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clinical question(s)

OK gang, here's the scenario:

I have a 62 year old cowboy/Realtor who first injured his back in a 1500 ft fall in a helicopter, outside of Aspen, CO, in 1974. He has suffered chronic LBP since this incidence. I have seen him as a private pay patient 2x (1x March, 1x in May): treatments (neck and low back) focused on mobilization/manip, instruction in self-mobilization and stretches and some core strengthening. He is considering a home, inversion (or not inverted) traction unit. His wife had a 'disc-ie' condition I helped greatly, so he trusts me.

Now, I was off on vacation last week and this gentleman had a severe episode of LBP (no leg pain). He tried to get in with a PT at our clinic, but the schedules conflicted, He went to a local 'VAX-D' clinic and had a consult (local chiropractor owns the local franchise), an MRI and advise that the program of 20-30 Rx would rehydrate (his words) the discs (MRI showed 3-4 levels of DDD) and reduce his chronic LBP dramatically. He then saw a PT at another clinic who told him his problems was caused by a torsion of his pelvis ('my hips and pelvis are twisted') and that this was what needed 'correcting'. He had some relief with the manual therapy, but showed up for treatment promptly this week.

He brought his MRI report and gave me the recent history. He has asked me in the past about a "back swing," or inversion traction unit, which I have had some clients find gives them a effective home management strategy for their chronic LBP. We discussed the Cochrane review on traction for acute and chronic LBP. We did a literature search for any evidence of re-hydration with traction: None that I found. We went to Google and found some interesting websites on traction (Aetna had a nice review of the evidence and some definitions), but sorting the commercial websites (with an agenda of sales or denying care (ie. 3 rd party payors)) from academically legitimate websites was difficult.

We discussed the osteopathic model of the pelvic obliquity and asymmetry. I have found little or no evidence that constitutes validation of the model. We also discussed what evidence is required to determine true cause-effect relationship (again, the Bradford-Hill criteria).

Chiefly, we commiserated about the difficulty in being a good consumer of health care in this marketplace. We wondered aloud why do we (medicine & society) create so much confusion.

Any thoughts or comments, again, on VAX-D? Any evidence of re-hydration?
Any thoughts on models of lumbopelvic problems? Making some one better with a technique does not constitute proof of a theoretical construct.
Any  definitions of what constitutes 'autotraction,' which is the form of traction the Cochrane Review on Traction found robust at all (not very) for effectiveness in treating LBP? I am familiar with the 1980's 'autotraction' machines (3-dimensional self-guided traction). Is a backswing autotraction?
Britt

Concurrent Criterion-Related Validity of Acromioclavicular Joint Physical Examination Tests: A Systematic Review

This recent article was published as an online-only, open access supplement to the last issue of the Journal of Manual and Manipulative Therapy and systematically reviews the available research on concurrent, criterion-related validity of physical examination tests for the diagnosis of acromioclavicular joint (ACJ) dysfunction.  The review concludes that the currently available best research evidence supports the inclusion of a number of tests with a specific interpretation in a physical examination format for the diagnosis of painful ACJ dysfunction:

- A negative find on the cross-body adduction test, tenderness on palpation of the ACJ, and the Paxinos sign may serve to rule out a painful ACJ dysfunction

- A positive finding on the active compression test, the cross-body adduction test, and the acromioclavicular resisted extension test may serve to rule in a painful ACJ dysfunction

- A positive finding on all three tests for the cross-body adduction, active compression, and resisted acromioclavicular extension may be relevant when the physical therapist is considering a medical-surgical referral and associated higher-risk interventions.

Future research is obviously necessary to examine the results of these tests in combination with other historical and physical examination findings, but this is a good start.  The full text article can be accessed at:
http://jmmtonline.com/documents/PowellV14N2E.pdf.  Additional full-text open-access material has been added to the last two volumes of the journal and can be accessed by way of the past issues link on the journal home page: http://jmmtonline.com/.

By the way, join AAOMPT for a very reasonable annual rate and you get the journal as part of your subscription.  So, if you're not a member, join what will be the fastest growing PT professional association for years to come!  You can say that you were a member during its infancy!  Of course, don't forget about APTA. That should be a given.

John

Charity, Research, and the Drug Industry

The money trail involved in research is highly complex and often not transparent to consumers of the research, much less the patients being treated based on the latest research findings. Conflicts of interest abound. This article in the New York Times does a great job illustrating the problem. Not sure whether there are any easy solutions, but I think it's safe to say we have a long way to go.

John

Evolution of the Crew 'Do

We have discovered the possible evolution of Tim Flynn's hair "approach". Perhaps this could shed some light...

Thanks to David Feltwell for the photo.

J

Quote of the Week

"Whoever undertakes to set himself up as a judge of Truth and Knowledge is shipwrecked by the laughter of the gods."

- Albert Einstein

Clinical Consult

I have a patient I am currently treating but have had minimal success with. 
She is a 74 year old female who woke in the am with L ant groin/thigh pain radiating to her knee but not distal to it.  She went to the ER where they performed an X-ray and sent her home with pain medication.  The next day she saw her PCP who diagnosed her with sciatica and referred her for physical therapy.  The symptoms had increased to the day of eval (2 weeks after onset).  She reports her pain to be greatest with standing and walking, however it is still present when seated.  She reports pain in L S/L, however is painfree in R S/L and when seated with her L leg crossed over her R (L foot on R knee).  Pain equal 9/10 at worst and at eval.

Objective findings:  Standing posture: Flexed trunk with lat shift shoulders to R.  Lat shift resolves when seated.

Pain with palp L PSIS

DTR's equal bilaterally at knees and ankles, L Hip flex strength equal 4-/5, quad strength equal 4/5

AROM:  Flex= 75%, ext to neutral with increased thigh pain, RSB= 50%, LSB=25% with increeased thigh pain.

She was unable to tolerate any testing in prone or supine, in hooklying she also had pain but was able to tolerate L hip flex passively to 100 degrees before reporting increased thigh pain.  Sx's were mildly decreased with seated flex.  In R S/L she complained of pain with P to A pressure from L2 - L5.  She was ambulating with a standard cane with flexed trunk and lat shift with shoulders to right.

I have been treating her for 6 visits with mild decrease in sx's with pelvic traction.  She modestly corrects the shift with shift corrections in wt bearing, however they resume when she stands after sitting down, which she does not avoid since this is her only position of relief.  Attempts at shift correction exercises are also painful.  Currently her pain has centralized somewhat, with less ant thigh pain and more lat hip pain, however there has been no change in pain intensity and she continues to present with a lat shift.  She has no history of osteoporosis, so I today attempted a neutral gapping  manipulation with no change in sx's.  Any suggestions would be appreciated.

Thanks.

Andy

Veracity of Subgroup Id. acknowledged in BMJ by Dutch

Koes et al have recently reviewed the diagnosis and treatment of low back pain in BMJ (June 17, 2006). The last section (Promising developments) has a lead section called 'identifying subgroups of patients more amenable to specific treatments.' The authors cite the Brennan et al Spine, 2006 article as evidence for better functional outcomes with matched treatment vs. unmatched treatment for LBP patients. They also cite Childs, et al's validation of the CPR for spinal manipulation for acute LBP.
I believe this is the first public acknowledgement by Dutch authors of the veracity of the efficient and effective care by SUBGROUP Identification in the treatment of LBP. The systematic review in Annals of Internal Medicine (Assendelft et al 2004) dismissed the possibility of identifying meaningful subgroups. Now, because Koes and van Tulden are Dutch doesn't mean they share opinions with Assendelft, but this is a step in the right direction.
Britt
Download koes_van_tulden_thomas. lbp summary.bmj.06.pdf

The secret is in the product...It's called Crew!

I shared a room with Tim Flynn during Annual Conference in Orlando last week and was able to uncover the secret underlying the spikes in his now not so recently transformed hairstyle. See the photo in case you have yet to see. Using the camera on my Treo 650, I was able to capture this exclusive photo of the product itself. The secret is out! He uses American Crew Fiber, Pliable Molding Creme. Men all over the world who are seeing the early stages of hair loss and who wish to emulate Tim's hairstyle will rally this product via word of mouth to its highest visibility and sales ever! Buy the same Crew creme used by Tim from here or any of your favorite hairstyle vendors! John

Pay For Performance in PT Practice

In light of yesterday's P4P debate at Annual Conference in Orlando, the publication of this article is timely. Via changes in health policy in the Netherlands, the study detected a small decline in the number of treatment sessions from the early 1990s to 2002. Exercise therapy was also the most frequently prescribed treatment in 2002, whereas more passive modalities were prescribed in the early 1990s, indicating increased utilization of evidence-based interventions. To my knowledge (I could certainly be mistaken), this is the first publication in the peer-reviewed literature on the implications of P4P initiatives specifically related to physical therapy practice. There will certainly be more to come.

John

Get Hooked!!

APTA's Hooked on Evidence article extraction database has been steadily growing and improving since it's inception, but the latest feature has just taken it to a whole new level with regard to methods for finding clinically relevant information: introducing the "Search Clinical Scenarios" feature that was released just last week.

Instead of searching for an answer to a clinical question posed by a patient, instead you search by matching your patient's case presentation as closely as possible with the representative cases listed in the drop down menu (by practice pattern).  You are then presented with current available evidence that has been extracted into the database and sorted by study design according to the evidence hierarchy.  Just "click" and you taken to the extracted study.

This method of searching for answers is based on pattern recognition and much more intuitive than the more standard way of searching.

So for Mark B, who just posted the most recent Clinical Consult, go to the new feature on Hooked on Evidence and search the Knee scenarios under the Musculoskeletal practice pattern.  You just might find your answer! (yes, Hooked is an APTA member benefit so you have to be one to access)

Enjoy!

Rob