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Articles Of The Week December 5, 2021

We quite often talk about this topic but rarely in the case of athletes. Important for us to take into account how the thought of pain and tissue damage is effecting this population and how we can communicate with them to help.

Why Pain Doesn’t Always Mean You’re Injured – Alex Hutchinson

Well, the holidays are coming and if you’re anything like me you’re probably going to overdo it on the treats and cocktails! However, this shouldn’t discourage us and there are some ways that we can still work to stay healthy during this holiday season.

How To Stay Healthy During The Holidays – Gina Harney

Dec 1st is “World Aids Day”. This is really important because when AIDS & HIV were first known about we had little knowledge about it and unfortunately there wasn’t much in the way of treatment. However, nowadays this is a manageable condition and we are likely to see more people in our clinics with this who could use our help. Thus, it’s really important to educate ourselves on the condition.

World AIDS day | 40 years on – Rehabilitation is Key – Kim Jackson

When I was 19 I got pulled through the wheel well of a tractor and dislocated my patella. Ten years later I had surgery to repair this and my leg was in a splint for 3 months…it was literally 1/2 the size of my other leg when the splint came off. I wish I had access to this article back then!

How to Fight Muscle Atrophy After Injury: A Personal Trainer’s Guide – Michelle Carroll

So it isn’t just the manual therapy professions who deal with poor information getting shared around, it’s rife within the nutrition industry as well. But, there is some really quality, evidence-based information out there…you just have to look for it.

Superstition, sciencestition, and how to stop overthinking food. – John Berardi

Podcast Episode #18 Manual Therapy: Exploiting The Role Of Human Touch.

 

You can get access to the paper we are discussing by clicking HERE

Articles Of The Week November 28, 2021

We quite often highlight things around mental health but to this day I don’t think we give enough attention to athletes and the toll mental health can take on them. This is a great example of how a professional athlete is using their platform to raise awareness around this.

Tyson Fury opens up on his mental health: ‘I have been unwell all my life. I didn’t know what it was’ – Kevin Garside

No matter what part of healthcare you work in, informed consent is a crucial part of the patient/therapist interaction. What we see here is a healthcare provider giving treatments with no evidence behind them. Unfortunately, we see this regularly in our profession with many of the narratives behind some modalities that are offered as continuing education. This should be a warning to all of us in healthcare about informed consent and proper treatment.

Naturopath who gave vitamin IVs to mental health patient without doctors’ knowledge faces renewed probe – Bethany Lindsay

We often preach about evidence-based practice and the importance of incorporating research into practice. But it turns out this is even an issue with doctors and this questions their ability to deliver effective care. While we often preach that we can do better as a profession, turns out all healthcare professions need to do better as well.

How doctors are betraying the Hippocratic oathIan A Harris & Rachelle Buchbinder

It’s not often that pain science is applied to athletes but in this study (which highlights the work of our friend Morten Hogh) it argues that, in the context of sports medicine, pain and injury are two distinct entities and shouldn’t be lumped together.

Why Pain Doesn’t Always Mean You’re Injured – Alex Hutchinson

What do we do with the initial information we receive when a new person comes to see us? Well, there are several things and this article gives some great advice on how to proceed.

Making First Contact: What To Do With All That Information! Part 1 – Bronnie Lennox Thompson

Things I Wish I Knew About “Rotator Cuff Disease”

It was the first time I’d seen this patient. 

When I asked what brought them in they showed me how they could only get their shoulder to about 90* abduction and it had been this way for two years. 

Digging a little deeper to find out what happened, they explained they had a rotator cuff surgery due to a tear. 

This was life-changing for them. 

Not only could they not move their shoulder correctly, but it also resulted in a change from a job they loved to one they hated due to the lack of mobility. 

So, was surgery the best approach in this case? 

While I’ll never know the true answer to this, I can look at the most up-to-date research and attempt to make an educated guess ( and I think I know where this is going). 

Rotator Cuff Disease

A recent paper¹ came out on this topic, and I’ll admit I was surprised to see them refer to this condition as a “disease.”

However, when we look at the dictionary definition of disease² it states: 

disease, any harmful deviation from the normal structural or functional state of an organism, generally associated with certain signs and symptoms and differing in nature from physical injury.”

So, in this case, the limited function of the shoulder has deviated from its normal functional or structural state, so I guess it can be classified as such. But, I would never want to communicate it to a patient that way as it suggests a more damning diagnosis than it is. 

Now, in order to define this “disease” they put some classification around it which includes: 

  • Pain that is worse at night
  • Pain exacerbated by specific movements which included overhead activities
  • Loss of function and weakness

In addition to the above rotator cuff disease was basically used as an umbrella term to classify issues with the rotator cuff regardless of the cause and would include: 

  • Positive painful arc test (physiotutors gives a great example of how to perform the test HERE)
  • Positive external rotation resistance test

These tests together were the most accurate diagnosis unless it was a full-thickness tear. In this case, the use of a positive lag test was most appropriate. Here is one example of how to do the test, but this can also be done with the shoulder at 90′ rotation, called the “drop arm sign.” 

It is also worth noting that the review found an increased prevalence of this with age, especially in those people who performed repeated overhead activities. 

What Do We Do For Treatment?

So, this paper was a BIG review; there were 3620 participants in 60 different trials with a median age of 51. 52% of these were women and the average duration of symptoms was 11 months. 

What they found was that people were rarely given just one intervention. 

This makes it really difficult to say if just manual therapy, just exercise, or a single other intervention was the best approach as there was always a combination of things offered. 

The average duration of therapy offered was six weeks. When they looked at what manual therapy was offered, this included: 

  • Joint mobilizations
  • Massage
  • Spinal or neck mobilizations
  • PNF stretching
  • Dicutaneous Fibrosis (I had to google this as I’ve never heard of it, but it’s IASTM with a stainless steel hook)

Exercise interventions included: 

  • Strengthening
  • Stretching
  • Progressive resistance
  • Pendulum exercises
  • Eccentric training
  • Postural training
  • Motor control
  • Proprioceptive training
  • Self-mobilization (yay for self-care)
  • Dynamic humeral centring (movement aimed at humeral head depression) 

Interestingly, they compared the above to some other trials that included things like steroid injection, NSAIDs, surgery, naturopathic care, and a few other interventions. 

When it was all said and done, they compared what was seen as high-quality evidence to low-quality evidence. 

Under the umbrella of “high quality evidence,” their findings showed no difference between manual therapy, exercise, and placebo for overall pain, disability, and function. But there was also a risk as manual therapy and exercise were frequently associated with adverse effects like short-term pain (although very mild). 

When looking at “low quality evidence,” it was pretty consistent with the aforementioned high-quality evidence but also showed that the use of glucocorticoid steroid injections helped with global treatment success. 

Overall, this doesn’t sound like a real positive for manual therapy and exercise, but there are some things to consider. Throughout the studies, manual therapy and exercise were always incorporated with some other type of therapy. Also, much of the exercise used was very vague by description and didn’t include whether this was done supervised in the clinic, or at home. Finally, while the comparison to glucocorticoid steroid injection seems like it could be of benefit, this was based on low-quality evidence, so this doesn’t give the intervention much credence. 

Looking at what they considered placebo, they used modalities like ultrasound (which in other studies has been shown to have a high level of placebo). This review doesn’t really talk about the interaction between patient and therapist or other contextual factors of treatment. We might see a more detailed description of the exercises and modalities used as interventions if these were included. 

However, when we look at other papers that discuss the clinical guidelines of MSK care the best steps are typically shown to be: 

  1. Reassurance
  2. Education
  3. Exercise
  4. Some manual therapy

If we were to apply the same to issues with the rotator cuff, we’d likely see better outcomes than if these weren’t used. Even though this review says there is no clinically important benefit to manual therapy and exercise over placebo, it doesn’t mean they aren’t of benefit. But if we used those as a combination in treatment the high-quality evidence shows this to be the best approach. So, with any shoulder issue, continue to use exercise and massage. Just remember there are other factors that contribute to a successful treatment. Things like patient preference, demeanour, education, reassuring them, and providing validation will all help contribute to better patient outcomes. Let’s just remember to incorporate as much as possible.

 

Articles Of The Week November 14, 2021

The more we recognize in regards to mental health, the more we will likely see new research coming out about it. This article is proposing that perhaps some mental health issues aren’t a disorder, but rather an adaptation to our environment.

Researchers Doubt That Certain Mental Disorders Are Disorders At All – Alison Escalante

So many things in the manual therapy (and exercise) professions are based on old outdated biomechanical theories. One such thing is doing a squat and not allowing your knees to go past your toes. But, is this really a big deal and could it actually be beneficial in some cases?

How Bad Is It Really if Your Knees Go Over Your Toes During Squats and Lunges? – Caroline Juster & Chris Cooper

More on mental health, but this time we look at how body image affects men. “A new study from Harvard and the Norwegian University of Science and Technology (NTNU) is the first of its kind to investigate the cruel relationship between men and their muscles. And the findings suggest boys and young men struggle much more with body image disorders than we were aware.”

Mounting Evidence Shows a Dark Side to Our Obsession With Ripped Men – Carly Cassella

Quite often when people are confronted with facts, they don’t (or refuse to) change their minds. Well, there is apparently a few reasons for this, not the least of which is our societal views.

Why Facts Don’t Change Our Minds – Elizabeth Kolbert

If you have a hard time sifting through research papers, here’s a curated list of some that you’ll find useful for your practice.

List of Open Access Research Articles for Massage Therapists – Richard Lebert