JosephBrence

• Extension biased seem to be safest (research by Sinaki et al showed 68% of woman who performed flexion biased exercises developed subsequent fracture vs. 16% who performed extension)
• Avoid flexion stresses during ADLs; even if they haven’t yet experienced fracture
• Perform modified classical yoga poses including: stretching into shoulder flexion, quadruped opposite arm/leg, prone trunk extension and lunges with shoulder flexion.
• Respiratory muscle exercises combined with back extensor strengthening
• Self mobilization by lying supine on a foam roller

For additional manual, bracing and taping suggestions read:

Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-Related Hyperkyphosis: Its Causes, Consequences and Management. JOSPT. 40 (6); 352-360.

JosephBrence

Tags: back, brence, kyphosis

As the baby boomers get older, the occurrence of post-polio syndrome (PPS) in the clinic is becoming more prevalent.  Approximately half of the 640,000 polio survivors will be afflicted by post-polio symptoms and it takes about 35 years from the acute case to develop PPS.  With our ability to differentially diagnose in a direct access setting, it is vital that we understand how to recognize signs and symptoms of this disorder.

Below are some helpful guidelines in recognizing post-polio syndrome:

• A confirmed previous case of poliomyelitis;
• Neurological and functional recovery after the original polio occurrence;
• A period of appx. 15 years where neurological and functional stability was maintained;
• Complaints of gradual or abrupt onset of muscle weakness, atrophy, and arbitrary weakness;
• Clinical manifestations including fasciculations, cramps, cold intolerance, joint pain, shortness of breath, dysphagia, and changes in vocals;
• No other medical explanation for the patient’s signs/symptoms.

Treatment for PPS focuses on prevention of further deterioration or weakening of muscles.  Below are a few helpful suggestions:

• Endurance programs that consist of moderately high-performance exercises;
• A muscular training program lasting between 6 weeks to 7 months that contains both isokinetic and isometric exercises;
• Avoid overuse by allotting multiple breaks in the program;
• Conduct treatment in a warm environment or in water;
• Utilize proper orthoses or assistive devices as needed;
• Educate on the importance of losing weight if appropriate;
• Early introduction of non-invasive respiratory aids if needed.

Burk J, Agre JC.  Characteristics and management of Postpolio Syndrome.  JAMA.  2000; 284 (4):  412-414.

Farbu E, Gilbus NE, Barnes MP, Borg K, deVisser M, Driessen A, Howard R, Nollet F, Opara J, Stalberg E.  EFNS guideline on diagnosis and management of Post-Polio syndrome.  Report of an EFNS task force.  European Journal of Neurology.  2006; 13:  795-801.

Ernstoff B, Wetterqvist H, Kvist H, Grimby G.  Endurance Training Effect on Individuals With Post poliomyelitis.  Arch Phys Med Rehabil.  1996; 77:  843-848.

Above article was contributed by Kaitlin Witmer, SPT. Kaitlin is a student PT from Slippery Rock University.

JosephBrence

In a majority vote during Tuesday’s primary elections, the voters of Missouri chose to invalidate a mandate of the new health care bill which presses for individuals without healthcare to purchase healthcare.  The overwhelming 71% support of this referendum, Proposition C, was the first of its kind to be passed before the 2014 law goes into effect.   Due to alot of uncertainty with the new healthcare bill, there will likely be many court decisions on how the bill will be interpreted and if states will be able to pass such measures.  We will have to simply sit back and see how things weigh out. To read more about Missouri’s decision, read a recent post in the New York Times.

JosephBrence

A few days ago, I received a call from a patient whom  another clinician and myself have been treating for pes anserine bursitis.  The patient reported that she went home from PT and noticed increased discomfort in her lower leg.   I asked what her symptoms were and she reported the following: Bruising over a small portion of the inside of her calf, a swollen vein (she has + hx of varicose veins) and discomfort over the vein.  She denied swelling, a history of DVTs or pain with dorsiflexion. I explained that it sounded like phlebitis vs. a true blood clot but for her to go to the ER if she is concerned about a clot.  Instead, she came into my facility.

In situations like the one that I just experienced, it is vital that we as direct access practitioners understand when it is crucial for us to refer patients and when we can recognize that something less serious may be occurring.   I screened her leg and used the clinical prediction rule for a DVT and determined it was likely phlebitis.  I also contacted her physician with the findings and he agreed with the assessment.  Below I have provided the clinical prediction rule for screening a DVT.

Wells Clinical Prediction Rule for DVT:

1. Active Cancer (treatment ongoing or within previous 6 months)
2. Paralysis, paresis or recent plaster immobilization of the LE
3. Recently bedridden for 3 days or more, or major surgery within the previous 12 weeks requiring anesthesia
4. Localized tenderness along the distribution of the deep venous system
5. Entire leg swelling
6. Calf Swelling at least 3cm larger than asymptomatic leg (measured 10cm below tibial tub)
7. Pitting Edema confined in symptomatic leg
8. Collateral superficial veins (nonvaricose)
9. Previous DVT
10. Subtract 2 if there is an alternative diagnosis at least as likely as a DVT

High Probability if score > 3

Moderate if score is 1-2

Low if score is 0

Bottom Line: With our profession gaining increased autonomy, it is vital that we understand how to screen for serious pathology and when to refer.

Citation:  Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretrest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350:1795-1798.

JosephBrence

Tags: brence, clinical prediction rule, DVT

The New York Post recently highlighted a study by the American Cancer Society which showed those who sit for long periods of time during the day have an increased risk of death.  The study followed over 123,000 people over 14 yrs and results indicate that men who sit > 6 hrs per day have a 17% higher risk of death and women who sit >6 hrs per day have a 37% higher risk of death.  This study even included those who work out regularly!

Below are 5  things you can do throughout the day to help reverse your risk of becoming a statistic:

1. If taking the bus or subway to/from work, give up your seat and enjoy the trip standing
2. Instead of emailing a coworker in your office, get up and walk to their desk to discuss the issue
3. Take a “standing break” every 15 minutes; enhance this by adding in heel raises or squats to the equation
4. Try eating lunch standing up
5. Find a reason to walk around the office at least once an hour.  Good reasons include: water/coffee break, copying, faxing, etc.

JosephBrence

In the recent months, I have had a number of patients ask what I thought of Sketchers shape-ups.  My answer: I’m not a huge fan. Heres why:

• Shape-ups appear to “tone” the calf through creating a constant balance deficit for the patient. This causes a constant “ankle response” and forces the calf muscles to work overtime.  I believe future research will show a higher risk of achilles tendonitis in individuals who wear these long term.
• The shoe changes your gait. The shoe assists during all phases of gait, especially from heel strike –> loading response which can decrease your neuromuscular education of muscles active during these phases.  This will make you more relient upon these shoes, and may make it difficult to ambulate without them.   Enough said.
• Sketchers claims are that they will tone the calf, LEs and core.  This ideology allows wearers to think the shoes can replace a fitness program and will prevent problems from developing.

Sketchers claims 4 studies have been performed to prove that they help tone muscle and improve energy consumption.  I attempted to locate these articles and only found reviews on the Sketchers website.  Here are the results of each of the articles:

1. Study performed by 2 chiropractors and a personal trainer.  Study showed weightloss in individuals who wore Sketchers.
2. No authors info provided. EMG study on 10 females.  Results showed increased activity of LE muscles while wearing shape-ups.
3. Again no authors info provided. The results showed increased core activity due to an unstable center of balance.
4. Another study performed by one of the chiropractors from study 1. The results showed increased usage of postural muscles.

All 4 of these studies were funded independently by Sketchers and I was unable to locate any of them in major peer-reviewed databases for a true analysis.

Bottom Line: I am still extremely skeptical about shape-ups.  Proper footwear should not create an unstable surface and no shoe should ever claim to be able replace a proper physical fitness program.

JosephBrence

Tags: brence, shape ups, sketchers

For years, there has been varying literature to connect symptoms occurring at the carpal tunnel with symptoms in those in the cervical spine.  De-La-Llave-Rincon et al recently published an article in JOSPT examining a relationship between carpal tunnel syndrome with postural dysfunction/decreased cervical range of motion.  This article examined how a treatment of the cervical spine may have an effect as distal as the carpal tunnel. More conclusive research has indicated proximal grade 5 thrusts to the CT junction can have effects as distal as the lateral epicondyle.

So, if the median nerve has motor and sensory contributions derived from nerve roots of C6-T1 that can become compressed proximally in addition to the carpal tunnel, why not examine/assess the cervical spine in the treatment of individuals with CTS (Even the test for examining neural tension of the median nerve involves lateral flexion of the cervical spine away from the effected side). There are several syndromes that can present with proximal/distal features such as: thoracic outlet, multi-crush and T4 syndrome but could carpal tunnel syndrome actually be a misunderstood diagnosis and have a more proximal player (how many median nerve releases have you seen be relatively non-effective?).

I believe, we should attempt to investigate further into individuals who present carpal tunnel symptoms.  I believe compression of the median nerve may not always be at play directly within the carpal tunnel and that a proximal compression may be playing at least an equal role.  There has been research on regional interdependence in between the low back, hip and knee and I believe there could be similar findings from the cervical spine down to the carpal tunnel.

JosephBrence

Tags: brence, carpal tunnel, cervical spine

The Washington Post ran an article yesterday, commenting on a recent article in the Journal of American Medicine (JAMA) examined the effects of glucosamine for the treatment of chronic low back pain. Glucosamine has been widely thought in the past to help calm symptoms of degenerative osteoarthritis. This article was a double-blinded, randomized , placebo-controlled trial in which subjects were administered glucosamine or placebo for 6-months and then rated rated their pain related disability.  The results: oral glucosamine had no beneficial effects in reducing pain related disability.
 
A similar study in 2007, published in the Annals of Inernal Medicine discovered that a similar suppliment, chondroitin, does not appear to help individuals with hip/knee pain caused by osteoarthritis.
 
The Take Home Message: To diminish an individuals complaints of low back pain, the most effective approach continues to appear to be a physical therapy regime consisting of a combination of manual techniques, neuromuscular reeducation of the transversus abdominus/multifidi and gluteus medius/maximus to reset muscle spindles and postural reeducation.
 
Citations:
Wilkens P,  Scheel I, Grundnes O, Hellum S,Storheim K. Effect of Glucosamine on Pain-Related Disability in Patients With Chronic Low Back Pain and Degenerative Lumbar Osteoarthritis.
JAMA. 2010;304(1):45-52. 
 
Reichenbach S, Sterchi R, Scherer M, Trelle S, Burgi E, Burgi U, Dieppe P, Juni P. Metaanalysis : Chondroitin for Osteoarthritis of the Hip or Knee. Ann Intern Med. 2007; 146 (8):580-590.

JosephBrence

1. The New Frontier
2. Hip muscle weakness in recreational runners
3. Arthrofibrosis Guidelines
4. Fatigue from cycling…is it in your head?
5. Shape-Ups: Do they shape up or down?