http://www.cbc.ca/marketplace/2010/stretching_the_truth/main.html

He has written a guide to basic ergonomics that anyone can use to make their workplace better, more efficient and safer.

This guide is based on the latest 2010 research into ergonomics.  Mike welcomes your questions on specific ergonomic issues.  If you require ergonomic services, please don’t hesitate to contact Mike at (807) 344-5242 or email.

Download here:  basic guide to ergonomics

This study investigated the validity and diagnostic accuracy of the McMurray’s test. While the typical gold standard for diagnosis a meniscus tear is through MRI and arthroscopy, which often involve lengthy waiting times, it is necessary to have a collection of highly specific and sensitive tests in our clinical set. The systematic review concluded that, based on the best available studies, both the specificity and sensitivity were variable. This often resulted in numerous false negative and false positive results in the studies.

Clinical Implication: Given the lengthy wait times for both MRI and arthroscopy, often delaying both conservative and surgical treatment, it is necessary to consider the validity of additional physical tests. Recent research into use of the Thessaly’s test (sometimes referred to as a KKU knee compression-rotation test) in isolation and in conjunction with a typical McMurray’s test is quite promising. Use of the Thessaly’s test in combination with a traditional McMurray’s has been shown to improve diagnostic sensitivity for a meniscus tear to 90% and 97% for specificity. Use of the Thessaly’s test in isolation has also been shown to have a diagnostic accuracy of 94% for the medial meniscus and 96% for the lateral meniscus. Both carry a higher than a typical McMurray’s rating, but particularly in the diagnosis of a lateral tear.

2) Effects of Early Progressive Eccentric Exercise on Muscle Size and Function after Anterior Cruciate Ligament Reconstruction: A 1-year Follow-up Study of a Randomized Clinical Trial (RCT). 2009. Gerber et al. Physical Therapy. Volume 89, Issue 1.

This RCT involved random assignment of 40 patients who had undergone ACL reconstruction to 3 months of physiotherapy. One group received eccentric resistance training, while the other group received standard rehabilitation. MRIs of the thighs were taken at 1 year and compared to previous studies taken 3 weeks post-ACL reconstruction. The group receiving eccentric resistance training showed a statistically significant improvement in quadriceps and gluteal muscle volume and strength at 1 year. A 20% greater improvement in muscle size and strength was present.

Clinical Implication: Focusing on the stage of healing following an ACL reconstruction is quite important in order to ensure success. However, the method of performing close-kinetic chain strengthening is also essential to a successful long-term recovery. But which strengthening exercise tends to produce the most gains? Several studies have been published within the past year that examined the typical forms of eccentric gluteal strengthening used by physiotherapists. The most beneficial exercises appear to be a single-leg squat and single leg dead-lift. Now that we see that eccentric close-kinetic training may be more beneficial post-ACL reconstruction, knowing the choice of exercise becomes even more important in maximizing recovery. These are simple, yet challenging activities that can be safely included post-ACL during the appropriate stage of healing.

3) Effect of Thigh Strength on Incident Radiographic and Symptomatic Knee Osteoarthritis in a Longitudinal Cohort. 2009. Segal et al. Arthritis Care & Research. Volume 61, Issue 9.

This study addressed the question: “Can knee extensor strength predict risk for radiographic tibio-femoral osteoarthritis (OA) or knee pain?” Approximately 5000 knees were evaluated in a group of 50-79 year old individuals. At baseline, these knees did not have any evidence of radiographic knee OA. Quadriceps isokinetic strength was measured at baseline (when asymptomatic) and at a follow-up x-ray at 30 months. The results indicated that approximately 10% of the study participants developed knee OA, and those with weak quadriceps at baseline, had more OA and pain.

Clinical Implication: Much debate has occurred in the literature as to whether quadriceps weakness is associated with or can predict knee OA. It is important to note that knee extensor strength in the current study was not predictive of radiographic OA, but was predictive of symptomatic knee OA. Perhaps this is why the majority of patients which we see in practice presenting with knee OA have associated quadriceps weakness; this may have been present before the OA occurred. This is an important point, as the above study indentifies that early strengthening in asymptomatic individuals may have a strong role in preventing symptomatic knee OA. Our role as physiotherapists has always been one to include remediating a problem (i.e. pain) once it has occurred; our role in prevention should also be considered and used early on to prevent future pain and disability in our shared patients.

4) Self- and Manual Mobilization Improves Spine Mobility in Men with Ankylosing Spondylitis – A Randomized Study. 2009. Widberg et al. Clinical Rehabilitation. Volume 23, Number 7.

The study addressed the question, “Can Physiotherapy help those with ankylosing spondylosis (AS)?” Thirty-two men, age 23-60 , with AS were randomized to an active therapy group (manual therapy) and a no treatment group for 8 weeks. Physiotherapy intervention was tailored to each individual based on their current health status, pain and mobility, with the goal of having the treatment be as painless as possible. The intervention included individualized self- and manual mobilization for 1 hour twice a week over the 8 week period. This included thoracic and rib cage manual therapy, soft tissue therapy, active range of motion, a home exercise program and patient education. The results demonstrated an increase in laterocostal chest expansion, with no difference in vital capacity when compared to controls. Posture (occiput-to-wall) also improved, as did thoracic and lumbar spine flexion. All improvements were found to be maintained at a 4 month follow-up.

Clinical Implication: Focus on self-management for patients with AS is a strong component in their rehabilitation process. The ability to give these tools for dealing with this chronic condition tends to empower patients and improve their outlook. The above study demonstrated that an initial course of manual physiotherapy in conjunction with a home exercise program, not only resulted in significant functional and mobility improvements, but also resulted in long-term maintenance of these gains. We know that in chronic conditions, like AS, patient self-perception regarding their prognosis impacts their activity compliance, pain levels and attitudes. Knowing that there are physical options for managing their mobility is quite important for these patients; the reverse is also true. Patients who convince themselves from the start that their pain is permanent and progressive tend to present with more disability down the road. Findings like these are quite important to manual physiotherapists, demonstrating another avenue in managing chronic inflammatory conditions, like AS.

I welcome your comments on the material posted to this site. Please feel free to contact me at jtaddeo@fairwayphysio.ca . Jason Taddeo, M.Sc.(PT), H.B.K., CAFCI, RCAMPT

September / October 2009

Increased Forward Head Posture and Restricted Cervical Range of Motion in Patients With Carpal Tunnel Syndrome. 2009. De-la-Llave-Rincón et al. J Orthop Sports Phys Ther 2009;39(9):658-664, Epub 19 March 2009.

In this case control study of 50 women, the objectives were to: 1) to compare the amount of forward head posture (FHP) and cervical range of motion (ROM) between patients with moderate carpal tunnel syndrome (CTS) and healthy controls; 2) to determine the relationship among FHP, cervical ROM, and clinical variables related to the intensity and duration of pain due to CTS.

Results & Conclusions:
1. There was a significant difference between groups for FHP, with patients with CTS having had a smaller craniovertebral angle,
2. Patients with CTS showed decreased cervical ROM in all directions; however, only cervical flexion and contralateral flexion were associated with lower pain scores over the preceding week.

Physiotherapy Implications:
1. We know that in approximately 50% of chronic CTS, there exists additional pathology, for example, a double crush phenomenon to the median nerve. Approximately, 15% of cases demonstrate this within the cervical spine. As such, detailed manual physiotherapy assessment of the upper quadrant / neck with particular attention to additional sites of entrapment is essential to the management of CTS both pre-operatively and post-operatively.
2. Postural dysfunction cannot only result in additional problems, such as nerve compression, but is often an adaptive behaviour for underlying compression. Our posture often defines the type of repetitive work that we do and directly impacts our ability to respond to conservative care.

Manual Physical Therapy and Exercise Versus Electrophysical Agents and Exercise in the Management of Plantar Heel Pain: A Multicenter Randomized Clinical Trial. 2009. Cleland et al. J Orthop Sports Phys Ther 2009;39(8):573-585, Epub 24 June 2009.

In this randomized clinical trial on 60 subjects with plantar heel pain, the objective was to: 1) compare the effectiveness of two different conservative management approaches in the treatment of plantar heel pain. One group received treatment with electrophysiological agents plus exercise, while the other group received manual physiotherapy and exercise.

Results & Conclusions:
1. Both pain and perceived levels of disability were significantly reduced at a 4 week and 6 month follow-up, in favour of the manual physiotherapy and exercise group.

Physiotherapy Implications:
1. Treatment of plantar heel pain in general (not simply plantar fasciitis or fasciosis) by manual physiotherapy may be superior in the short-term and long-term for recovery, when compared to use of electrophysiological agents (i.e. ultrasound) and exercise alone.
2. As causes of plantar heel pain are often multi-factorial, and often led to by repetitive tissue stress over time, proper assessment and management of compounding factors is necessary. This involves care consideration of the impact of the knee, hip, gait mechanics and foot biomechanics and integrity.

A Systematic Review of the Effectiveness of Exercise, Manual Therapy, Electrotherapy, Relaxation Training, and Biofeedback in the Management of Temperomandibular Disorder. 2006. Medlicott et al. Physical Therapy. Volume 86 Number 7.

Main Recommendations Related to Physiotherapy:
1. active exercises and manual mobilizations may be effective;
2. postural training may be used in combination with other interventions, as independent effects of postural training are unknown;
3. mid-laser therapy may be more effective than other electrotherapy modalities;
4. programs involving relaxation techniques and biofeedback, electromyography training, and proprioceptive re-education may be more effective than placebo treatment or occlusal splints;
5. combinations of active exercises, manual therapy, postural correction, and relaxation techniques may be effective.

NSAIDs: Use or Avoid post Acute Injuries?
Reference: Ferry ST, et al The effects of common anti-inflammatory drugs on the healing rat patellar tendon. Am J Sports Med. 2007 Aug;35(8):1326-33. Epub 2007 Apr 23.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed in the treatment of ligament and tendon injuries. There are several studies supporting their benefit with respect to pain and functional improvements compared to controls…but the question is
“what effect do NSAIDs have on the actual quality of the tendon or ligament repair?”

Interestingly the studies, which are done primarily on rats and rabbits, give conflicting results. Some say NSAIDs have no adverse effect and others say NSAIDs significantly reduce the quality and strength of the tendon during healing…oh whom to believe?

A total of 215 rats were deliberately inflicted with patellar tendon injuries then they were randomly administered various meds for 14 days.

At 14 days, all the rats were sacrificed, and repair site tissue was analyzed. Conclusion: “Anti-inflammatory drugs, with the exception of ibuprofen, had a detrimental effect on healing strength at the bone-tendon junction” and “Acetaminophen had no effect on healing strength.” Clinical Relevance: One must appreciate that this is still a rat study, but I would personally avoid NSAIDs if my pain was tolerable …if pain effected my sleep, I’d take Ibuprofen in a heartbeat!

Personal comment:
Result: Tendon strength in the control group (No meds) was significantly stronger and had greater maximum load compared with the Celecoxib, Valdecoxib, and Piroxicam groups (P < .05).

Result #2: Tendon strength in the acetaminophen and Ibuprofen groups was significantly stronger than the Celecoxib group (P < .05) [Originally posted June 4th, 2009 on www.aptei.com]

Atherosclerosis & Disc Degeneration & Back Pain
Reference: Kauppila LI. Atherosclerosis and Disc Degeneration/Low-Back Pain -A Systematic Review. Eur J Vasc Endovasc Surg. 2009 Mar 25.

The aim of this 2009 systematic review was to assess associations between atherosclerosis and degenerative disc disease (DDD) or LBP. They identified 179 relevant studies and of those 25 papers were included.

Conclusion #1: Post-mortem studies showed an association between atherosclerosis in the aorta and DDD.

(So DDD is NOT just related to ‘old age’, perhaps by controlling atherosclerosis through proper nutrition and exercise, we can influence DDD!)

Conclusion #2: Post-mortem studies also showed a strong association between occluded lumbar arteries and a life-time of LBP.

(Sadly, only when the patients had passed away, it is realized their chronic LBP was likely due to vascular issues and NOT mechanical or related to psychosocial issues!)

Conclusion #3: Epidemiological studies showed that smoking and high serum cholesterol levels were the most consistent associations with DDD and LBP.

(And all this time we dwell on the abdominal strength of a patients with a pot belly and LBP, when we should tell them to stop smoking and avoid eating ‘fast foods’, eat 5 servings of fresh fruits and vegetables, consume Omega 3s in fish oil and most importantly, EXERCISE …
as it is the best way to reduce your cholesterol, high blood pressure and back pain!) [Originally posted August 17th, 2009 on www.aptei.com]

Cervical Kinaesthesia…a Must to Address!
Reference: Revel et al 1994 Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: A randomized controlled study. Archives of Physical Medicine and Rehabilitation. (75);895-899 Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med. 2003 Jan;35(1):36-43.

Following an acute ankle injury (e.g. an inversion sprain), it is common sense that ankle proprioception is reduced and that Physical Therapy management must include balance and proprioceptive retraining. Following ankle injuries, patients are frequently put on wobble boards, uneven surfaces with eyes open or closed etc… in order to retrain proprioception. It is well known that if ankle proprioception is not addressed, recovery may be delayed and the risk of recurrence of another ankle injury may increase.

Does it not make sense to evaluate and ‘treat’ kinaesthesia / proprioception following cervical injuries (e.g. following an MVA)? Is proprioception of the neck not as important as proprioception of the ankle?
One simple method of evaluating cervical kinaesthesia in a patient with a whiplash associated disorder is by asking the patient:
1. Find the neutral position for your head is sitting,
2. Now close your eyes and VERY slowly turn to the left or right (as far as you can comfortably go),
3. Keep the eyes closed and return to the ‘neutral’ position again,
4. Once you believe you have reached ‘neutral’, open the eyes.

The Physical Therapist notes for two things:
1. A subtle ‘cog wheeling’ effect during the exercise… instead of a smooth motion,
2. Inaccuracy at finding the ‘neutral’ again…either over or under-shooting.

Treatment options:
1. The same exercise as above! Repeat 5 times and perform 3-4 times per day,
2. Close the eyes and SLOWLY draw a figure 8 with the nose.

Note: By closing the eyes, greater dependence is placed on the mechanoreceptors in the cervical spine soft-tissues. This exercise will inevitably improve an individual’s awareness of where their head is in space…which is pretty important! [Originally posted August 17th, 2009 on www.aptei.com]

Therapeutic Taping

Cervical Headaches - “Differential Diagnosis, Muscular Retraining & Mobilizations”

Cervical (Neural Mechanosensitivity) - “Mobilizations, Thoracic Manipulation & Muscular Retraining”

Please contact Jason at the clinic with any questions regarding the course (807) 344-5242. Registration can be completed online at www.aptei.com