Shades of grey, the challenge of grumbling CES in older adults with lumbar stenosis.

(Comer, Finucane, Mercer, & Greenhalgh, 2019)

Aims: This paper explores the challenges and evidence gaps relating to CES in older adults with LSS.

Methods: Professional issue : author’s point of view.

Results: Lumbar Spinal Stenosis (LSS) can evolve into CES with degenerative changes increasing the compression phenomenon. The symptoms can be “grumbling” and fluctuate according to position and movements. Symptoms can be under-reported as considered “a normal consequence of ageing” Differential diagnosis should be based on careful questioning, consideration of timeframes, and correlation between onset of signs and symptoms that might indicate early or impending CES.

If new or progressing CSE symptoms over few hours or days or weeks refer for urgent MRI.

If gradual progression over months request routing imaging unless other cause explains symptoms if so, provide “safety net” card and advices.

Limitations: author’s opinion.

In Practice: Differential diagnosis should be based on careful questioning, consideration of timeframes, and correlation between onset of signs and symptoms that might indicate early or impending CES. Give card, explain to patients that are at risk of CES the monitoring.

Comer, C., Finucane, L., Mercer, C., & Greenhalgh, S. (2019). SHADES of grey – The challenge of ‘grumbling’ cauda equina symptoms in older adults with lumbar spinal stenosis. Musculoskeletal Science and Practice, (August), 102049.

Opening clinical encounters in an adult MSK setting.

(Chester, Robinson, & Roberts, 2014)

Aim: This study aims to identify the phrasing preferred by physiotherapists when opening clinical encounters in an adult musculoskeletal outpatient setting.

Methods: Cross-sectional observational study (Audio record of 15 clinicians’ interaction with 42 LBP patients in first and follow up appointments) + an electronic survey with ranking top five and or add their favourite.

Results: Clinicians seems to favour open questions. In the present study, physiotherapists favoured the question: “Do you just want to tell me a little bit about [your problem presentation] first of all?” which is a problem-focused symptom query and is both a question and an invitation.

Limitations: Small & selected sample, low response-rate, verbal communication only.

In practice: Use an open question to give opportunity to express what is important for themselves. Use “first of all” to express that discussion can go further. Mention a topic to gather information with a focus whilst allowing expression.

Think about pré-Key-Question too: Greetings, introduction of name and role, ask for preferred name, explain what will come, and general (social) questions : finding office, weather etc …

Chester, E. C., Robinson, N. C., & Roberts, L. C. (2014). Opening clinical encounters in an adult musculoskeletal setting. Manual Therapy, 19(4), 306–310.

Effect of neurodynamic mobilization on fluid dispersion in median nerve at the level of carpal tunnel: a cadaveric study.

(Boudier-Revéret et al., 2017)

Aims: To evaluate the effect of neurodynamics mobilization (NDM) on an artificially induced œdema in the median nerve at the level of the carpal tunnel in unembalmed cadavers and to assess whether NDM tensioning techniques (TT) and NDM sliding techniques (SLT) induce similar effects on intraneural fluid dispersion.

Methods: Seven cadavers. Transverse carpal ligament and forearm fascia incised. Blue dye injected under the median epineurium. Dye spread measured with digital calliper at baseline, after spread stabilized 5 min of tensioner/glider. Sutures opened to measure spread. First one technique, then sutures tightened and then the other technique performed for 5 min (if started with slider, then tensioner and the other way around). Both limbs.

Results: Tensioners and sliders provided significant increase of longitudinal spread (compared to when the spread was stabilized). Not significant difference between sliders and tensioners related to the amount/length of spread. Most spread after first session.

Not any significant difference between limbs.

Limitations: Cadaveric study so limited when generalising to live subjects / The dissection to allow the fluid to be injected alters the carpal tunnel anatomy and carpal tunnel pressure may have reduced / The injection does not precisely replicate physiological oedema / No control group.

In practice: Both ND techniques seem to help spread of œdema intraneural.

Boudier-Revéret, M., Gilbert, K. K., Allégue, D. R., Moussadyk, M., Brismée, J. M., Sizer, P. S., … Sobczak, S. (2017). Effect of neurodynamic mobilization on fluid dispersion in median nerve at the level of the carpal tunnel: A cadaveric study. Musculoskeletal Science and Practice, 31, 45–51.

Patient expectations of benefit from interventions for neck pain and resulting influence on outcomes.

(Bishop, Mintken, Bialosky, & Cleland, 2013)

Aims: To (1) examine patients’ general expectations for treatment by physical therapists and specific expectations for common interventions in patients with neck pain, and (2) to assess the extent to which the patients’ general and specific expectations for treatment, particularly spinal manipulation, affect clinical outcomes.

Methods: Retrospective cohort. 140 patients with neck pain, were asked for expectations. Randomly allocated to 2 groups: stretching / strengthening, vs manip / mob / stretching / strengthening. Analysis of relationship between satisfaction of expectation and outcomes at 1 and 6 months calculated.

Results: 137 at 1 month and 114 patients at 6 months. Better expectations led to better outcomes. At 1 and 6 months patients who received what expected did better than those who did not.

Limitations: Statistical analysis / 6 month = is it still the result of 2 sessions of manip? / dropouts / voluntary basis

In practice: Patients with expectations of relief do better. Patient who’s expectations are met tend to do better than the opposite.

Bishop, M. D., Mintken, P., Bialosky, J. E., & Cleland, J. A. (2013). Patient Expectations of Benefit From Interventions for Neck Pain and Resulting Influence on Outcomes. Journal of Orthopaedic & Sports Physical Therapy, 43(7), 457–465.

Individual Expectation: An overlooked, but pertinent factor in the treatment of individuals experiencing MKS pain.

(Bialosky, Bishop, & Cleland, 2010)

Aims: The purpose of this clinical perspective is to highlight the potential role of expectation in the clinical outcomes associated with the rehabilitation of individuals experiencing musculoskeletal pain.

Methods: Perspective = Expert opinion

Results: Expectations are associated with clinical outcomes, satisfaction, and influence of behaviour. 4 levels: Predictive = What he believes will happen, Ideal = what he wants, Normative = what should occur, or unformed = lack of preconceived notion. The current definition of expectation is highly variable. Expectation appears to be influenced by a number of individual factors; however, the influence of these factors may be specific to the situation and individual. Currently, the measurement of expectation is not standardized, and failure to fully clarify expectation may lead to confusion regarding measurement methods and numerous measurement approaches. Variability in the measurement of expectation has implications for the generalization of results among studies and from research to clinical practice, as self- report of expectation differs by the measurement tool used.

Despite these inconsistencies, an association exists between predicted expectations and outcomes related to musculoskeletal pain regardless of the method of measurement.

Studies suggest an association between predicted expectation and outcomes related to MSK pain conditions. Furthermore, they suggest a prognostic value for expectation in the treatment of individuals experiencing MSK pain that may surpass the type of treatment provided. Specifically, the exact intervention may not be as important as the individual expectation for the intervention.

Outcomes, therefore, may not depend wholly upon the type of treatment provided, but also are influenced by individual attitudes or beliefs regarding the treatment. Manipulation of expectation, as is common in the placebo literature, suggests a causative effect of expectation on pain-related outcomes that may translate to the clinical management of MSK pain conditions.

Limitations: Review

In practice: Considering expectations (Predictive and normative and not ideal) may help to choose among treatments with similar level of evidence to maximize effects.

Bialosky, J. E., Bishop, M. D., & Cleland, J. A. (2010). Individual Expectation: An Overlooked, but Pertinent, Factor in the Treatment of Individuals Experiencing Musculoskeletal Pain. Physical Therapy, 90(9), 1345–1355.

Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus

(Beaufils et al., 2017)

Aims: To provide a reference frame for the management of DMLs, based both on scientific literature and balanced expert opinion.

Methods: Formal consensus process (HAS). Steering group: 15 experts (Surgeons, 1 physio, 1 statistician). Frame + Extensive review. Quality assessed with Cochrane methodology.

Altogether, the complete consensus initiative involved 84 clinicians from 22 European countries. The question–answer sets were related to the four following subjects: the background of degenerative meniscus lesions (A), their imaging (B) and management (C), as well as a diagnostic and therapeutic algorithm (D).

Results: See Leaflet or below.

Limitations: European countries only.

In practice: Framework for decision when operation is needed in degenerative meniscus see below.

Beaufils, P., Becker, · R, Kopf, · S, Englund, · M, Verdonk, · R, Ollivier, · M, & Seil, · R. (2017). Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus. Knee Surgery, Sports Traumatology, Arthroscopy, 25, 335–346.

Full document (Open access) :

The effectiveness of neural mobilization (NM) for neuromusculoskeletal conditions: a SR with MA

(Basson et al., 2017)

Aims: To determine the efficacy of neural mobilization (NM) for musculoskeletal conditions with a neuropathic component.

Methods: SR with MA. Included if MSK issue with ND component, assessing NM efficacy assessing pain, disability, and function. Studies’ risk of bias assessed, 2 reviewers …

Results: 40 studies with 1759 participants. NM is effective in the management of nerve-related low back pain, nerve-related neck and arm pain, and plantar heel pain and tarsal tunnel syndrome. NM seems not to have a positive effect on outcomes measured in the management of carpal tunnel syndrome. Positive neurophysiological effects were present in groups that received NM.

Bias: Limited evidence, small study samples most of the time + heterogeneity of included studies.

In Practice: NM helpful to improve pain, function & disability in patient with MSK conditions with ND involvement. It also reduces intraneural œdema.

Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., & Mudzi, W. (2017). The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 47(9), 593–615.

Gluteal muscle activity and Patello Femoral Pain (PFP) syndrome: A SR.

(Barton, Lack, Malliaras, & Morrissey, 2013)

Aims: Synthetize EMG findings in order to better understand the role of gluteal muscle activity in the aetiology, presentation and management of PFPS

Methods: SR 2 independent assessors, Downs and Black Quality Index25 and the PFPS diagnosis checklist. 10 studies included.

Results: Current research evaluating the association of gluteal muscle activity with PFPS is limited by an absence of prospective research. Moderate-to-strong evidence indicates that GMed muscle activity is delayed and of shorter duration during stair ascent and descent in individuals with PFPS. Additionally, limited evidence indicates that GMed muscle activity is delayed and of shorter duration during running, and GMax muscle activity is increased during stair descent.

Limitations: Quality too used, no blinding of assessors, low quality of included studies.

In practice: Assessing, targeting interventions toward hip muscles may have an impact on PFPS? However, the effects and effectiveness of such interventions is yet unknown.

Barton, C. J., Lack, S., Malliaras, P., & Morrissey, D. (2013). Gluteal muscle activity and patellofemoral pain syndrome: A systematic review. British Journal of Sports Medicine, 47(4), 207–214.

The mechanisms of Manual Therapy (MT) in the treatment of Musculoskeletal (MSK) pain: A comprehensive model.

The mechanisms of MT in the treatment of MSK pain: A comprehensive model

(Bialosky, Bishop, Price, Robinson, & George, 2009)

Aims: Present a comprehensive model of potential individual mechanisms of MT that the current literature suggests as pertinent and the potential interaction between these individual mechanisms.

Methods: Expert Literature review.

Results: The literature suggests:

Biomechanical effect of MT; however, lasting structural changes have not been identified, clinicians are unable to reliably identify areas requiring MT, the forces associated with MT are not specific to a given location and vary between clinicians, choice of technique does not seem to affect outcomes, and sign and symptom responses occur in areas separate from the region of application. The effectiveness of MT despite the inconsistencies associated with a purported biomechanical mechanism suggests that additional mechanisms may be pertinent.

Neurophysiological mechanisms:

-Peripheral mechanisms: Studies suggest a potential mechanism of action of MT on MSK pain potentially mediated by the peripheral nervous system through cytokines, b-endorphin, anandamide, N-palmitoy- lethanolamide, serotonin, endogenous cannabinoids and substance P levels.

-Spinal mechanisms: MT may exert an effect on the spinal cord. MT may decrease activation of the dorsal horn of the spinal cord (shown in rats). MT is associated with hypoalgesia, afferent discharge, motoneuron pool activity, and changes in muscle activity all of which may indirectly implicate a spinal cord mediated effect.

-Supraspinal mechanisms: Literature suggests the influence of specific supraspinal structures such as the anterior cingular cortex (ACC), amygdala, periaqueductal gray (PAG), and rostral ventromedial medulla (RVM) in response to pain. A trend was noted towards decreased activation of the supraspinal regions responsible for central pain processing. The model accounts for direct measures of supraspinal activity along with associated responses such as autonomic responses and opiod responses to indirectly imply a supraspinal mechanism.

Biases: Expert’s review = low level of evidence.

In practice: This model suggests a mechanical stimulus initiates a number of potential neurophysiological effects which produce the clinical outcomes associated with MT in the treatment of musculoskeletal pain.

Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy, 14(5), 531–538.