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Acute L/S pain

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Acute Low Back Pain

Wait and See…… or Immediate Physiotherapy?

Is it too early to send my patient to Physiotherapy?

Will Physiotherapy make the injury worse?

The sports medicine approach has long been successful with immediate physical rehabilitation. The focus is early return of function allowing these people to return to sport as quickly as possible. Research has recently been questioning our reasons for having not employed the same approach to returning individuals back to work when they have suffered an occupational injury.

Traditionally medical practitioners treating occupational injuries have focused on pain relief and symptom control. While obviously important in the early stages of rehabilitation, the main emphasis should be functional restoration.

Internationally there are countries who’s health authorities still propose a "wait and see" approach to acute low back pain. Health authorities in North America and the UK recommend various forms of early physical intervention.

One study divided patients into 3 groups based on the time post injury at which Physiotherapy was initiated. This study showed that the earlier the intervention the better the results.

Group 1: Immediate (1-2 days post-injury)

Group 2: Early (3-7 days post-injury)

Group 3: Delayed (>7 days post-injury)

A second study compared assess/advise/treat against assess/advise/wait approaches to management of acute low back pain.

At 6 weeks the early treatment group demonstrated significantly greater improvements in disability, mood, general health and quality of life than those patients in the "wait" group. This is showing an early return to function.

The psychosocial impact of early treatment still continued to show benefit long term. This is a very important feature of early intervention as the psychosocial status of a client can provide significant barriers to physical rehabilitation.

References:

Zigenfus GC, Yin J, Giang GM, Fogarty WT. Effectiveness of early physiotherapy in the treatment of acute low back musculoskeletal disorders. J Occup Environ Med. 2000 Jan;42(1):35-9

Wand BM, Bird C, McAuley JH, Dore C, MacDowell M, DeSouza L. Early Intervention for the Management of Acute Low Back Pain: A Single-Blind Randomized Controlled Trial of Biopsychosocial Education, Manual Therapy and Exercise. Spine. 2004 Nov1;29(21):2350-6

Outcome Measures

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OUTCOME MEASURES

To download copies of the outcome measures used at Parkway Physiotherapy click each link below:

Neck Pain Functional Scale

Roland Morris Disability Index (low back)

Upper Extremity Functional Index

Lower Extremity Functional Index

Temporomandibular Joint Disability Index

Outcome Measures are tools that allow a clinician to undertake an evaluation of treatment. Outcome Measures include, but are not limited to, the change in patient impairment, activity limitations (disability), participation restrictions (handicaps), or quality of life.

Effective use of valid and reliable Outcome Measures improves treatment planning and proves that the service provided has been effective. The patient is shown in meaningful terms that they are moving closer to their goals.  Clinicians area able to gather data regarding a specific injury or patient subset for research purposes. Outcome Measures also give early warning signs when there is a lack of progress so that changes to the treatment approach can be made.

An article written this year in The Journal of Arthroscopic and Related Surgery recommends the use of a combination of different types of Outcome measurement tools.

Clinician measured outcomes:

Joint or problem specific measurements done by the practitioner.  E.g. Range of motion, isometric strength.

Patient reported measures of symptoms:

Measurements of pain such as the Visual Analogue Scale or Numeric Rating Scale.

Functional Outcome Measure:

These questionnaire are reliable and valid measures of a client’s function within the context of the measure.  E.g. Lower Extremity Functional Index, Roland Morris Disability Index.
Patient reported measures of general health status:
This final group of measures looks at the patient’s quality of life.  E.g. the Medical Outcomes Short Form (SF-36 and SF-12)

Outcome use in the physiotherapy office:

During treatment it is common for therapists to use range of motion measures and a battery of tests (usually +ve or –ve) to define the current and progressive level of ability.  These are checked nearly every visit and guide treatment progression.

At Parkway Physiotherapy and Performance Centre we also have implemented use of the Visual Analogue Scale and patient reported region specific measures of function.  They are completed by the client at the initial consult, every fourth visit and again at discharge. The measures we have chosen to use are:

· The Neck Pain Functional Scale
· The Upper Limb Functional Index
· The Lower Limb Functional Scale
(These 3 are scored 0-80 with 80 as normal)
· The Roland Morris Disability Index
(Scored 0-24 with 0 as normal)

In our communications with physicians we use, whenever possible, a combination of objective (clinician measured), subjective (patient reported), and functional outcomes. Consistent use of this data will allow better tracking of treatment results.  If you would like copies of the measures that we have chosen please download them from the links at the beginning of this article.

Reference:
Level V Evidence: Measuring Arthroscopic Outcome.  Arthroscopy: The Journal of Arthroscopic and Related Surgery: 24(6) 2008, pg 718-722

Vertigo

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Repositioning maneuvers for testing and treatment plus a suggestion on differentiating BPPV vs cervicogenic dizziness.

Frozen Shoulder

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Adhesive capsulitis classification and clinical guidelines.

Stretching

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A comparison of techniques to improve tissue length.

Ankle sprain prevention

Recurrent Ankle Sprains

Ankle sprain is one of the most common orthopaedic injuries.  It accounts for greater than 25% of all sports related traumas.  Most patients have full symptom resolution; however between 10% and 40% continue to show symptoms of chronic instability.  This causes ongoing functional limitations and increases the risk having chronic recurrent ankle sprains (CRS).

What they Say

•  Recurrent rolling of ankles

•  Difficulty with uneven surfaces

•  Sensation of giving way of the ankle

•  “Weak ankles”

What We See 

•  Decreased proprioception during single leg stance.

•  Often find ligamentous laxity or poor end feel of the lateral ankle ligaments.

•  Weakness of ipsilateral hip abduction and ankle eversion.

•  Tenderness on palpation of lateral ankle ligaments.

What We Do

•  Biomechanical Evaluation:

   For most ankle sprains, clinical measures of impairment resolve within 4 to 6 weeks. Underlying biomechanical deficits may persist, however, and these require manual therapy, bracing or training to correct.

•  Unstable Surface Training:

Many studies show positive results with 6-12 weeks training on unstable surfaces for postural stability and onset latency.  Program progression is required to positively influence proprioception.  Progressions are made through further destabilization, changing position, distraction and becoming more activity specific.

•  External Perturbation Training (elasticresistance):

A recent study looked at the use of band resistance around the opposite ankle to train the injured stance leg.  This method imparts external forces via the elastic band on the body forcing the closed chain stance leg to react.  With 4 weeks of  balance training every second day, all subjects in the study showed significant changes in balance when measured on a force plate.  Progression was made by stretching the band tighter thus providing a higher level of perturbation.  A benefit of this program over many others is that the band is portable and inexpensive.

Conclusion

   Prevention of chronic instability is of utmost importance because of the relationship between instability and long-term sequelae such as post-traumatic Osteoarthritis, increased fall risk and further ankle sprains.  Those with poor balance suffer between six and seven times the number of ankle sprains.  Rehabilitation programs focus on improvement of postural stability, proprioception and improving muscle onset latency. These interventions have shown a decrease in recurrence rates of 50%-70%.


Reference:
Han, K. Ricard, M. Fellingham, G.  Effects of a 4-week exercise program on balance using elastic tubing as a perturbation force for individuals with a history of ankle sprains.  J Orthop Sports Phys Ther.  2009 Apr; 39(4):246-55
Taghavi, C. SooHoo, N.  Foot and Ankle: Lateral ankle instability.  Curr Othop Pract. 2009; 20(2):117-22

NSAIDS

Do NSAIDs negatively impact the healing process?

When we see a client who is in obvious discomfort with an acute injury, it is common practice to attempt to control those symptoms.  This gives the client quick relief of the inflammatory symptoms, but at what cost?

There is no doubt that NSAID medications control the symptoms associated with the 2 early phases of healing; inflammation and proliferation.  They do so by inhibition of inflammatory chemicals.  There are many studies supporting their benefit for pain and function but what is the effect on the actual quality of the repair?   The concern is that these chemicals are a necessary part of a healing process that has developed over millions of years. 

Note that inflammation is the first stage of healing.  Without inflammation, how can we expect to progress on to stages two and three of the healing process? 

Healing follows these basic steps:


Inflammatory Phase (about 3-5 days): 

A response to tissue injury.  Viewed as a cascading chemical event, where each step leads into the next.  The cardinal signs are: Calor(heat), Rubor(redness), Tumor(swelling), Dolor(pain), Functiolasea(loss of function).


Proliferative Phase (to day 21):

Fibroplasia and Angiogenesis are the 2 fundamental processes that occur.  Fibroplasia is the proliferation of fibroblasts that produce new collagen.  Angiogenesis is the mitosis of the capillary cells producing blood supply to the new collagen. 


Remodeling Phase (day 21 to >1year): 

Macrophage, fibroblast, capillary and water concentrations all reduce and sensitivity decreases.  The collagen fibers reorganize into directions of tensile stress.

Findings in different tissues:

Tendon: 

Dimmen et al. 2009 showed a decrease in transverse and sagittal diameters of the tendons of rats that were giving parecoxib or indomethacin during the first 7 days post injury.


Tendon to bone junction:

Dimmen et al. 2009 found significantly lower maximum pull out strength and stiffness on tendon re-attachments at the 14-day post-op for rats given parecoxib or indomethacin.  Ferry et al. 2007 also found decreased maximum load on tendons subjected to celecoxib, valdecoxib, piroxicam vs. control.  Tendon strength was also higher in the acetaminophen and ibuprofen groups than the celecoxib group.


Bone healing: 

Dimmen et al 2009 treated rats with parecoxib, indomethacin post fracture.  The results showed a negative effect on bone mineralization during the early phase of fracture healing.  The statistical power of this study was too low to show differences at 6 weeks.

Clinical Conclusions: 

Remember that most solid evidence is in animal studies, human studies have not been done in this nature.  The stages of healing are similar.  If a client’s pain is tolerable, they may wish to avoid the introduction of NSAIDs to ensure the best possible repair quality.  If they are unable to function or sleep due to the symptoms of an inflammatory response, then acetaminophen or ibuprofen may be the best choice until the end of the proliferative phase of healing. 

 
Reference:
Dimmen S et al.  Negative effects of parecoxib and indomethacin on tendon healing: an experimental study in rats. Knee Surg Sports Traumatol Arthrosc. 2009Mar 19.

Dimmen S et al.  The effect of parecoxib and indometacin on tendon-to-bone healing in a bone tunnel: an experimental study in rats.  J Bone Joint Surg Br. 2009Feb;91(2):259-63.

Ferry ST et al.  The effects of common anti-inflammatory drugs on the healing rat patellar tendon.  Am J Sports Med. 2007Aug;35(8):1326-33.

Dimmen et al.  Negative effect of parecoxib on bone mineralization during fracture healing in rats.  Acta Orthop. 2008Jun;79(3):438-44.

Atherosclerosis

Occlusion of the lumbar arteries a factor in non-specific low back pain!

Non-specific low back pain(LBP) can be a frustrating and confusing entity for both the health professional and the patient.  If there is a lack of benefit of medication, physiotherapy and lack of findings on diagnosic investigations we might start to consider neuropathic pain and/or a psychosocial link.  Recent research into arterial blood flow suggests another differential diagnosis or contributing factor.

Lumbar Arterial Anatomy:
 

Pairs of lumbar arteries arise from the aorta at each lumbar level.  At L5 the lumbar arteries arise from the middle sacral artery which has previously arisen from the aorta.  As the lumbar arteries pass around the vertebral body, primary and secondary periosteal arteries arise to supply the vertebral bodies.  They continue to anastomose  with the periosteal arteries of the adjacent vertebrae over the surface of the disc.  At this point they supply the disc.


 

Cholesterol levels and Low Back Pain:

A study published in Spine looked at the relationship between findings on aortography and serum cholesterol levels in patients with long term non-specific LBP.  The study included patients whose age ranged from 35 to 70 years (with a mean age of 56).  Four major findings:
·    Over 75% of those with LBP showed occluded lumbar and/or middle sacral arteries!
·    The prevalence of occluded arteries was 2.5 times more prevalent in the LBP group than in an age matched control group!
·    Disc degeneration was significantly associated with occluded arteries.
·    Those with high LDL serum cholesterol had significantly greater neurogenic symptoms and complained more of severe pain.
This study suggests that some or all the pain may arise from ischemic tissues.


Atherosclerosis  and Disc Degeneration(DDD):

Another study indicated a relationship between arterial occlusion of the lumbar and middle sacral arteries and DDD.  Shockingly the reviewers identified 179 relevant studies and included 25 papers on this topic.  This review concluded that:
·    There is an relationship between atherosclerosis and disc degeneration. 
·    There is a strong relationship between occlusion of these arteries and chronic LBP.
·    Aortic calcification is associated with LBP and stenosis of the more distal branches was linked to DDD and LBP
·    Smoking and high cholesterol are the most consistent associations with DDD and LBP.


Clinical Application:

The evidence is clear that there is a relationship between Atherosclerosis, LDL elevation , LBP and DDD.  We need to be careful not to place clients into absolute categories.  Improving obvious biomechanical issues has a proven track record at reducing the incidence and severity of LBP.  For those who do not completely resolve, a multidisciplinary approach may be the most effective.  Physiotherapists and Physicians collaborating to treat all biomechanical findings and identify any factors that might cause a deficient arterial supply to the involved tissues may provide superior long term results. 

references:
Jam, B. APTEI Report.  Summer 2009.
Bogduk N. (1997).  Clinical Anatomy of the Lumbar Spine and Sacrum.  UK:  Churchill Livingstone.
Kauppila LI, Mikkonen R, Mankinen P, Pelto-Vasenius K, Mäenpää I. MR aortography and serum cholesterol levels in patients with long-term non-specific lower back pain.  Spine. 2004 Oct 1;29(19):2147-52.
Kauppila LI.  Atherosclerosis and Disc Degeneration/Low-Back Pain- A Systematic Review. Eur J Vasc Endovasc Surg.  2009 Mar 25.

Internet Learning

Patient Education and the Internet

As clinicians we understand the importance of patient education. Health information is now one of the most frequently sought topics on the internet. Most of these information searches are condition specific and are carried out before the clinical encounter to improve self-care, and after the consultation for reassurance. The result has been a shift in the role of the patient from passive recipient to active "informed" participant. Health professionals have responded in three ways:   

• The health professional feels threatened and responds by asserting their expert opinion

• The health professional and patient collaborate in obtaining and analysing the information

• The health professional will guide the patient to relevant and reliable information

Most of us would prefer to imagine ourselves as falling into one of the latter two categories. The shift of mindset regarding self-education has occurred therefore we must ask three questions to decide how best to help our patients find the right information.

Will they use it? 

In 2004 the patients most likely to seek internet medical education were younger and college educated. Now, well into 2009, people are more connected to the internet than ever before. There is no question that patients of all ages and backgrounds are interested in educating themselves. If the resource education source is evidence based, easily accessible, endorsed by the physician or physiotherapist, and free, then the chances of the patient using the information will increase.  

Will they learn it? 

 Each person has a number of learning styles, some stronger than others. A visual learner needs to see and read words and images to most effectively learn; the auditory learner needs to hear the information or education provided; while the tactile or kinesthetic leaner needs to touch and feel for effective learning to ensue. No wonder half of the information received at the doctor’s office is forgotten. Internet based learning is most likely to appeal to the visual learner although the auditory learners can benefit by reading aloud the information received.

What will change?

 Most of the patient education studies look at education in conjunction with some other intervention. Most the studies are condition specific; for example we can say that sub-acute and chronic back pain patients will likely experience less disablility by receiving a back care booklet. Similarly we can conclude that patients waiting for total knee replacements will likely benefit from therapeutic education. Potential advantages of Web-acquired information include helping patients make informed health care choices, shared decision-making with a collaborative, teamwork approach, more efficient use of clinical time, augmenting of physician-provided information, online support groups, and/or access to patients' own health information. Alternatively, factors such as misinformation due to highly variable quality of Web information, possible exacerbation of socioeconomic health disparities, and shifting of conventional notions of the physician-patient relationship present their own set of challenges for the health care provider.

The practice implication for any health professional is to become a "net friendly" clinician, engendering a genuine partnership with patients towards the highest quality health care.

Reference:

Wald HS, Dube CE, Anthony DC. Untangling the Web--the impact of Internet use on health care and the physician-patient relationship. Patient Educ Couns. 2007 Nov;68(3):218-24.

Ultrasound for Fractures

Fracture Repair with Low Intensity Pulsed Ultrasound 

There are millions of fractures worldwide each year with an estimated 5-10% resulting in either delayed or nonunion. All told, these injuries constitute the largest cause of morbidity and socioeconomic cost in the developed world. As our population ages it becomes even more important to understand the cellular events associated with fracture repair. Low intensity pulsed ultrasound stimulation (LIPUS) is one of the proposed interventions to both enhance and accelerate bone healing.

 Traditional use of ultrasound directs energy into the tissues producing heat. At lower intensities, however, there is <1°C of temperature increase. Traditional use of ultrasound continues to be contraindicated at a fracture site whereas low intensity ultrasound has proven to be a benefit in the healing rate of both fresh fractures and delayed or nonunion fractures.

 Bone tissue is sensitive to the micromechanical stresses of low intensity ultrasound waves. Histologic studies show positive influence on osteoblasts, osteoclasts, chondrocytes and mesenchymal stem cells. Animal model studies demonstrate increased cellular calcium uptake, decreased cytokine release and suggest enhanced angiogenesis and blood flow around the fracture site.

Accelerated Healing of Acute Fractures

Cook et al. looked at tibial and distal radius fractures of smokers and non-smokers. Participants received either LIPUS or sham ultrasound starting within 7 days of the fracture. In those who received the LIPUS treatment, the healing time of tibial fractures was reduced by 41% in smokers and 26% in non-smokers; the healing time of distal radius fractures was reduced by 51% in smokers and 34% in non-smokers. The end point of the study was a healed fracture as judged by clinical exam and radiographic evidence (3 of 4 cortices bridged). Fractures not healed at 150 days were deemed delayed unions. Delayed union was also reduced in the LIPUS treatment groups: 8% vs. 27% placebo in non-smokers and 0% vs. 36% in smokers.

Healing of Delayed and Nonunion Fractures 

Clinical Application 

• No side effects.
• Conservative, easily administered.
• Excellent cost benefit.
• LIPUS not studied in the skeletally immature.
• LIPUS not for unstable fractures, bone loss > 15 mm, severe torsional deformity, large soft tissue defects, or low patient compliance.

Treatment Parameters

Women's Health

 Women’s Health Edition:

 Pelvic Floor Physiotherapy  

 Who is it for? What do we do?

Women are often surprised to learn that physiotherapy interventions can help them with seemingly gynaecological and urological symptoms.  Often, they are not sure what to expect as far as assessment and treatment.  The approach to pelvic floor physiotherapy remains strongly rooted in the paradigm of an orthopaedic musculoskeletal exam. The primary difference with the pelvic floor exam is that it includes a digital vaginal and rectal exam.  Using these techniques, the assessment ensures that all musculo-skeletal systems are addressed:

 ·         Peripheral neurological scan (reflexes, myotomes, dermatomes)  

 ·         Articular system (sacro-coccygeal, sacroiliac joints, lumbosacral junction and lumbar spine

 ·         Muscular system (strength, tone, coordination, quality of contraction)

In addition, systemic pathology is screened for pelvic organ prolapse and pelvic pain as well as a complete subjective history including an evaluation of behavioural or lifestyle factors which may be contributing to the problem.

Urinary Incontinence

Women with either stress or urge incontinence can benefit from this conservative approach.  A systematic review from the Cochrane Collaboration suggests that “pelvic floor muscle training helps women with all types of incontinence although women with stress incontinence who exercise for three months or more benefit most.”.  Specifically, “women who did pelvic floor muscle training were more likely to report they were cured or improved than women who did not. Pelvic floor muscle training women also experienced about one fewer incontinence episodes per day.”  Other studies found reduced incontinence severity, increased pelvic floor strength, decreased voiding frequency and increased overall quality of life.

Pelvic Pain 

Vulvodynia, provoked vestibulodynia (PVD) (formerly called vulvar vestibulitis syndrome (VVS)), vaginissumus and dyspareunia are complex, multi-factor pathologies that family practitioners struggle with in guiding their patients towards good results.  Currently, psychological counselling with pharmacotherapy (tricyclic antidepressants) seem to be the front line treatment of choice.However, evidence is accumulating that including pelvic floor physiotherapy in this combination yields greater results.  80% of members from the International Society for the Study of Vulvovaginal Disease found this combination to be very effective or somewhat effective.  In fact, of women with PVD, 51.4% of participants noted a complete or great improvement and 20.0% had a moderate improvement within an average of 7 treatments.  This study specifically inquired about pain during intercourse and gynaecological exam, frequency of intercourse and levels of sexual desire and arousal.  Other literature suggests an overall decrease in pain and improvement in quality of life.

Coccydynia

Acute pain around the coccyx can be treated medically with the use of a stool softener, adjustable seating and NSAIDs.  However, if symptoms persist for longer than 8 weeks, a combination of pelvic floor massage and cortico-steroid injection has been found to be successful once other pathology such as tumour have been ruled out.  Interestingly, levator ani (pubovaginalis, puborectalis, pubococcygeus and illiococcygeus) muscle massage and stretch were found to be more effective than joint mobilization and manipulation in persons with a normally mobile coccyx.

  The five muscles of the pelvic floor:

• pubovaginalis
• puborectalis
• pubococcygeus
• illiococcygeus
• ischiococcygeus

are often forgotten when patients attend their family practitioner with complaints of gynaecological or urological symptoms.  

A body of evidence is accumulating linking the role of the pelvic floor with some of these problems. Practitioners may be able to offer more comprehensive treatment options to their patients complaining of urinary incontinence, pelvic pain and coccydynia.

A referral to a pelvic floor physiotherapist for an assessment is a good first step in determining whether this is a viable treatment option. To find a physio who specializes in women’s health contact us at 250-478-7227.  Shannon Bourrassa is our Women's Health Practitioner at Parkway.

References:

Eyjolfsdottir H, Olafsdottir M, Geirsson G . Pelvic floor muscle training with and without functional electrical stimulation as treatment for stress urinary incontinence. Laeknabladid, The Icelandic Medical Journal, 2009 Sep; 95 (9):575-80

Bergeron S, Brown C, Lord M, Oala M, Binik Y, Khalife S. Physiotherapy for vulvar vestibulitis syndrome: A retrospective study. Journal of Sex and Marital Therapy, 2002; 28 (3): 183-192.

Maigne J; Chatellier G; Le Faou M; Archambeau M; The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study, Spine, 2006 Aug 15; 31 (18): E621-7.