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Everything I Wish I Knew About Rotator Cuff Tears

July 29, 2019/1 Comment/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Jamie Johnston

They came in frustrated, it was a two-year ordeal, I had never seen this patient before, but they clearly needed some help.

“Jamie, for the past two years, I haven’t been able to lift my arm past this point”!

They raised their right arm to about 90° abduction. When asked I why they explained there had been a previous surgery to repair a torn rotator cuff. The frustration had more to do with life circumstances than just the limited range of motion.

Two years ago a surgery had taken place to repair this torn rotator cuff, but more concerning was the altered life because of it.

This person had a job they loved but were unable to do anymore due to the surgery.

You see, the job required holding their arms up for extended periods, so they had to quit that job in favour of a desk job. The worst part (other than the limited range of motion) was they HATED the new job. Sitting at a desk doing computer work was not what they had in mind as a satisfying career.

When asked why they weren’t doing the job they loved the response was bone-chilling to hear as a healthcare practitioner:

“My surgeon said I could never go back to that job, and the other therapist I went to told me that if I went back to my job, the surgery I just had would pale in comparison to the surgery I would need if I continued”.

I hope my face didn’t reflect what was happening in my head after hearing this, otherwise, the patient probably would have walked out the door. How could two other healthcare professionals say this to a patient!?

Reliability Of Orthopedic Tests

The rotator cuff consists of the “SITS” muscles: supraspinatus, infraspinatus, teres minor, and subscapularis which all work together to produce movement and stability of the glenohumeral joint.

While rotator cuff tears are quite common, it doesn’t always mean the person is going to experience pain as this generally depends on the degree of the tear. A partial tear is when one of the muscles is frayed or damaged, whereas a full tear indicates the muscle is completely torn, or the tendon has pulled off the bone.

When we look at some of the orthopedic tests recommended to use clinically as a test for rotator cuff tears, it is important to look at how accurate they are between sensitivity and specificity. Sensitivity is the ability to detect that something is actually happening (in this case it could just be a sore shoulder), whereas specificity is used as a true representation of the condition you are trying to test for (in this case specific to a rotator cuff tear).

There are three orthopedic tests generally used, so we will look at two of them here.

The drop arm test has a sensitivity of 73% and a specificity of 77% and also has a 26% chance of coming up with a false positive and a 4% chance of a false negative. This tells us this test isn’t likely to give us an accurate chance at predicting a full-thickness tear of supraspinatus or infraspinatus.

The external rotation lag test has a sensitivity of 46% and specificity of 94% which tells us that we have a good chance of a positive test indicating full-thickness tears in supraspinatus and infraspinatus.

It has also been suggested that the subacromial bursa contains a high amount of nociceptors and doing the orthopedic tests we talked about could place pressure on the bursa, in turn recreating the pain.

While we can still use these tests to give us an idea what’s going on with a patients shoulder there is no guarantee these tests will conclusively tell us there is a full rotator cuff tear. While it can be more accurate to use imaging to see the difference between partial and full-thickness tears, there is poor relation between imaging and clinical signs.

Using Education To Help

Time and again we are told biopsychosocial aspects are crucial to treating our patients, and this pathology is no different. Although the “bio” may be less important as we think. When looking at the movement of the glenohumeral joint in the scapular plane between symptomatic and asymptomatic people with tears, pain-free movement was still possible even with abnormal kinematics.

So this shows us that abnormal biomechanics alone are not the only reason for painful symptoms.

One study showed that 55% of rotator cuff tears are asymptomatic, had more to do with age, and didn’t correlate with pain. In fact, one study showed just how much age is a part of the degeneration and should be considered normal with age. They found:

Age 50-59, 13% had tears.
Age 60-69, 20% had tears.
Age 70-79, 30% had tears.
Those aged over 80, 51% had tears.

While asymptomatic tears can become painful, studies show it is probably more important to take care of pain management with these patients in order to maintain functionality, rather than being concerned about the tear itself. In fact, one study points out that our treatment should centre around clinical findings and not imaging results.

So, if we understand how pain management should be our primary concern, we have a massive opportunity to make a difference for these patients.

How many people over the years have come into your clinic either waiting on surgery or at least contemplating it for their rotator cuff issue? If we can educate them how this is usually an age-related issue (unless there was a traumatic injury), reduce pain, and increase their functionality maybe we can negate a surgery.

While surgery is usually recommended for full-thickness tears or more extreme disability, conservative measures can and should be recommended before going under the knife. The person I spoke about at the beginning of this post was obviously post-surgery for two years but still had limited mobility and functionality. This was certainly a case where biopsychosocial factors were a major influence. The person was told by two practitioners they would never get better and their shoulder would always be damaged, to the point they had to change careers. Once we actually got the shoulder moving, used a little education, and were told they were going to be okay…that shoulder went from 90° to 160° abduction. It was also followed up with the statement: “how the hell did you do that!?” It’s amazing how giving a patient a little confidence can make a massive difference. In the coming weeks, we will go over some movement techniques that can help with this.

Movement That Gives You the Feels

June 3, 2019/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Therapeutic Exercise/by Todd Hargrove

A baseball player walks into the batter’s box. He shifts weight from front foot to back while circling the bat. Rotates his right heel into the ground. Orients his gaze to the pitcher while pointing his bat to center field. Slowly swings his bat three or four times to an imagined contact point with the ball. Then crouches lower to wait for the pitch, still shifting weight from foot to foot. What’s the point of all this seemingly useless motion?

You can see similar routines in any sport that allows an athlete a few free seconds before taking action.

Waggling the club before a golf shot.

Bouncing the ball before a free throw or tennis serve.

Doing all manner of bizarre shit before a deadlift.

Are these rehearsals for the upcoming action? Sure doesn’t look like it. Do these movements get you in the groove? Maybe so but why? And, did you actually watch the deadlifting video? Go back and watch please, show Jujimufu some respect.

Epistemic Actions

I think these movements might be what are called “epistemic actions.”

David Kirsh and Paul Maglio introduced this term as a way to distinguish between physical movements done directly in the performance of a physical task (“pragmatic actions”) and movements done to reduce the difficulty of the information processing necessary to control the task (“epistemic actions”).

Accurate motor control requires you to have information about the moving parts in the body and environment. You also need to interpret the meaning of that information so that it helps you plan the right movements. An epistemic action is one that either delivers the right information at the right time, or assists in the interpretation of that information. You might say it is a movement that gives you a good sense of “feel” about how to move.

Here’s an example of an epistemic movement that is trivially obvious – turning the eyes or head to see objects in the environment. Check out this video of Frank Lampard playing soccer with his head on a swivel.

Part of the reason he is turning so much is that he needs updates on a changing environment. But even when analyzing a static scene, such as a room full of objects, you must constantly shift your eyes back and forth to make any practical sense of the information (for example, finding where you left your keys.) The information won’t arrive passively just by staring in the right direction. Vision is therefore a very activeprocess – you need to move to perceive, and you need to move the right way to perceive the right things.

Proprioception is the same way, it is an active process, not a passive one. Many of the our movements have a primarily epistemic purpose – they are not done so much to directly accomplish a physical goal, but to create proprioceptive information that optimizes or simplifies motor control.

I think this is what the batters are doing in the box while waiting for a pitch. They are moving in a way that actively seeks all the sensory information that will help them hit the ball. They are looking for the “feel” of the position of the feet relative to the plate and the pitcher; the angle of the head; the place where they will contact the ball; and the orientation of the hands, shoulders and hips relative to the bat.

Of course these players have already built, through many years of practice, maps or representations inside their brains that have information about all of these factors, and this allows them to “feel” the right stance even in the absence of these preparatory movements. But all this representing and mapping places a burden on memory and information processing. “The best map for the world is the world itself”, therefore it is far more efficient to gather information about the body and environment right when it is needed, as opposed to constantly maintaining an internal model of that information. Epistemic actions are a way to check in with the state of the world through movement.

(By the way, the idea of “offloading” the demands of information processing to the body or environment is very consistent with the ideas about “extended mind” that I discussed in my previous post.)

Conclusion

So why is this interesting? Well it just is. Here’s a few more reasons.

I think a good deal of the movements seen in various forms of corrective exercise are much more epistemic than pragmatic. That is, their value consists more in feeling your body than in rehearsing actual movements you might do some day. And remember that this feel is temporary – you need to keep refreshing it through movement.

Another reason epistemic action is interesting is that it should be a caution to analyzing the technical merits of a movement with too much reliance on its biomechanical “pragmatism.” What appears to be a pragmatic bug in someone’s movement technique might actually be an epistemic feature. Put another way, some ways of moving just “feel” better, and this might be more important than how it looks to the coach.

Degenerative Disc Disease Correlation To Pain Doesn’t Matter As Much As You Think

April 22, 2019/5 Comments/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Uncategorized/by Jamie Johnston

He came in with a look that resembled someone in grief.

I asked if he was okay and his response was a bit surprising.

“I was just told I have a disease which is causing my back pain, as a result, the pain may never go away.”

As I inquired more he told me the diagnosis was degenerative disc disease, which was causing his spine to shrink and as a result, it was causing the low back pain he was experiencing and would now have to seek treatment on a weekly basis just to deal with it.

This once active person (in his 50’s) was now disheveled because of this MRI diagnosis he had been given by another practitioner, he felt hopeless.

Why MRI Is Just One Tool That Should Be Used

Stories like this happen all too often with our patients.

They experience some sort of low back pain, (which usually they have never experienced before) and their doctor or other healthcare practitioner orders an x-ray or MRI and the results seem catastrophic. They are diagnosed with a “disease” or “syndrome” of some sort but aren’t given any really good information surrounding their condition.

While there is a possibility that disc degeneration (DDD) could be a contributing factor to their pain, it’s not as simple as just looking at some medical imaging to get a proper diagnosis.

There are several contributing factors including environmental factors, genetics, and associations with heavy physical work, lifting, truck-driving, obesity and smoking (smoking has been found as a risk factor for pain and DDD) found to be the major risk factors. However, these do not point to a clear pattern between degeneration and clinical symptoms.

Something that doesn’t get mentioned as often, is how this is also simply a part of normal aging. One systematic review points out some interesting facts to show just how much this happens. When looking at 3110 images of asymptomatic people the review showed:

Prevalence of disc degeneration in people at 20 years old was 37% which increased to 96% in 80-year-olds.
Disc bulges occurred in 30% of people at 20 years old and 84% in those at 80 years of age.
Disc protrusions were 29% of 20-years-old and 43% of 80-years-old.

And all of these individuals weren’t experiencing any pain!!

Another study showed changes in the disc at multiple levels were more common in the elderly (in this case above 60 years) as well as other degenerative changes around the facet joints, ligamentum flavum, and disc bulges.

Even though degeneration has been seen in the younger population as well, there is little correlation between radiological findings and pain. Quite often people whose imaging shows major issues have no pain and those who present with minor signs experience severe pain.

Unfortunately, many of these people are referred for surgery (usually a spinal fusion) which eliminates motion and can lead to degeneration of adjacent parts of the spine. Another part of the problem here is this only addresses a symptom, not the cause and the surgical outcomes are not great. It is also important to note that 70-80% of people who have surgical indications for back pain or disc herniation recover whether they have surgery or not.

These surgical referrals usually happen because imaging has been used as a diagnosis, rather than just a tool used in the process. This isn’t to say imaging shouldn’t be used, but it should not be the only thing used. Overall we see the association between MRI findings and DDD are unreliable, so the importance remains on our clinical reasoning and of course, patient history as well as looking for any neurological deficits.

The Role Of Depression

Now that we understand DDD risk factors, it’s age-related changes, and correlation with pain there is another factor we need to look at.

Depression.

In a three year study looking at veterans who were asymptomatic with low back pain, they were given repeated MRI’s over this three-year span. The researchers made a point of not telling the participants the results of what they saw as they didn’t want the patients to alter their symptoms by becoming sensitized to trivial issues or amplifying their symptoms.

Imaging findings varied, some discs were less severe, or even normal, and some became worse. The study concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings that may be risk factors for future back pain, however, protrusions were not a risk factor.

But, the strongest predictor for low back pain was depression.

Of those who self-identified (and were being medically treated for it) as having depression, their pain scores were greater at EVERY follow-up, whereas the progression of disc changes was only occasionally associated with new pain. Some of the participants also pointed out their activities were limited because of their depression.

As we know (when reviewing the clinical guidelines of low back pain) bed rest used to be one of the main recommendations for those dealing with acute low back pain, but now exercise and movement is the far better recommendation. When we look at discs exercise does not affect them adversely and they respond well to long term loading strategies.

So, think about that patient who comes in and is catastrophizing about the diagnosis they have just received. We know part of what we have to do is provide reassurance, in fact, this is a MAJOR part of what we have to do. Looking at all the information we have just discussed, letting them know that disc degeneration is a part of normal aging, there is little correlation between their diagnosis and pain (unless there are neurological symptoms) and quite often the issue resolves itself without surgery. Could we actually reverse their catastrophizing? Could we also assist this by encouraging them to exercise, even by getting them moving on your table to show that movement is safe? We know that exercise has great results in helping with depression and now we know it also helps with disc health, so aren’t these the things we should pay more attention to rather than focusing on MRI results? I’d say yes…and the research agrees.

A Novel Mobilization for Acute Ankle Inversion Sprains

April 2, 2019/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Erson Religioso

The case in the video was a severe ankle inversion sprain on the left and moderate on the right. The patient is a high-level gymnast who injured herself tumbling during a floor routine.

The video below was taken almost a week after the sprain. She had significantly decreased mobility with pain in all planes. Normally I would try a posterior glide to the lateral malleolus and ankle inversion/plantarflexion, which has worked on her in the past with great results. This time, that was too painful as was lateral malleolus contact.

Instead, I tried slacking the irritated skin and ligaments while gradually moving the forefoot/ankle into dorsiflexion and eversion. This was pain-free and after working my way to end range, her active/passive non-weight bearing range was much better and her gait was nearly pain-free. This got her started with loading and was easily replicated for an hourly home exercise program to modulate pain.

A Novel Mobilization for Acute Ankle Inversion Sprains

The case in the video was a severe ankle inversion sprain on the left and moderate on the right. The patient is a high level gymnast who injured herself tumbling during a floor routine. The video below was taken almost a week after the sprain. She had significantly decreased mobility with pain in all planes. Normally I would try a posterior glide to the lateral malleolus and ankle inversion/plantarflexion, which has worked on her in the past with great results. This time, that was too painful as was lateral malleolus contact. Instead, I tried slacking the irritated skin and ligaments while gradually moving the forefoot/ankle into dorsiflexion and eversion. This was pain free and after working my way to end range, her active/passive NWB range was much better and her gait was nearly pain free. This got her started with loading and was easily replicated for an hourly home exercise program to modulate pain.

Posted by Modern Manual Therapy on Monday, January 22, 2018

Self-Efficacy A Well Used Term But Well Understood?

March 4, 2019/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Ben Cormack

Self-efficacy is a term banded around in therapy quite regularly at the moment especially as more active approaches to rehabilitation are being embraced.

So we have to ask exactly what does it mean, why does it matter and how do we improve it?

In fact, my twitter friend/colleague Jerry Durham asked me this question whilst I was in the process of writing this blog, talk about great timing! It also shows that we often don’t have a well-defined definition for a well-used term.

Let’s Start With What Does It Mean?

It was a term first coined by Bandura in the 70’s, he described it is the ‘belief of an individual on whether they have the ability to perform behaviours relative to a specific activity’. Self-efficacy has also been described as a ‘resilient self-belief system’.

I like to describe it as a sense that ‘I have got this’ or ‘I can do this”.

This could be self-efficacy in relation to pain, such as the perception of the ability to remain functional and perform activities of daily living whilst you have pain, or it could be treatment-related activities such as a specific activity or exercise.

So let’s say that your kind therapist has suggested that you go to for a walk to help out with your back pain, do you think that you will be capable of doing this?

Maybe you don’t feel motivated?

Perhaps you don’t feel confident that you physically can?

Could be that you feel you can’t fit it into your busy life?

Low self-efficacy may result in challenges, such as changes in behaviour, being seen as threats to be avoided rather than things that can be overcome. Bandura identified a number of psychological processes involved with self-efficacy, these being cognitive, motivational and affective (emotional). Having valued goals and activities appears to be associated with these factors as well and self-efficacy and resilience literature points towards valued activities being an important part of this process HERE.

Bandura also identified four main sources of self-efficacy.

Mastery

Previous mastery of an activity or action influences our future perception of capabilities. We are starting to learn that human beings use prediction based on past experiences to navigate the uncertain nature of the world around them. If we have been successful at something in the past then it is likely we will perceive that we can overcome it again. This is also related to the ease of successes.

If our successes have been easy then we may be quickly dissuaded by obstacles. If the successes have been tough then we may also be used to overcoming any obstacles that come our way.

In line with this view, we see that previous adherence and participation in exercise has been shown to be important in future exercise adherence HERE.

Experiences

The world around us also influences our perception of capabilities. If people surround you that you perceive as similar, who are achieving similar things that you are being required to achieve, then you will also be more likely to see these things as attainable. This could be from the media that we consume to the involvement in social activities or our family circle, this underlines the social aspects of pain that appear to be pretty important.

This is a great recent paper on social factors in pain HERE

Persuasion

Now, this can be both positive and negative, and of course, it is easier to be influenced negatively than positively! But those that are persuaded, both verbally and experientially, that they are capable of achieving a task are more likely to be able to do so especially if we see previous success as a key factor.

Negative Emotions

Strong negative feelings towards an activity or the negative perception around an activity also will influence the level of self-efficacy someone has. Self-doubt is often an emotion that influences behavior negatively.

So We Have To Also Ask, Why Is It Important?

It appears that self-efficacy has been linked in multiple papers to worse outcomes across various measures of pain and disability. Now we cannot suggest it is causative or even that improving it will simply improve outcomes at this moment in time. But if I were to go out on a limb I think it probably would : ), especially if we are promoting more active approaches to therapy.

Certainly exercise as a treatment relies on it being performed and evidence-based medicine falls flat on its face if we cannot apply the treatment to the patient.

Foster, in 2010, found that for people with low back pain, low confidence in their ability to perform normal activities, or low self-efficacy, was predictive of a worse outcome in terms of disability at 6 months, in fact, better than fear avoidance, catastrophizing or depression HERE.

Keedy, 2014, found that those without the ability to engage in pain management related behaviours, pain self-efficacy, is related to the outcomes for back pain rehabilitation HERE.

Greater passive behaviour scores were also found to be associated with worse outcomes at a five year follow up for lower back pain by Chen, 2018 HERE. Passive coping strategies rely on external resources for pain control rather than internal resources such as our belief systems HERE that also influence self-efficacy.

Self-efficacy has also shown to be fundamental to the adherence of exercise interventions. These studies found that low self-efficacy was a predictive factor for poor adherence to a home exercise program HERE & HERE. For all the focus on the nuts and bolts of exercise, it is a pretty redundant process if the person does not feel capable of doing it. Time spent in this area rather than a focus on sets and reps may drastically improve adherence and therefore outcomes.

I call this focusing on the hole rather than the donut (the whole!)

What Can We Do To Alter It?

Success

The first steps may simply be to create a successful experience!

Previous successful adherence and progress have been associated with increased self-efficacy and this ties in with a Bayesian perspective of human function. So perhaps our aim for those that display low self-efficacy should be to set a low threshold for activity that can lead to easy adoption and fast progress. We often aim for a dosage of activity that leads to some kind of physical overload and adaptation. This could potentially lead to a negative experience for some and limit increased participation, without a positive initial experience they may not achieve longer-term sustainable success. So essentially good for psychology but not so much for physiology in the short term but hopefully leading to greater longer-term physiological impact through sustained participation.

It could be that just making an exercise session fun and not boring could be a very beneficial outcome. We often don’t place much importance on these things within medicine though. Why do people play sports? Maybe because they enjoy other aspects beyond just the physical exertion component.

People are often driven by challenge, fun & competition, how often do you incorporate these aspects into your training?

Some questions I often ask to gauge self-efficacy around exercise & activity are:

“Would you describe your self as confident around moving and exercising?”

“Do you feel you are currently capable of increasing your activity levels if required?”

“Would you describe yourself as motivated with regards to activity and exercise?”

Motivation

Motivation also appears to be a key aspect of self-efficacy. Helping people find something that actually motivates them could also be important and this could be through a goal-setting process that identifies valued activities. We could then break it down into more perceived manageable chunks that create little wins to help motivate the person.

I call this helping them find their ‘why’.

Lots of exercise programs don’t resonate with people, especially if they have not really participated in one before so exercise in itself is not enough of a ‘why’ for them.

We might ask “what would your perfect day look like with regards to activity?” or “what are some things you love to do that you don’t or can’t?”.

Autonomy is another factor associated with successful exercise, HERE, so also giving choices and options rather than a ‘this is the exercise you have to do’ approach.

Planning

Sitting down and planning with people when they might do things and how much might also have an impact on self-efficacy. Being able to do this for themselves might be a limiting factor and the participation in activity may feel like too great a challenge without some guidance.

What days might be best?

What time of day?

What type?

For how long?

What kind of effort level?

Set a reminder on the smartphone?

How to progress?

Alternative options if you do not succeed?

Takeaways

Previous experiences with behaviours are involved with future self-efficacy
Social environment and support is important
Self-efficacy can make or break an active approach to treatment
Self-efficacy is involved in outcomes for pain and disability
Self-efficacy is important for exercise adherence
Create behavioural wins and good experiences
Your input in terms of planning and motivation is vital if self-efficacy is low

Testing, Graded Exposure, And Reassurance For Low Back Pain

February 25, 2019/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Jamie Johnston

Over the past couple of weeks, we have been looking at and discussing the clinical guidelines for treating low back pain.

We have covered how important reassuring our patients their tissues are safe is a crucial component in their recovery from pain as well as building our therapeutic relationship with them.

We also discussed how important using graded exposure as part of that reassurance is, along with its importance in getting them moving again. So, this week we’ll cover how you can do some simple and effective graded exposure right in your massage therapy treatment room.

But first, we’ll have a look at the orthopedic test that was commonly recommended throughout those clinical guidelines and how to do it. There is a bit of controversy between papers as to how effective this test is, but it is the one that was most commonly recommended, so we felt it important to review.

Here is how to do an SLR (straight leg raise).

Even though the more common use of an SLR for low back pain is to look for a disc issue if you get a positive it is still important to reassure your patient they are okay. Use terms like “it just shows us the area is sensitized right now, so we just need to calm it down”. Try not to alarm them or instill any fear around there being a damaged disc or tissue.

Quite often when patients with low back pain come in, there will be some movements they are fearful of doing. Commonly forward flexion is the one I’ve seen in practice that most people have an issue with, so we’ll look at how we can do some graded exposure to help with that.

If you have a hydraulic table here are some simple things you can do to not only reassure the patient movement is okay, but also to help build up their trust in you:

If you don’t have a hydraulic table, here’s how you can do the same thing with some of the furniture most of us have in our treatment rooms.

The biggest takeaways:

Provide reassurance to the patient that they are not “damaged”.
Make them feel safe with the movements.
Gradually expose them to an increased range of movement.
Encourage, encourage, encourage your patients!