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Articles Of The Week March 15, 2020

 

The Covid-19 virus is filling all of our news feeds right now and I’m sure we’ve all had a few cancellations in our clinic because of it. One good thing we can do is actually demonstrate to our patients what we are doing to keep things clean, this article gives some great advice on how to do that.

“Massage Therapy—Demonstrating How You Are A Safe Space For Your Clients” – ABMP

I’m sure we’ve all been hearing some new terms in the past couple of weeks with this coronavirus outbreak. A new one for me is: “Social Distancing,” which is explained in this article along with the reasons why we should do it.

“Social Distancing: What It Is And Why It’s The Best Tool We Have To Fight The Coronavirus” – Thomas Perls

Sleep deprivation can cause a whole host of issues for a person, but this is amplified when someone is dealing with a concussion. New research is showing how blue light can actually help those with a concussion get better sleep.

“Light Improve Your Sleep Following Concussion?” – Complete Concussion Management

Leadership is not something that comes easy, but we could use more leaders in our profession, not only for the benefit to other practitioners but also to benefit our patients. This post outlines seven attributes of good leadership that we all could learn from.

“Leadership Matters” – Jason Giesbrecht

Athletes commonly use cortisone injections in their knee to mask pain, but research is starting to show this may actually cause more harm than good.

“Cortisone Injections For Hip And Knee Pain Are More Dangerous Than Was Thought” – Laura Donnelly

 

[REVIEW] Why We Sleep: Unlocking the Power of Sleep and Dreams

 

After being in PT for almost 20 years, I’ve spent the last 5 years looking at methods outside of traditional physical therapy and patient education. Everyone is searching for the elusive magic bullet that will help the non-responders. That is why I started studying mindfulness, nutrition, and sleep. I’ve touched upon sleep here before.

I’ve known that sleep is vital to recovery, for athletes with recurrent injuries, and is associated with individuals in chronic pain. So I wanted to dive into the why. I often educate my patients on the importance of sleep but did not have the background on the mechanisms of why sleep is so vital.

After reading Why We Sleep: Unlocking the Power of Sleep and Dreams, I’ve become convinced that of all the basic pillars (Sleep, Nutrition, Exercise), Sleep may be the most vital and often ignored.

How this Book Can Help Your Patients

Decreased sleep less than 8 hours on average can lead to

  • persistent flight or fight mechanisms – increased levels of cortisol
    • this was the most AHA moment I’ve had while listening to the audiobook on Audible, as poor sleep quality/quantity has been associated with persistent pain states and central sensitization
  • decreased athletic performance, increased likelihood of injury and delayed recovery times

Learning these vital points and learning about their specific mechanisms will only strengthen your patient education.

How this Book Can Help You

I purchased the audiobook and ebook in order to learn how to better educate my patients.  I also got A LOT out of it for my own health and recovery. Turns out my “I can get along with 6 hours of sleep a night” would put me in a less than 5% of the population with a rare genetic profile. I’ve been getting 8 hours a night for about 5 weeks. Similar to when I went mostly plant-based, I’ve had
  • increased energy levels
  • better recall – which honestly I just blamed on getting older and having an army of children
  • better ability to concentrate and increased productivity
Reading this text has been game-changing for me, in the same way, changing my entire nutritional profile has. The audiobook, in particular, is narrated excellently by Steve West, who has an accent on part with the Headspace app guy.
The author, Dr. Matthew Walker, breaks down sleep in a way accessible to everyone, and not just clinicians. It’s highly recommended and at the Top 5 of my Non-PT related books that everyone needs to read.
For this review, I purchased the Audiobook on Audible with my own funds, but the links to the book are Amazon affiliate links. If you purchase either with the link, you are supporting our blog. Thanks ahead of time if you do! Next step, get the author on Therapy Insiders Podcast!
Check it out on amazon!

Articles Of The Week March 8, 2020

 

As we all know, college is really expensive. This is an interesting story of how one mature student took things into his own hands to keep costs down.

“One Night I Woke Up With Ice All Over My Face”: This Mature Student Sleeps In His Camper Van To Afford School – Jamieson Lamb

We published a post on FAI this week, then this article was brought to our attention. This is how one of our colleagues went through hip surgery and what recovery looked like in the first week. A great story from the patient perspective.

“Hip Labrum And FAI Surgery Recovery Week 1” – Rachel Carroll

The words we use when helping our patients can have both a positive and negative effect. With that, if we are able to help patients “rephrase pain” could have a positive effect on their emotions around their experience and thus make a difference in their morale.

“The Right Words Matter When Talking About Pain” – Michael Vagg

Quite often we have a patient come in believing their pain experience is because of a single cause. Part of our responsibility is to help them realize it is not necessarily one thing…but many.

“Not One Thing But Many” – Tristen Attenborough

Many of us at one time focused primarily on a biomechanical model of pain in our practices. However, as we learn more we have to take more factors into account like; mechanical, contextual, neurological, and affective touch.

“The Limitation Of A Biomechanical Model Of Massage Therapy” – Richard Lebert

How Watching An Evidence Based Doctor Helped Me Learn About FAI

An athlete came in experiencing some groin/adductor pain after the game.

I chatted with them a little bit and got them on the table. I did FABER’s test which resulted in a negative, but figured I would do a bit of massage to calm things down.

Then from behind me the doctor (who is much smarter, and more experienced than I am) came up and asked what was going on, so I explained what I had found.

She then asked, “oh did you try FADIR’s test?”.

I stood there looking like a deer in the headlights because I couldn’t for the life of me remember that test, I felt like an idiot.

So she grabbed the athlete, did FADIR’s (flexion, adduction, internal rotation of the hip), got a positive and then looked at the joint with a portable ultrasound machine and determined there was a possible FAI.

FAI stands for Femoroacetabular Impingement and to this point in my career had never encountered it (that I know of), so I just sat back, watched, and learned.

Femoroacetabular Impingement What Is It?

So what exactly is this anyway?

It can be defined as an abnormal bony feature of the acetabulum or femoral head or both, that leads to abnormal joint contact and stresses with deep flexion and rotation movements.  This can also lead to labral injuries, and has been related to osteoarthritis of the hip.

This can be further broken down into three different classifications:

  1. CAM type impingement – anterolateral or lateral femoral head-neck junction or the entire femoral head is prominent (the femoral head isn’t perfectly round).
  2. Pincer type impingement – acetabulum presents general or focal coverage (there is excessive coverage of the femoral head)
  3. A combination of both of the above.

This usually effects young and middle-aged active people and presents with groin pain and no history of trauma to the area. It is quite commonly seen in young athletes and has been proposed there is a possibility of gender differences which contribute to the issue. One study showed that males had less ROM with internal and external rotation when the hip was flexed at 90° as well as internal rotation with the hip at 0° of extension. But the presence of a positive FADIR test was pretty much the same for both genders. 

However, athletes who had a positive test did have greater external rotation with the hip at 0° extension than those who tested negatively. Athletes also had a higher prevalence of positive tests in asymptomatic people compared to our general population. 

There is also some discussion around physical or activity impairments and one systematic review set out to see which impairments are prevalent. They found the main issues were with range of motion (particularly with movement toward impingement, basically the FADIR test) and showed that pain likely played a role in this compared to the asymptomatic group.

When looking at the asymptomatic group, they had reduced ROM as well,  but this is likely due to bony impingement, or damage to the surrounding soft tissue and even suggests that 35% of young adults have asymptomatic FAI. 

Hip ROM when walking was also called into question but the review pointed out the amount of reduction is of little clinical relevance. The only other significant issue with movement was with squatting which could be due to the shape of the hip and pain avoidance strategies.

FADIR  is quite often used to detect pain in the hip however it’s a good test for detecting sensitivity but is not very good for specificity (60% and 52% in youth hockey players), which results in a lot of false positive outcomes. It usually elicits groin pain when being performed, some studies have shown there to be lateral hip and buttock pain as well. 

So, part of the issue with this test is the prevalence of a positive test in asymptomatic people. For this reason it can only be used as a screening tool and has to be coupled with some medical imaging to get a proper diagnosis. One study also shows that in addition to imaging, symptoms, and reduced function have to be key aspects of a diagnosis. Fortunately, the doctor in this story had imaging done, the athlete presented with symptoms and reduced function, so the doctor checked all the boxes to get a proper diagnosis (which is great to see an evidence based practitioner at work especially since diagnosing is out of my scope). 

Surgery Or Treatment?

The indication for this is usually surgery, but there are some things to take into account.

One study set out to determine if conservative treatment could be effective (although it was based on “mild” impingement). To do so, they put patients through four phases of conservative treatment:

  1. Avoidance of excessive physical activity and use of NSAID’s during an acute attack.
  2. Physiotherapy and stretching for hip external rotation, abduction, extension, and flexion.
  3. Performing ADL’s with reduced ranges of motion in internal and external rotation.
  4. Modifications of ADL’s with running and cycling (some avoidance or altered movements when not avoidable).

With the study the authors had some reasonable success with the goal of conservative treatment to be a reduction in hip pain, and avoiding further cartilage damage without reducing ADL’s. However, the results were only good if the patients could modify ADL’s so the hip could adapt. 

Another interesting point is while it was commonly believed that FAI would lead to Osteoarthritis of the hip, one analysis showed that 82% remained free of OA for 18.5 years, some up to 19 years and to date there are no studies that actually show this progresses to OA of the hip. Some surgeons even suggesting surgery is happening unnecessarily.

One systematic review showed that surgery had been the most successful, but it was also necessary to look at the reasons why people were electing for surgery. The main reasons were:

  • 33% was to alleviate pain.
  • 20% feared the condition was getting worse.
  • 16% hoped to improve ADL’s.
  • 11% due to failed non-operative treatments.
  • 10% hoped to improve for sport.
  • 10% other reasons.

So the review showed many asymptomatic people have abnormal imaging, so it is important to “treat the person not the x-ray.”

It also showed that 50% of people are overly optimistic about the surgical results and improvement, but since this does not necessarily equate to “feeling good,” it is necessary to take psychometric properties into account.

With all we know nowadays around the biopsychosocial aspects of pain, when we look at this list above, how can this change the way we’re helping people with this condition? Well, first we want to make sure every aspect of a diagnosis is done. Next we can look at ways help alleviate pain, but also build up the patients resilience and provide reassurance that the condition is probably not going to get worse (well at least for 18-19 years). Can we change up their ADL’s enough that they’re still doing the things they enjoy, but maybe just in a different manner, frequency, or intensity? In the case of the athlete, is there a guarantee that surgery will improve them for their sport? For the athlete, this may be the one area where a surgery might be necessary, but let’s take into account every option first. And as suggested, let’s make sure we treat the person, not the X-ray.

I will admit, that while I felt like a bit of an idiot when this happened (because I wasn’t familiar with the test and FAI in general), it was a GREAT learning opportunity to watch someone with more education, more experience, and let’s face it smarter than me do their work. Fortunately the doctor was pretty gracious in sharing her knowledge with me, and it made me look at the research on this and write this blog…so I learned a lot. 

Articles Of The Week March 1, 2020

I’ve never really given any consideration to the history of cupping but this is a really interesting history on the history of cupping. While it is still an ancient remedy, it did not come from where many blogs and articles have cited it’s history.

“Did Ancient Egyptians Invent Cupping?” – Rachel Scott

Pain is a real part of everyday life for each of us. While some deal with it less than others, we will all experience pain at some point of our lives. So, how do we help our patients who are coming in and dealing with this? By helping them move from being patients, to being people.

“Did You Miss Me?” – Bronnie Thompson

We have long been proponents of involving the reading of research in your practice. This is a great article that will help you determine what’s good research and what’s bad research.

“Six Details To Ask When Reading Massage Therapy Research” – Nick Ng

You know if I see an interview with an athlete praising the use of massage therapy in their recovery, I just have to share it.

“A Conversation With Michael Phelps” – AMTA

This one stirred up some controversy this week, but I still like it. As Massage Therapists, we are involved in healthcare and the way we speak, conduct ourselves, and treat our patients should all be reflective of an evidence based practice.

“Massage Therapy Is Healthcare, So Start Acting Like It” – Lauren Cates

 

Are The Days Of Assessing Movement Over

In all honesty in its current format the answer here has to be an unreserved YES, we should STOP assessing movement.

This opinion is based on the two predominant concepts we appear to have currently when assessing movement.

Firstly the concept that a deviation from a movement or muscle firing ‘ideal’ is the cause of someone’s pain such as seen with the pathokinesiology model.

Secondly that we can also ‘screen’ movement to identify faulty movement that might lead to injury, this is FAR too big a subject to get into but it seems we weekly have new data suggesting screening does not fulfil the role it was designed for.

Both of these concepts have so far proved to be elusive in providing concrete evidence that they do exactly what they say they do.

A modern understanding of all the contributors to pain means the likelihood of pain being consistently caused by one single factor across ALL people is pretty absurd really.

IT’S VARIABLE

The more we study movement the more we find that it is in essence highly variable. This variability is not only between people but even the same person seems to move differently when they repeat a movement. It has been suggested, and with a fair amount of evidence, that healthy movement is variable and losing variability may be a problem within itself. It is important to realise this about movement because it allows us to appraise the idea of movement assessment more critically.

I have previously discussed this *Here* and *Here* along with the concept of corrective exercise.

Now this means that being able to identify a ‘faulty’ movement pattern will be highly likely if you are measuring it against a singular ‘ideal’ version. The problem is the singular ideal version does not really exist and also does not seem to be linked to very much, rendering the whole process a bit of a waste of time.Slide1

It makes little sense not to be variable:

  • Multiple options affords us redundancy
  • Ability to respond to varying stimulus
  • Spreading load over a joint in repetitive tasks
  • Avoiding fatigue through variable motor unit recruitment
  • Unavoidable at a biological level

We also may go further down the rabbit hole in that some now ASSUME that pain is simply the RESULT of a faulty movement pattern without any kind of critical analysis at all. Think how some people approach back pain, “Its your TvA not be firing” rather than lets find out if it is or not (obviously no clinical test tells us this, just an example).

MOVEMENT DOES NOT EQUAL FORCE

Now I am no biomechanist but we also must realise that just because a movement goes into a potentially ‘faulty’ position does not tell us the whole picture of how much damage that poses to a tissue. Sure it might increase the risk in some contexts but alone it does not give you the ACTUAL force applied and we would also need to know the acceleration as well. A fast movement within proposed ‘safe’ parameters that generates a large force (F=MA) could provide a much greater load to a tissue than one that was proposed as ‘faulty’ that moved much slower.

In fact under greater loads our movement seems to change, so assessing in a low load environment may not give you an indication of how movement is in another situation. This was an interesting piece from Frost et al *Here* showing exactly that!

Some seem to have developed the idea that if you get a movement right you can put it under ANY load. The way the body manages loads internally through the way it moves may be far LESS important the overall volume of load that the body may go through overall and this could be in volume, frequency or intensity.

A DIFFERENT PERSPECTIVE?

So can we STILL look at movement in practice?, I believe so. Everything has it uses and limitations and its working out WHEN thats the tough bit.

Pain DOES have an effect on the way we move, this is pretty well researched showing alterations in what happens with both kinematics AND kinetics at a joint, to adjacent joints and right up to avoiding movement completely for fear of pain. This is a great paper by Hodges & Smeets discussing this *HERE*

Like any other thing that we can measure, it may or may not be related to the problem and may or may not have to change to get a successful result.

Certainly it very difficult to suggest that the way someone moves is a cause of their problems. Do you know what it looked like before? Could it be the RESULT not the cause or pain? BUT is there also a possibility that a change in movement strategy COULD also have an effect on reoccurrence or another injury. We know that the best predictor of future injury is previous injury *Here* and this could be a factor. This has also been mooted with back pain *Here*.

It is a good place to use your reasoning skills. Is this the first time it has happened? Is it acute? Both of these simple questions might help to determine if it is currently an adaptive strategy (helpful) because of pain or is it a maladaptive behaviour (unhelpful) that maybe contributing to the maintenance or reoccurrence of a problem.

LOOK AT THE INDIVIDUAL

A potentially more individualised concept for how we view movement is that rather than a binary right and wrong view that we have currently, we could say your current strategy is unhelpful and swapping that for another might be more helpful, there are often a whole bunch of other ways that could be beneficial rather than the ‘right’ way.

This might only be for the short term, such as a symptom modification, or for the longer term if you believe a movement behaviour maybe coupled with a pain response.

Gait re-eduction for runners seems to follow this rationale, see whats going on, does that potentially relate to the issue and can we subtly alter it.

Now there maybe certain scenarios that do carry more risk such as loaded lumbar flexion or extreme knee valgus but they seem to be pretty load related. Unless someone is regularly under these loads perhaps it matters less. But ask yourself how many people in the gym have popped an ACL doing a single leg squat? Perhaps the caution can cause more problems than it solves here? Especially with the unhelpful beliefs people seem to be prone to forming.

SOME EXAMPLES OF UNHELPFUL

 

IT COULD BE THAT A MOVEMENT LOADS A SPECIFIC BODY PART THAT IS CURRENTLY SENSITIVE

Example

If some one has a very hip driven strategy whilst currently suffering from a proximal hamstring tendinopathy altering this could reduce further load/compression to the tendon to allow it to desensitise.

PRE MOVEMENT BEHAVIOURS

It could be that be that someone is bracing BEFORE they move and this is an unhelpful component. This maybe seen with lower back pain sufferers.

Example

Before bending over to do their shoelaces someone specifically braces and this has become coupled with the pain they are experiencing. Attempting to change this part of the motor strategy MAY affect the outcome.

IT COULD BE THEY ONLY HAVE ONE MOVEMENT STRATEGY

We see decreased variation linked with chronic pain at a number of areas of the body. This could cause repetitive loading or consistent patterns ASSOCIATED with pain.

Example

A specific task maybe is performed in a repetitive way. This might be the way someone lifts, reaches or even runs. A way to assess this could be to provide variable challenges and see how well someone can adapt.

What we do have to remember that this is all TRIAL & ERROR.

It may or MAY NOT have an effect and essentially this is everything we do. We should try to be informed by current best evidence but also  remember is just a probability generated in a controlled environment and may not directly translate to this person you are dealing with.

TAKE AWAYS

  • Specific movement ideals are pretty unsupported, especially linking them to pain
  • Movement screening is literally a can of worms
  • Movement is variable, EMBRACE it! This means it is tough to assume causative link with pain
  • Low load assessment tells little about high load behaviour
  • A movement does not simple equal the force applied to the tissue
  • Look at the individual
  • Be prepared that altering movement may have NO EFFECT or a very positive one