APTEI Report Spring 2015

Access all the past APTEI Report articles at www.aptei.com Clinical Library

Take the APTEI Report Quiz. Evidence-based answers are revealed inside! Pain catastrophizing is the strongest predictor of chronic pain rT rF

The best way to prevent patient litigations is to be perceived as caring rT rF

Myofascial work on the calf muscle can reduce plantar heel pain rT rF

Lumbar manipulation is more effective than PA mobs in prone rT rF The latest systematic review concludes that lumbar manips are not superior to other interventions for acute low back pain rT rF

Texting with head down can lead to arthritis and even neck surgeries rT rF

Aquatic therapy is an evidence-based intervention option for chronic pain rT rF

History of smoking is a risk factor for developing Tennis Elbow rT rF

Cervical dysfunctions are associated with persistent lateral elbow pain rT rF

Placebo is derived from Latin meaning I shall please Over a decade ago, 180 patients with painful knee OA were randomly assigned to one of three interventions, receiving arthroscopic debridement, arthroscopic lavage or placebo surgery. The patients in the placebo group received only the small incisions but no scope was inserted into their knees. At 6 weeks, 1 year and 2 years, they were all equally better with no differences in their pain and functional scores. In fact in the short-term, the placebo group had slightly better functional scores. This is of course not to say all surgery (or therapy) is placebo, but there is certainly a component of placebo in everything we do. Brain scans of pain patients who respond to pain killers, show that the cortex activations are almost identical irrespective if they receive real or placebo medications. A true medical breakthrough in the future will be learning how to consistently activate the sections of the cortex that produce the placebo effect. Now that would be truly revolutionary. A quote from Voltaire, a witty and highly respectable atheist French philosopher: "L'art de la mdecine consiste distraire le malade pendant que la nature le gurit". Translation: "The art of medicine consists of amusing the patient while nature cures the disease." & References: Moseley JB et al A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81-8.

For More Effective Physical Therapy Direct Patient Care

APTEI REPORT Advanced Physical Therapy Education Institute

Spring2015 Number 63 A report written by: Dr. Bahram Jam, PT

Edited by: Sophia Gilevich, PT


Pain Catastrophization & Reference: Sullivan MJ et al . Catastrophizing and perceived injustice: risk factors for the transition to chronicity after whiplash injury. Spine 2011;36(25 Suppl):S244-249. & Reference: Quartana PJ, et al Pain catastrophizing: a critical review. Expert review of neurotherapeutics 2009;9(5):745-758. There are now over 1000 published studies that have demonstrated the association between pain catastrophizing and increased pain severity, longer lasting disability, greater psychological distress, and even slower recovery from surgery. In fact, pain catastrophizing is now considered to be the strongest predictor of problematic pain outcomes. So is pain catastrophizing just caused by our way of thinking? Can it just easily be reversed by changing our thought patterns? Some studies have revealed on brain imaging that those who catastrophize about their pain show a pattern of brain activation different from non-catastrophizers. It is also hypothesized that catastrophizing may actually increase pro-inflammatory responses to noxious stimulation. In other words, what is now being researched is how our thoughts can contribute to inflammation plus the augmentation and spread of pain. Clinical application: The best way to maximize placebo is to prevent catastrophization in the first place. Prevent them from becoming a VOMIT (Victim of Medical Imaging Technology). Some people appear to not like the title VOMIT, so in my next version of the poster I will be changing it to PIT (Pitfalls of Imaging Technology) and telling people Dont fall in the pit If you wish, I can gladly send you the jpg versions of the poster in French, Italian, German or Norwegian. If you are able to translate it into any other language, please be kind and let me know!

Pain Truth Book Cost is Covered $$ For all PTs in Ontario, it is nice to know that The Pain Truth book sold to patients for $10-$15 is accepted by the insurance companies for MVA patients. When completing the OCF-6 Claim Form and if completing the OCF-18 form it is under Goods. The feedback on this book has been tremendous and even if it helps reduce catastrophization in a fraction of the patients, it has to be worth the few dollars. You may purchase the book for $8 from www.aptei.com

Best Advice to Preventing Litigation & Reference: Beckman HB et al The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994 Jun 27;154(12):1365-70.

This study analyzed a number of settled malpractice law suits by patients against their doctors in the USA. They wanted to see what exactly prompted each patient to sue their doctor. One would assume that poor health outcome or MD negligence would be the major reasons for deciding to sue. However, this study concluded that the decision to litigate was associated with: *Perceived lack of caring *Devaluing patient views *Discounting patient concerns *Perceived unavailability *Poor delivery of information


Based on this analysis, it appears that the majority of litigations may have been prevented if the health care provider had better communication and had been perceived as more caring. After all, we as health care providers are human and to err is human, but to be perceived as not caring when you err could mean a law suit. There are few things in life that are more stressful than dealing with a patient complaint or litigation against you. Fortunately PTs have relatively low litigation issues; helping to keep our malpractice insurance premiums low!

Ways to show patients that you Care & Reference: David Walton, PT OPA Pain Symposium 2014 Ask patients during your assessment, What do you think is causing all your pain? By asking this simple question you are perceived as actually caring about what they think and not dismissing their beleifs. At the end of your subjective exam paraphrase and say, Let me know if Ive understood you corrcetly, ...... Those two pieces of advice sound so simple, but can be effective in directly demonstrating to your patients that you are listening to them and care about what they are telling you. Not only does this reduce the chance of litigation, it will likely improve your clinical success with your patients. If you are perceived as caring, the patient will want to please you ...tada ...placebo!

Heel Pain & Myofascial Work

& Reference: Renan-Ordine R1, et al Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: J Orthop Sports Phys Ther. 2011 Feb;41(2):43-50. Treating heel pain can be frustrating especially when new shoes, heel cushions, orthotics, and self

stretching have failed. So you try ultrasound, shock wave, acupuncture still no relief. Here is another suggestion: try some myofascial work on the calf muscles. This RCT allocated 60 patients with plantar heel pain to: i) Self-stretching + soft-tissue release (STR) techniques to the calf muscles ii) Self-stretching program only Result: After 4 weeks, the patients in group 1 had significantly better outcomes in tenderness, pain and function than those in group 2. Clinical Relevance: Consider doing some kind of soft-tissue work on the gastroc-soleus complex muscles with your future patients with heel pain. Personal Comment: With only anecdotal evidence to support it, I have found Tissue Distraction Release (TDR) with movement to be very effective for helping those with either calf cramps or heel pain.

Warn the patient that it is very painful, but the treatment lasts only 3 minutes and I typically do it for only 2 sessions; when it works, it works immediately. You may download my free TDR manual and order the cups from www.aptei.com I personally rarely use any modalities other than the cups, (...and that is when I am desperate). If you have not yet tried TDR on tight muscles, I strongly recommend that you get a set of cups ASAP!


Slump Stretching may be Effective & Reference: Nagrale AV et al Effect of slump stretching versus lumbar mobilization with exercise in subjects with non-radicular low back pain: a randomized clinical trial. J Man Manip Ther. 2012 Feb;20(1):35-42. & Reference: Cleland JA et al Slump stretching in the management of non-radicular low back pain: Man Ther. 2006 Nov;11(4):279-86. I consider Slump stretching quite aggressive and have been hesitant about doing it on patients; however my hesitation to prescribe this exercise may be unfounded. So far there are 2 studies supporting it. Patients in India with non-radicular low back pain (LBP) were randomly assigned to one of 2 groups. All patients attended 2 PT sessions for 3 weeks. Group 1: PT included lumbar mobilizations and progressive stabilization exercises Group 2: Received the same PT treatments but with added self Slump stretching protocol

Slump stretching is performed with the patient in long sitting on the floor and the feet against a wall to maintain neutral ankle dorsiflexion. The neck and the trunk are fully flexed just to the point of mild symptom provocation (not pain). The position is held while the PT provides a mild cervical flexion over-pressure for 30 seconds and 5 repetitions. Patients are advised on performing the same Slump stretch at home once a day. Result: Improvements in pain and disability scores were significantly higher for the patients in group 2 who received the Slump stretching exercises. Clinical Conclusion: The addition of Slump stretching to other spinal treatments may be beneficial for patients with non-radicular LBP.

To Manip or not to Manip? & Reference: Learnan et al No Differences in Outcomes in People with Low Back Pain Who Met the Clinical Prediction Rule for Lumbar Spine Manipulation When a Pragmatic Non-thrust Manipulation Was Used as the Comparator. Physiotherapy Canada. 2014 Fall,66(4) 359-366 In the past decade, the lumbar manipulation Clinical Prediction Rule (CPR) has become quite popular. However studies seem to be knocking it down, such as the one published recently in Physiotherapy Canada. It turns out, patients who have low back symptoms of less than 16 days duration, with no symptoms below the knee and who have low fear avoidance beliefs do well with either manipulation or mobilizations. Perhaps the CPR is just a powerful prognostic influence regardless of the type of manual therapy they get. I love research, one year you believe in something and the next decade science proves it differently. Although I certainly promote spinal manipulations as one of many PT treatment options, we have yet to have a study showing that spinal manipulations are superior to mobilization techniques proposed by Robin McKenzie, PT and Brian Mulligan, PT (my heroes from New Zealand!)

Comparing 3 Manual Therapy Techniques for LBP

& Reference: Cleland JA et al Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial. Spine (Phila Pa 1976). 2009 Dec 1;34(25):2720-9. Patients with LBP who met the Clinical Prediction Rule (CPR) for lumbar manipulation were randomly allocated to receive one of three manual therapy techniques for 2 sessions followed by 3 additional exercise sessions.


The three manual techniques were 1) General lumbar rotation manipulation in supine

2) Specific lumbar rotation manipulation in side lying

3) Two sets of PA mobilizations over L4 and L5 spinous processes for 60 seconds

Conclusion: The patients who received either of the manipulation techniques had the same benefits at 1 week, 4 weeks and at 6 months follow-up. However those who received the PA mobs had significantly less improvements when compared to those who received the manipulations. Personal Comments: With the greatest respect to the father of manual therapy (G. Maitland, PT) I have yet to ever use straight PAs on patients with LBP. I probably used them for a few weeks after graduation 23 years ago, and then I abandoned them after not seeing results. For the majority of my PT career I have now mobilized only one way: mobilizations with movement (MWM) and have abandoned any static PAs in prone.

My anecdotal experience is that I consistently get better results with the correct MWM than I do with manipulations. I am still awaiting a study to prove me right or wrong!

Latest Systematic Review on Manipulation and LBP

& Reference: Rubinstein SM et al Spinal manipulative therapy for acute low back pain: an update of the cochrane review. Spine (Phila Pa 1976). 2013 Feb 1;38(3):E158-77. Spinal manipulation therapy (SMT) is performed on thousands of patients on a daily basis worldwide. There are now hundreds of studies that have investigated the efficacy of manipulation and dozens of systematic reviews summarizing the study results. Here is a quote from the latest systematic review. SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies. (Rubinstein SM et al 2013) Clinical Relevance: If you dont practice manipulation, its OK. There is no shortage of other potentially effective treatment options. Aquatic Rehabis worth getting wet for!

& Reference: Baena-Beato P et al Aquatic therapy improves pain, disability, quality of life, body composition and fitness in sedentary adults with chronic low back pain. Clin Rehabil. 2014 Apr;28(4):350-60. & Reference: Waller B1, et al Therapeutic aquatic exercise in the treatment of LBP: a systematic review. Clin Rehabil. 2009 Jan;23(1):3-14. I am impressed by the number of studies supporting aquatic-therapy for so many conditions. It seems like being in water can really be beneficial, its just hard getting people into the water in the first place. This recent study demonstrated that patients with chronic low back pain had significant improvements in fitness levels, pain and disability when compared to the wait list group. The patients attended 2 months of intensive aquatic therapy classes five times a week.

Group 1

Group 2

Group 3


A systematic review quote, There was sufficient evidence to suggest that therapeutic aquatic exercise is potentially beneficial to patients suffering from chronic low back pain and pregnancy-related low back pain. (Baena et al 2009) Clinical Relevance: If your patients are serious about recovery and dont mind getting into a pool, have them seriously consider aquatic therapy. The evidence certainly supports it. Personal Comment: Two years ago I recommended a 75 year old Scottish gentleman with lumbar stenosis and a great sense of humour to consider aquatherapy. He complied and went twice a week, and two years later he is still going. I told him that I was so impressed that he was still going to the pool as most men quit seeing that the classes are filled with women. He responded with his thick Scottish accent, Are you kidding me? Thats the reason I go, hahaha! A couple of months ago I experienced various manual therapy techniques in a warm pool done on me by Connie Jasinskas (an Exercise Physiologist). I must admit that I was very impressed by the way I felt after having my joint moved around in the water. Too bad a warm pool is not feasible in every physio clinic. If you are interested in practicing aquatic manual therapy, you can visit: www.AquaStretchCanada.com

Beware of Texting Fear Mongering & Reference: Hansraj KK. Assessment of stresses in the cervical spine caused by posture and position of the head. Surg Technol Int. 2014 Nov;25:277-9. This recent paper that regrettably got a lot of media attention (TV and radio) simply looked at the loads placed on the cervical spine during various angles of neck flexion simulating the typical looking down posture while texting.

Using badly explained biomechanical calculations they published a paper on something we intuitively knew as PTs. Basically at 0 of neck flexion the load on the cervical spine is approximately 10lbs which is the actual weight of the head. At 15 of neck flexion the load increased to 27lbs. At 30 of neck flexion the load increased to 40lbs. And finally by 60 of neck flexion (which the most typical angle seen on people while texting and crossing the street), the load on the cervical spine increased to 60lbs. The reason the load is not felt immediately while texting is that the spine is extremely adaptable and soon that posture feels normal and comfortable. Assuming that a typical person spends at least 2 hours a day looking down at their smart phone (a conservative estimate) equates to over 700 hours of sustained neck flexion a year. After 5 years of texting there is now over 3000 hours of sustained stress on the posterior neck structures. Moral of the story: Instead of always looking down at your smart phone, once in a while lift the phone up so it is in front of your eyes. Also do NOT text while walking or when crossing the street. If you get hit by a car, youll have more than just neck pain. Now the other side of the story: Human beings have been looking down since we started eating, cooking, reading, and playing chess. I got really annoyed when I heard the author of the paper getting media attention by fear mongering on the evening news. With no substantial evidence, he boldly claimed that texting could lead to arthritis, degeneration and even surgeries ...what nonsense!


Evaluation & effective management of the cervical spine is covered in the Advanced Cervico-thoracic program (4-day course).

Smoking & Tennis Elbow & Reference: Titchener AG, et al Risk factors in lateral epicondylitis (tennis elbow): a case-control study. J Hand Surg Eur Vol. 2013 Feb;38(2):159-64. 4. Other than repeated heavy gripping what are the other risk factors for developing lateral epicondylalgia (LE)? This large epidemiological study involved almost 5000 patients with LE plus age and sex matched controls. Statistical analysis showed that the risk factors associated with LE were (in order of risk)... 1. Rotator cuff pathology 2. De Quervain's disease 3. Carpal tunnel syndrome 4. Oral corticosteroid therapy 5. Previous smoking history Interestingly risk factors NOT associated with LE were... Diabetes mellitus, rheumatoid arthritis, alcohol intake, obesity and current smoking. That seems odd, if you used to smoke but quit, you get tennis elbow if you currently smoke and have not yet quit you dont get tennis elbow. Its amazing how stats work. If death from cancer is not enough reason, the fear of getting tennis elbow may be a better deterrent for teenagers to never start smoking! Personal Comment: This study failed to analyze if cervical pathology may be a factor in the development of lateral elbow pain. Imagine if C6 nerve root is sensitized, it can mask as rotator cuff pathology, elbow pain and De Quervains. Radial nerve may be sensitized even when patients dont complain of any specific neck pain....read on.

Lateral Elbow Pain Think C-Spine Dysfunction!

& Reference: Coombes BK et al Bilateral Cervical Dysfunction in Patients With Unilateral Lateral Epicondylalgia Without Concomitant Cervical or Upper Limb Symptoms: A Cross-Sectional Case-Control Study. J Manipulative Physiol Ther. 2013 Dec 27. pii: S0161-4754(13)00274-1. What is the prevalence of neck dysfunction in patients with lateral epicondylalgia (LE)? To help answer this important question, this study included healthy control subjects and compared them to patients who reported of unilateral lateral elbow pain and did NOT report of neck or any other upper limb symptoms (e.g. numbess). The unblinded PT examiner noted that 36% of the LE patients had some degree of paplpable neck pain and articular dysfunctions (between C4-T2), and 41% had a positive radial nerve neurodynamic test. Interestingly, a greater number of tendener points and stiff segments in the c-spine was positively associated with those with LE of longer duration. Also, a +ve radial nerve neurodynamic test was positively associated with greater severity of resting pain. Clinical Relevance: Every patient with lateral elbow pain must first have their cervical spine evaluated. If positive findings are present, address the neck and dont waste time ultrasounding the elbow or strengthening and stretching the wrist extensors!

Evaluation & management of lateral epicondylalgia is covered in the Elbow & Wrist Complex course.


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APTEI Report Spring 2015