Category Archives: Spine

Red Lights or Blue Lights: What Color Do You See?

Can you think of a time when your thoughts influenced how you felt about a situation? For example; have you ever heard a sound at night while you’ve been home alone? In a matter of seconds you can go from being relaxed on the couch to having a mild panic attack thinking that there is an intruder in the house with you. Did you actually see something? No, but your brain processed that information as potentially dangerous and kick started your body’s “fight or flight” response just in case.

This hypothetical situation can be applied to a variety of scenarios, including our perceptions of pain. In fact, Mosely and Arntz published a study in 2007 looking at how the context in which a noxious stimulus is delivered can alter the way people perceive pain. During the study, a cold metal rod (-20 degrees Celsius) was applied very briefly to the subject’s hand while they received various contextual information about the stimulus. This information was in the form of a light: red or blue. The subjects were told that the red light meant “hot” and the blue light stood for “cold.” The subjects were then asked to rate their pain intensity, pain unpleasantness, and the temperature that they perceived (on a 0-10 scale, with 0 indicating both no pain/unpleasantness, as well as being extreme cold).

Now the study was a little more complicated than just looking at the color light; the subjects were given different scenarios in which they rated their perception of the stimulus. For example, they either were provided a warning as to the color of the light versus no warning, or were allowed to look at the application of the rod versus being blinded to it (see the image below for a representation of the different scenarios).

 

blue light study

So what did they find? Well long story short, the subjects rated their pain intensity and unpleasantness as higher when looking at the red light versus the blue. In case you forgot…THE STIMULUS NEVER CHANGED! The rod stayed the same temperature; all that changed was the color of the light (see the graph below for the results of the study).

blue light graph

So what does this mean? Well Mosely and Arntz made the following conclusion, “the tissue damaging meaning of a noxious stimulus, warning about the stimulus and visual attention to the stimulus all affect the evoked experience.” That being said, our perceptions about an injury (whether they are accurate or not), can play a huge role in regards to our pain. This can be a game changer for us as physical therapists, as we have the opportunity to educate our patients not only about their injury, but about other factors that may be exacerbating their symptoms as well.

So what can we do about it? How many times have you had a patient tell you that they have imaging that shows they have arthritis, a torn rotator cuff, or a disc herniation? And obviously since there is evidence of these pathological tissues it must be the source of their pain, right? WRONG! One recent study published in 2015 by Nakashima et al examined the prevalence of abnormal findings on cervical spine MRIs. Over 1,200 healthy volunteers (key word, healthy, aka no symptoms) ranging in ages from 20 to 70 years were imaged. The findings? Over 85% of the subjects presented with disc bulges (even those subjects in their 20s, with over 70% of this population having evidence of some degree of bulging). Why is this information important? Well if you were a patient and you were told by a medical doctor that your MRI found degenerative changes, disc protrusions/herniations/bulges, narrowing, etc…what would you think? All of these words have such negative connotations associated with them, which may also serve as a “red light.” Could these “issues in your tissues” be causing the pain? Maybe, but we just saw how many “abnormal” findings were associated with individuals without symptoms. In fact, since the majority of the individuals presented with disc bulges wouldn’t it be “abnormal” not to have these changes…? Think about that.

Be mindful of how you talk to your patients, because the way you communicate to them may have the potential to change a few red lights to blue. For example, I love reviewing lumbar MRIs with my patients, because I feel that this can be a “make or break” point in regards to their fear of their prognosis. Often the images look like the following:

lumbar mriI choose my words very carefully at this point, and instead of pointing out the disc protrusions at L4/L5 and L5/S1 or the degenerative disc disease that they have, I may say that they have some “grey hairs” in their back (metaphorically speaking) which can be found in individuals without any symptoms at all. Now a once potentially red light may be slightly bluer. What I may highlight a little more closely would their multifidi, as you can see in the following example:

multifidi

The above image shows fatty infiltration of the lumbar multifidi; a common finding in individuals with low back pain. Now I tend to describe these changes to their multifidi in regards to hamburger meat (once again, metaphorically speaking); image on the left has the good stuff, high quality lean beef. Image on the right on the other hand, may be closer to 60/40 beef. Which would you prefer to eat? Why do I show them these muscles? If their impairments include lumbopelvic stability (not all patients with low back pain need “core” exercises though, see the following post), then we can address this through physical therapy. BLUE LIGHT! The once depressing, scary MRI now shows the potential for an improvement in their symptoms, and you may have a better adherence to your plan of care now that the patient understands more about their “tissue issue.” Remember, knowledge is power.

Check out the following statements that I’ve heard used by patients or other medical professionals, and see how they could potentially switch from a red light to a blue:

  • “I have bone on bone arthritis that the doctor said was the worst he has ever seen.”
    • Thank you for instilling fear avoidant behaviors. Educating the patient that arthritic changes are a normal part of the aging process, and that they probably have had these changes for several years. Maybe discussing some of the research behind “abnormal” imaging findings in asymptomatic individuals can drive home the point that pain does not always equal tissue damage.
  • I hurt my back 20 years ago lifting a box off of the ground, so my doctor told me never to lift anything over 10 pounds again.
    • Sounds like a red light to me. Using words like “never,” “always,” or “worst,” really stick in a patient’s mind, so try and be mindful when making suggestions or recommendations (even if it is regarding something like posture or exercise technique). This would be a perfect patient to talk about tissue healing rates, and dive into some more pain science education (ex: their tissues have healed at this point, but their nervous system may still perceive lifting as a dangerous stimuli…aka red light).
  • “That knot in your muscle is as hard as a rock and keeps coming back.”
    • So now the patient thinks of their muscles as rocks, and that there symptoms are resilient. I often have patient’s ask if things “feel tight” when I’m performing soft tissue mobilizations, and if applicable, I tell them how it is normal for certain muscle groups to be “tighter” or “stiffer” than others (ex: upper trapezius when doing myofascial work, or thoracic spine when performing joint mobilizations). While each patient is special and unique, we do not necessarily want to verbalize that their tissues are that way.
  • “I was told that since I tore my rotator cuff I’d never be able to swim again.”
    • A few things to address in this one. Once again, discussing the normal “abnormalities” found during imaging would be a good start. Also, never say never. Never. Automatically the thought of not being able to return to a sport, work, or life activities can prove to be a huge blinking red light. Now this patient may not be able to swim for hours, but talking about the benefits of addressing the potential impairments that they may have, and relating that back to their ability to achieve their goals may increase their confidence.

Each time a patient walks into your clinic, they may have a few red lights in the back of their mind. While some may be brighter than others, cumulatively they can add up, and when they do, your patient’s symptoms may go through the roof. Thankfully we have the potential to turn these lights off, and maybe switch on a few of the blue ones while we are at it.

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!

High-Velocity Thrust Manipulation: Don’t Get Addicted to the Crack

Your patient walks into the clinic complaining of low back pain, and they fit the clinical prediction rule for a lumbar manipulation. You deliver a high-velocity, low amplitude thrust manipulation…but there was no cavitation (pop). Everything about the set up felt right, but in the patient’s mind “nothing happened” because their back didn’t crack. Thankfully there is some research indicating that a cavitation is not required for success with an HVLA manipulation.

In 2006, Flynn et al examined the relationship between hearing an audible “pop” during an HVLA manipulation and symptom improvement. Over 80% of the participants cavitated during the manipulation technique, but there were no significant differences in improvement between those who popped and those who did not.

So what does this mean? Educate your patients prior to performing any manual technique, especially a thrust manipulation. I tell patients right from the beginning that you may or may not hear a “pop” during the technique, but our goal is to get a quick stretch to the joints and that the sound does not matter. Long story short, don’t get addicted to the crack.

Resources:

Flynn TW, Childs JD, Fritz JM. The audible pop from high-velocity thrust
manipulation and outcome in individuals with low back pain. J Manipulative
Physiol Ther. 2006 Jan;29(1):40-5.

Clinical Prediction Rule: Thoracic Spine Manipulation

A patient comes into your clinic complaining of neck pain…what do you do? For some patients, treating the thoracic spine may help improve their symptoms. Cleland et al published a study in 2007 in which they published a clinical prediction rule to find a subgroup of patients whom may benefit from thoracic manipulations:

  • Symptoms <30 days
  • No symptoms distal to the shoulder
  • Looking up does not aggravate symptoms
  • FABQ <12
  • Decreased thoracic kyphosis in the upper thoracic spine
  • Cervical extension range of motion <30 degrees

Cleland found that if 3 out of 6 factors were present the probability of success was nearly 86%. While this study proved to be helpful for this subgroup of patients, it was not validated. That being said, the validation study did show that patients with mechanical neck pain who received thoracic spine manipulation and exercise exhibited significantly greater improvements in disability at both the short- and long-term follow-up periods and in pain at the 1-week follow-up compared with patients who received exercise only.

So what does this mean? Take a look a the thoracic spine; if it is justified to perform a thoracic manipulation you may get your patient better faster!

Clinical Prediction Rule: Stabilization Classification

A patient walks into your clinic complaining of low back pain. You aren’t sure exercises to give them, but you think that they would benefit from “core stabilization.” Instead of using a “cookie cutter” approach to treating patients, in which everyone receives the same treatment approach, you may be able to identify those patients who would respond better to stabilization exercises by using this study by Hicks et al. In the study, the researchers identified four factors that may identify patients who would benefit from lumbopelvic stabilization exercises:

  • Positive Prone Instability Test
  • Aberrant movements present
  • Average straight leg raise >91 degrees
  • Age <40

NOTE: Instead of performing the traditional prone instability test as described in the Hicks article, I use a modified version of the test. I begin by having the patient lay prone on the examination table. Apply a posterior to anterior pressure to the lumbar spine, and make note of any pain. At this point, have the patient raise their arms off the table while applying the pressure. If pain is present in the resting position but decreases when the arms are raised, the test would be positive.

So why is it important to provide these patients with stabilization exercises? Well Hides et al conducted a study on the effects of providing patients with stabilization exercises after an onset of low back pain. The study found that in the first year, those who performed specific stabilization exercises had a recurrence rate of 30% versus over 80% for those who did not perform core stabilization exercises.

Use these articles to help educate your patients on the importance of physical therapy in their recovery process, and that completing their rehabilitation may reduce their risk of setbacks in the future.