought process. Any other thoughts?

[Michael McMurray]

Great discussion….and great job critically analyzing the article for the exclusion criteria, which is a huge limiter with this article. Two follow up questions: Is this an article that you would use to guide your treatment with a patient? Have you thought about APA, or similar concepts, with patients….and do you think it is something that we need to address with patients?
I have some thoughts but am interested to hear everyone’s thoughts…..

[Author]

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