Monthly Archives: June 2016

Ahh, Good Ol’ Tendinopathy

The following is a guest post from a good friend and awesome clinician, Joseph Paul Coviello. Check it out and let me know what you think!

Ahh, good ol’ tendinopathy.

You know, that delightful nagging pain that you keep ignoring until you can’t turn a doorknob?

Luckily, within the last two decades some intelligent people figured out that this is not just an inflammatory irritation, but actually a degeneration of the tendon itself.  Findings like these are wonderful for us researchers and clinicians alike so we can re-direct our creative minds toward interventions that will better treat this type of pathology.

Enter Thomas L. Sevier and W. Stegink-Jansen.  These ingenious folk did a little researching for us comparing ASTYM vs. eccentric exercise for lateral epicondylitis. As soon as I see an article advocating for the use of manual therapy (yay!) vs. me counting exercises repetitions (boo) (sorry, I mean lets make people better using the best evidence), I read the whole thing through and through.

Back to business… There is some encouraging literature out there advocating for the use of eccentric exercise for lateral epicondylitis, but the protocols are varied and an optimal program has yet to be established.  Eccentric exercise seems to have a reorganizational effect on the collagen fibers of the tendon which may be why it is so effective.  Wait, doesn’t ASTYM do something like that to?

Indeed my friends.

ASTYM claims to be a novel, systematic, treatment approach that is separate from the instrument assisted soft tissue mobilization category despite utilizing an instrument to elicit a response from soft tissues. The aim of ASTYM treatment is to apply a mechanical shear load to a specific dysfunctional tissue with the effect of stimulating fibroblast and fibronectin production, two chemicals thought to be essential to normal collagen organization.

In this 4 week trial, 1 group of subjects received a therapeutic exercise program consisting of 6 upper extremity exercises performed 2 times per week for 2 pain free sets of 15 reps (focus on the eccentric). The other group received an ASTYM protocol 2x per week that included the ASTYM treatment in conjunction with the same program of stretching and eccentric exercise as the therapeutic exercise group. 40.9% of the eccentric exercise group had a resolution of symptoms at the end of 4 weeks while 78.3% of the ASTYM group saw a complete resolution.  I think we can call that a success. They even took the recalcitrant subjects from the eccentric exercise group and gave them the ASTYM treatment after the initial trial.  As expected, they had wonderfully successful results. I’ll leave out the specific outcome measures as a little cliff hanger so you can all have the joy of reading this article.

In regards to using similar treatments to address tendinopathy, a controlled laboratory study on mice looked into the effects of instrument assisted cross friction massage (IACFM) on rat subjects.  In the report, the researchers induced a controlled MCL injury and then provided IAFCM treatment to the healing ligament.  The findings were that the treatment may have induced positive effects on collagen formation and organization.  While this was a ligamentous structure as opposed to a tendon, some of these effects could potentially carry over to other collagenous structures.

Moral of the story, ASTYM may help you get better results with your patient’s suffering from lateral epicondylitis. For those of you saying, “but Paulie I don’t want to spend the money on this ASTYM tool,” well truthfully it’s a beautifully sculpted piece of plastic used as part of a systematic approach.  Becoming an ASTYM provider would obviously be the optimal situation, but unless they’ve blessed this tool with water from the depths of the dead sea, I think you can use your clinical judgement and find something similar that will do the job.

Lets make people better,

Joseph Paul Coviello, DPT

I would like to thank Dr. Thomas Sevier for speaking with us regarding his product and informing us about the evidence backing this treatment approach. Be sure to check them out at ASTYM.com for more information.

 

About the Author:

Joseph Paul Coviello, is a recent graduate of the Ithaca College Doctor of Physical Therapy Program. Paul competed as a D-III football player during his undergraduate career, but realized after that his true athletic passion was in bodybuilding and the strength sports. Despite his personal love for sports, Paul enjoys treating people from all walks of life, stating with his persistent half-serious tone, “Let’s make PEOPLE better!” Paul’s clinical and research based interests revolve around manual and manipulative therapy as well as biomechanics. Currently Paul is involved a few research projects regarding the use of IASTM, cervical mobilization, and lower extremity biomechanics. Stay tuned to share the love of PT with this young clinician and researcher.

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Clinical Prediction Rule: Hip Osteoarthritis

A patient walks into your clinic complaining of hip pain. The referral from the orthopedist says “hip OA,” but how can you be sure that the symptoms that your patient is complaining of are truly arthritic in nature? With the help of clinical prediction rules (CPRs), you can help improve your ability to accurately diagnose the patient, which will allow for you to improve your treatment outcomes.

In 2008, Sutlive et al published a report regarding the diagnoses hip osteoarthritis in patients with unilateral hip pain. Using diagnostic evidence of osteoarthritis on X-ray as the reference standard, five predictors were found to help in the diagnosis of hip osteoarthritis:

  • Self-reported squatting as an aggravating factor
  • Scour test with adduction causing groin or lateral pain
  • Active hip flexion causing lateral pain
  • Active hip extension causing hip pain
  • Passive hip internal rotation less than or equal to 25°

If 4/5 of the above predictors were present, a positive likelihood ratio of 24.3 was found (a post test probability of 91%). What’s great about this CPR is how quick it is to run through the five predictors, and once you do, you can provide your patient with a more evidence based clinical diagnosis.

So now that you feel confident with your diagnosis, how do you treat your patient? I personally tend to utilize a lot of joint manipulation/mobilization techniques with these patients, and the research supports this type of plan of care.  Hoeksma et al published a paper in 2004 comparing manual therapy to exercise in the treatment of patients with hip osteoarthritis. The findings showed a significantly higher success rate after 5 weeks of treatment in the manual therapy group compared to the exercise group. Now this does not mean that you should completely neglect the use of therapeutic exercises when treating patients with hip OA, but more importantly, should reinforce the significance of using manual therapy with this population (aka if you are not doing hip mobilizations for your patients, you should!).

Both of these articles are great ways to not only improve your own clinical skills, but to educate your patient as well. If you are able to confidently tell your patient what you believe is causing their symptoms, and more importantly that you can improve them, their trust in you as their physical therapist will grow exponentially.

Joint Position Error: Talk About a Pain in the Neck…Literally

Nearly two thirds of the population will experience neck pain at some point in their life, and for some of those people, the symptoms will become chronic (in fact, Côté et al.  found the prevalence of persistent neck pain to be over 30%). One impairment from this ongoing neck pain that at times is overlooked involves proprioception, also known as joint positioning sense (where is my head in space). A recent systematic review and meta-anyalysis by Stanton et al.. looked at the current evidence regarding proprioceptive dysfunctions in people with chronic neck pain, and the following conclusion was made:

  • Individuals with chronic neck pain performed significantly worse in head-to-neutral repositioning tests (the subject’s head was passively brought into various positions, and a measure was taken between the initial neutral position and the final neutral position after the completion of the movement)

So why do we care? Nearly 80% of your cervical stabilization comes through the surrounding musculature, and previous studies have shown impairments in deep neck flexor muscle activation in individuals with neck pain. What does this mean? People who have persistent neck pain are unable to engage the important stabilizing muscles which helps keep their head on their shoulders. Basically your head is a 12 pound bowling ball stacked on top of a bunch of building blocks, so having a wobbly head would be expected if you are having trouble activating the necessary muscle groups.

So what do we do about it? Along with incorporating deep neck flexor exercises into your treatment plan, you may want to look into adding proprioceptive training for the cervical spine as well. But how do we know if we should be implementing these types of exercises? One objective test, the cervical joint position error test, will allow for you to establish baseline figures for your patient’s performance, and be able to track progress throughout therapy (check out this link for more information about how to conduct this test: Cervical Joint Position Error Test). While you can simply tape a laser pointer to the brim of a baseball hat to conduct the test/incorporate exercises, you can also look into purchasing a laser headlamp like the following: SenMoCOR Laser Headlamp.

Finally, why is it important to add this type of training? A 2007 study by Jull et al. examined the effects of proprioceptive training and craniocervical flexion training on cervical joint position error (JPE) in people with persistent neck pain. While both groups showed improvements in JPE, the proprioceptive group showed more significant changes. Why not add another tool to your toolbox to get your patients better? So next time a patient walks into your clinic with neck pain, take a look at their cervical proprioception, and hopefully their rehab won’t be a pain in your neck.

Clinical Prediction Rules: Cervical Spine

Your patient walks into your clinic with neck pain that radiates into their arm…now what? How do you know what it is, what you should do, and if they are going to respond well to conservative therapy? With the help of several research studies we thankfully have the answer to some of these questions.

Wainner et al published a study investigating the reliability and accuracy of different examination procedures for cervical radiculopathy. In the study he found four key features to help rule in the diagnosis of a cervical radiculopathy, with a positive likelihood ratio of over 30 if patients were positive on the rule. These four findings were the following:

  • Positive Upper Limb Tension Test A
  • Positive Spurling A Test
  • Positive Cervical Distraction Test
  • Cervical Rotation <60 degrees (to the involved side)

By using the above clinical prediction rule, you can provide a more accurate diagnosis for your patient, as well as better direct your interventions at addressing the underlying cause of the patient’s symptoms.

Now that we know what it is, how do we fix it? Today we are going to focus on one specific intervention technique; cervical traction. In 2009, Raney et al developed a clinical prediction rule to determine whether or not a patient was more likely to benefit from traction as an intervention:

  • >55 years of age
  • Peripheralization of symptoms with C4-C7 mobility testing
  • Positive Cervical Distraction Test
  • Positive Upper Limb Tension Test A
  • Positive Shoulder Abduction Test

If your patient has 4 out of 5 of the above predictors there is nearly a 95% likelihood that they would benefit from cervical traction as an intervention technique.

Finally, is there any way to know whether or not your patient will short-term success with therapy? Cleland et al found that there were four factors that indicated that the patient will have a positive outcome within 28 days:

  • <54 years old
  • Dominant arm not affected
  • Looking down does not increase symptoms
  • Multimodal treatment approach including manual therapy, cervical traction, and deep neck flexor muscle strengthening for at least 50% of visits

When all four variables were present, Cleland found the probability of success was nearly 90%. Not a bad statistic to provide your patient with to motivate them to come to physical therapy.

By using the articles and research above, you can provide better quality care for your patients that complain of neck and arm pain. Stay tuned for more posts about how we can get these patients better faster!