Category: Papers (Eng)

(Finucane, Greenhalgh, & Selfe, 2017)

Aim: Discuss red flags.

Methods: Author’s insight

Limitations: Low level evidence, author’s opinion.

In practice: Patients with a past history of cancer that has an affinity to bone such as lung, prostate and breast cancer, who present with new symptoms that persist should be thoroughly evaluated with a high suspicion of MBD. A safety netting process of closely observing patients at risk over time is reasonable and an important consideration in effectively managing these potentially serious cases. Using knowledge of a patient’s risk of developing MBD and current red flags may help to raise a clinician’s index of suspicion and result in timely investigation and management of the patient.

Finucane, L., Greenhalgh, S., & Selfe, J. (2017, July 10). Which red flags aid the early detection of metastatic bone disease in back pain? Physiotherapy Practice and Research. https://doi.org/10.3233/PPR-170095

(Finucane, 2013)

Aims: This case reports highlights the importance of early diagnosis of metastatic disease, and identifies symptoms that may help to raise the index of suspicion for the clinician.

Methods: Case report

Results: Patient presentation :

Band like pain / Abdominal pain / Numbness non dermatomal / Vague leg pain / Night waking pain / Intermittent pain / Agg by walking sitting standing, eased by supine lying / Tramadol relieved / no CES symptoms. History of breast K, weight loss 3 kg in 3 months, failed conservative treatment. Previous episodes of LBP but not same sy / no resting pain / limited spinal extension and flexion reproducing LBP but no other / SLR=50° bilaterally and reproduced back pain. Femoral nerve tension test was negative and sensation, power and reflex testing was normal. Babinski and clonus tests were negative

Limitations: Low level of evidence

In Practice: Red Flags = History of cancer, failed conservative treatment, weight loss, night pain, multi-segment pain, band-like pain and odd-funny feelings in legs. Cancers that produce metastasis BLP (LBP) Breast Lung Prostate. Pain can be intermittent and respond to NSAIDs then progress to become worse and unremitting. The pain can radiate into the abdomen or chest and is often described as sharp, shooting deep and band-like. Pain symptoms can be aggravated by lying supine and there is often night pain. The patient may complain of bilateral leg pain. Funny, strange, odd vague feelings in leg can exist.

Finucane, L. (2013). Metastatic disease masquerading as mechanical low back pain; atypical symptoms which may raise suspicion. Manual Therapy, 18(6), 624–627. https://doi.org/10.1016/j.math.2013.02.009

(Flynn, Childs, & Fritz, 2006)

Aim: To assess whether audible pop during manips are related to/affects outcome.

Methods: 70 participants primary complaint of LBP. 13 physios 5 sessions 4 weeks. Outcome measures: NPRS, Oswestry and Lx F° with inclinometer at baseline, 1 week and 4 weeks. In the two first sessions they received HVLA-manips. Manips to the symptomatic side, if no pop/cavitation heard, 4 attempts max: two on each side. + ROM exercises. 3-4 x10 rep/daily on the days they did not attend physio. Pain during PA + Stiffness subjective “scale”.

Results: 84 % of the patients had a pop, 16 % had no pop. No sign diff in ODDS ratio between poppers and no-poppers in pain, disability and lumbar ROM at any of the times points (baseline, 1 week, 4 weeks).

Limitations: More than one manip if no pop thus difference in treatment dose / Only one type of manipulation tested. / Other interventions may influence results (Cofounding factors)

In Practice: Perceived audible pop may not relate to improved outcomes from HVT manip for P with non-radicular LBP at immediate or long-term follow-up.

Flynn, T. W., Childs, J. D., & Fritz, J. M. (2006). The audible pop from high-velocity thrust manipulation and outcome in individuals with low back pain. In Journal of Manipulative and Physiological Therapeutics (Vol. 29, pp. 40–45). https://doi.org/10.1016/j.jmpt.2005.11.005

(Weppler & Magnusson, 2010)

Aims: Understand literature regarding stretching effects.

Methods: Author’s review

Results: “Muscle’s extensibility” concept is conflicting, discrepancies in the use of term “length or extensibility”, and measures of those parameters. Mechanical theories seem not supported by literature. The most probable theory is currently an increase in sensation / tolerance by the person through the stretching. All studies are short term 3 to 8 weeks; no studies above. One study may contradict findings but uses a high dose regimen: 20 min stretching program for one muscle group in one limb, 5 days a week over 6 weeks, may shift torque/angle curve to the right with effects not completely reversed after 30 days. Still question about the relevance of the stretching, the impact of “short / tight” muscles on function, what is optimal extensibility? etc …

Limitations: Author’s point of view, low level of evidence, not standardized review.

In Practice: Insight on what are we trying to achieve when stretching? Why, how etc. We can improve person’s sensation at least in short term, one session brings immediate results, 3 to 8 weeks too. Maybe not helpful to increase muscle length.

Weppler, C. H., & Magnusson, S. P. (2010). Increasing Muscle Extensibility: A Matter of Increasing Length or Modifying Sensation? Physical Therapy, 90(3), 438–449. https://doi.org/10.2522/ptj.20090012

(Pentelka, Hebron, Shapleski, & Goldshtein, 2012)

Aims: To investigate the effect of the number of sets (up to 5) and different durations (30 vs. 60 s) of PA mobilisations on pressure pain thresholds (PPTs) at different sites.

Method: Single blinded, randomized, repeated measures crossover study. ≠ Days and randomized order. 19 Healthy physio students. 5 sets of large amplitude oscillatory mobilisation L4 1 Hz 242N measured by metronome & force plates. Duration was either 30 or 60 sec. 6 measures of PPT, before and after each set (3 times at 4 sites).

Results: No significant effect of duration on PPT across all sites combined (but insignificant trend towards longer duration locally). Significantly higher effect at local than remote location. Maximal increase with significant ≠ with 1^st set at the 4^th set. Smaller increase until last 5^th set (for 30sec) or slightly down (for 60sec).

Limitations: Underpowered, healthy participants, no control group and sample biased towards physiotherapy so blinding may be compromised.

In Practice: 4 sets of mobilisations may provide the higher hypoalgesic effect. We cannot conclude on duration as underpowered: so insignificant but with trend towards longer duration. Local effect superior to remote.

Pentelka, L., Hebron, C., Shapleski, R., & Goldshtein, I. (2012). The effect of increasing sets (within one treatment session) and different set durations (between treatment sessions) of lumbar spine posteroanterior mobilisations on pressure pain thresholds. Manual Therapy, 17(6), 526–530. https://doi.org/10.1016/j.math.2012.05.009

(Hoch & McKeon, 2011)

Aims: To examine the bilateral symmetry of the WBLT in healthy adults and elucidate the individual influences of age, height, mass, leg length, foot length, and posterior displacement of the ankle subtalar-joint complex on WBLT performance.

Methods: 35 healthy adults. 6 trials on each limb, 3 last analysed. Progress every cm until lifting of heel, then smaller increments. Measurement of post displacement of subtalar joint and other individual variations.

Results: Strong intra tester-reliability of the WBLT. No significant relationships between WBLT performance and age, height, mass, left leg length, left foot length, or left posterior talar displacement. Majority of healthy adults exhibited lunge distance asymmetries on the WBLT of 1.5 cm or less (68% of the distribution); however, some individuals demonstrated up to approximately 3 cm bilateral differences. Norm is = 12cm +/- 2,8cm.

Limitations: Healthy adults only. Only intra-tester reliability. Small sample.

In practice: Norm for WBLT is 12cm +/-2,8cm. Normal ≠ between legs 1,5cm. Good intra-tester reliability.

Hoch, M. C., & McKeon, P. O. (2011). Normative range of weight-bearing lunge test performance asymmetry in healthy adults. Manual Therapy, 16(5), 516–519. https://doi.org/10.1016/j.math.2011.02.012

(Powden, Hoch, & Hoch, 2015)

Aims: To collect, critically appraise, and synthesize the published evidence describing the inter-clinician reliability, intra-clinician reliability, and responsiveness of the WBLT to measure dorsiflexion ROM

Methods: SR, 2 databases, 2 researchers, Inclusion primary aim to examine reliability, no restrictions on population or measurement method. English only. QUAREL for quality.

Results: Strong evidence of good inter and intra-tester reliability of WBLT for all measurements with bests results for tape distance measurement. MIDC = 1,6cm inter clinician or 1,9cm for intra clinician.

Limitations: English only, differences in quality. 9-12 studies included.

In Practice: MIDC values from the included studies inter-clinician changes of 4.6° or 1.6 cm and intra-clinician changes of 4.7° or 1.9 cm should be used.

Powden, C. J., Hoch, J. M., & Hoch, M. C. (2015). Reliability and minimal detectable change of the weight-bearing lunge test: A systematic review. Manual Therapy, 20(4), 524–532. https://doi.org/10.1016/j.math.2015.01.004

(Finnerup et al., 2016)

Aims: Evaluate and update grading system for labelling of nociceptive pain.

Methods: Expert meeting consensus after SR.

Results:

Limitations: Expert consensus.

In practice: Follow flowchart to know the level of confidence regarding neuropathic pain. Definite neuropathic pain requires imaging, biopsy or other medical test.

Finnerup, N. B., Haroutounian, S., Kamerman, P., Baron, R., Bennett, D. L. H., Bouhassira, D., … Jensen, T. S. (2016). Neuropathic pain: An updated grading system for research and clinical practice. Pain, 157(8), 1. https://doi.org/10.1097/j.pain.0000000000000492

(Da Silva et al., 2015)

Aim: To analyse if neural mobilisation can change the expression of myelin protein zero (MPZ) and Nerve growth factor (NGF) in the sciatic nerve of adult rats after chronic constrictive nerve injury Reminder: (MPZ is important for myelin formation and may play role in adult axon regeneration and NGF has been found to stimulate nerve regeneration)

Method: Male rats, and 4 groups: 1) Chronic constrictive nerve injury with neural mobilisation group (CCI-NM) 2) Chronic constrictive nerve injury without neural mobilisation (CCI) 3) Sham surgery group 4) Control group The chronic constrictive nerve injury was applied by dissecting to expose the sciatic nerve and 4 ligatures were used to constrict the nerve before the incision was closed. The NM technique in slumped position with ankle flex/ex was applied after 14 days. The technique was applied for 2 mins, with 25 sec pause, for 10 mins and performed on alternate days for a total of 10 sessions. The sciatic nerves were then dissected and analysed by transmission electron microscopy and western blot.

Results: Significant increase in MPZ and NGF found in CCI-NM group suggesting that neural mobilisation may improve axonal regeneration after chronic constrictive nerve injury.

Limitations: Rat study. The artificial application of nerve injury (by application of ligatures) may not represent the type of nerve injury see in human subjects. Dosage between rats / humans for same effect is unknown.

Practice: Tensioners with oscillations may help nerve regeneration by promoting NGF MPZ transcription.

Da Silva, J. T., Dos Santos, F. M., Giardini, A. C., De Oliveira Martins, D., De Oliveira, M. E., Ciena, A. P., … Chacur, M. (2015). Neural mobilization promotes nerve regeneration by nerve growth factor and myelin protein zero increased after sciatic nerve injury. Growth Factors, 33(1), 8–13. https://doi.org/10.3109/08977194.2014.953630