As physiotherapists there is something intuitively attractive about biological joint replacement relative to traditional implant devices. The attraction of normal biomechanical charactaristics, physiological tissue loading behavior and less surgical destruction are obvious advantages. I was excited to see this excellent 6min video from the wonderful TED website discussing these issues and future directions of biologic joint replacement in relation to knee pathology. We have discussed  knee replacement cases previously.

I have only seen 1 patient with a cartilage allograft to her patella. She was a 22 year old elite hockey player /athlete who had 6 arthroscopic debridements from the age of 16. Despite my enthusiasm and considerable effort with her rehabilitation she did not return to competitive sport. Nonetheless I think this is still a very exciting area and one I hope we will see more of. It will also be interesting to see how the mulit-national prosthetic manufacturers respond to this challenge? It looks like the future research in this area is focused in a different direction to the typical disciplines of materials science, mechanics and computer modelling.

Has anyone had experience with this type of caseload?

Let us know.

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2011. | Permalink | 2 comments | Add to del.icio.us
Post tags: biologic joint replacement, manual therapy, musculoskeletal practice, Physical therapy, physiotherapy

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I caught up with Professor Bill Vicenzino to talk about his new book “Mobilisation with Movement” and explore more of his thoughts on Tennis elbow treatment.

Bill is prolific publisher and has added greatly to clinical management of chronic elbow pain. We discussed some of his ideas in  previous posts.

Today’s interview discusses these concepts in detail together with a review his new book  “Mobilisation with Movement” which is destined to become a core text of the manual therapy library.

Click in the link below to hear the interview. (30min)

Treat yourself  get hold of a copy – or put it on the birthday wish list.

Enjoy the clinical challenge

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2011. | Permalink | 3 comments | Add to del.icio.us
Post tags: bill vicenzino, manual therapy, mobilisation with movement, Physical therapy, physiotherapy, tennis elbow

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Current treatment options

May involve modalities such as;

Ultrasound

Interferrential

Laser

Deep transverse frictions

Acupuncture

Manipulation

Strengthening exercises

Epicondylar clasps

Corticosteroid

Surgery

Not surprisingly most of the modalities do not come out particularly favorably when subjected to rigorous critical review with the exception of indication’s that laser may be beneficial.

There was definitive and important research regarding the role of corticosteroids in chronic lateral epicondylalgia.  Suffice it to say in summary that the initial acute symptomatic relief frequently obtained with corticosteroid infiltration is associated with a relapse rate of up to 70% at six month review.

In essence, Professor Vicenzino highlighted the role of specific manual therapy interventions to continuously assess function on a test / re-test basis using a grip strength measure following the application of manual therapy techniques.  We have discussed in previous posts the relevance of using grip strength measure and there was particular emphasis on the use of pain free grip strength as opposed to maximal grip strength as a measure of treatment effectiveness.

The preferred manual therapy interventions involve the use of mobilisation with movement (MWM) as originally pioneered by Brian Mulligan.  Bill has developed a manual therapy intervention protocol based on a sequence of specific MWM techniques with the assessment of pre and post treatment pain free grip strength as the measure of effectiveness.

If you get a chance I strongly recommend attending one of these workshops to learn the specific handling techniques and the sequence for application, which he has developed.  Some of these techniques were described in a master class paper published in Manual Therapy in 2003.  We also covered soft tissue taping techniques to unload painful tissues for cases in which the condition was so irritable that manual therapy did not offer significant relief of symptoms.

Much of the conventional wisdom regarding the etiology and pathology of this notoriously resistant condition was challenged in discussion and certainly provided an ample volume of data from which to review our clinical practice.

Some interesting concepts regarding muscle imbalance between wrist extensors and long finger extensors was also presented with a tantalising observation that chronic lateral epicondylalgia sufferers display reduced wrist extension bilaterally on grip assessment.  I wonder if this will become part of a pre-employment/pre-participation screening profile?

We also covered specific exercise prescription as part of a corrective regime and reviewed the convincing data indicating that six to eight weeks of weekly, structured, supervised, progressive exercise is an essential component for effective outcomes.

The day concluded with a lively Q&A session and Bill fielding questions with great efficiency and refreshing Australian directness.  Some of this discussion veered into topics we have discussed before on this blog, regarding therapist creditability and the delivery of effective care.

Suffice to say it is essential that our interventions demonstrate measurable effect and are associated with a positive response (even if we don’t fully understand the response mechanism). The implication is that we therapists must wisely choose the selection of techniques on the basis of their most likely efficacy. In the real world we do not have the luxury of repeatedly trying different techniques in the hope of improving a patient’s well being.  They simply won’t hang around to allow us to run this type of experiment.

All in all a very worthwhile day, some excellent practical clinical information obtained.  Again I recommend you keep an eye out for Bill’s work and also for his forthcoming coming publication on mobilisation with movement, which is due out in the end of 2010, published by Elsevier.

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2010. | Permalink | One comment | Add to del.icio.us
Post tags: Acupuncture, chronic lateral epicondylalgia, corticosteriod injection, Deep transverse frictions, Epicondylar clasps, Interferrential, laser, manipulation, manual therapy, mobilisation with movement, pain free grip, Physical therapy, physiotherapy, Strengthening exercises, Surgery, ultrasound

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It is fitting to pay tribute to Geoff Maitland who died recently in Adelaide, South Australia.  Geoff was a pioneer in manipulative physiotherapy.  He gave his name to one of the most widely used manual therapy concepts around the globe today.  Although his primary clinical interest was in musculoskeletal dysfunction, he can certainly be credited with developing a systematised subjective examination which is used across all physiotherapy specialities.

It is perhaps this ability to systemise the subjective process, the clinical examination and the treatment selection, which are the real legacy of this true pioneer.  I had the privilege of working and meeting Geoff and his wife Anne on several occasions and had the fortunate experience of working on a three day video shoot for a clinical teaching module back in1991. He was a truly humble man whose general demeanour gave no indication of his achievements.

Most who trained in these shores would have been introduced to the Maitland concept as an integral part of undergraduate teaching of musculoskeletal practise.  As an enthusiastic (but somewhat naive) new graduate I remember the mental conflict I experienced when trying to understand Maitland’s classic concept of the “semi permeable brick wall” regarding diagnosis, pathology and clinical findings.  In fact if I am totally honest I was a little dismissive of this idea, which at the time I thought was somewhat woolly, non- specific and a little vague.  Such was my disillusionment that I enrolled in a six month Orthopaedic Medicine training programme which taught the principles of another pioneer James Cyriax.  What appealed to me at the time was the preciseness if somewhat dogmatic nature of Cyriax’s teachings, which appealed greatly to my thought processes at that time.  As the clinical mileage began to increase it became increasingly clear that precise diagnostic patterns were the exception rather than the rule and that my search for a definitive diagnosis based on clear cut symptoms and history were a little fanciful so say the least!

This realisation redirected me back to the more fluid clinical approach, which was such an integral part of the Maitland concept.  This prompted further exploration involving study in Perth, Western Australia in 1990 and remains a core component at my clinical practice, twenty years later.

In these days of multi-structural treatment and integration of concepts the focus on pure manual therapy techniques has moved down the agenda to some extent.  The proverbial “chicken and egg” debate regarding muscle dysfunction causing joint pathology or visa versa is a circular debate.  The clinical reality is that we need tools in our armoury to address these components whatever way we arrive at a system of prioritisation.

To address this Maitland postulated a concept of dysfunction based on:

new use

abuse

disuse

overuse

classification system, which I think all clinicians would do well to bear in mind when assessing any musculoskeletal presentation.

One could be critical that the Maitland system did not teach direct muscle treatment strategies or focus on movement re-education as part of a patient management strategy but it did leave us with an unbelievable rigorous system for evaluation and treatment of joint dysfunction using manual therapy techniques.  Developing the manual therapy skills to assess, treat and exclude joint dysfunction as a component musculoskeletal impairment is an essential daily requirement for every clinician.  It is hard to see how one could dispense with his work if we accept the need to directly treat joint’s exhibiting dysfunction.

A contemporary, Freddy Kaltenborn, simultaneously devised a treatment system based on joint mechanics and accessory motion but in reality much of this fundamental biomechanical understanding was integrated into the Maitland approach. Although Maitland’s writings did not expand in detail on pathology he cleverly integrated manual therapy provocation / exploration tests which could readily identify dysfunction – even if the diagnostic accuracy was not a high priority. As it often boils down to assessing treatment response this is the most practical clinical approach which is true scientific method using comparable sign’s and pre / post-treatment analysis of relevant patient markers. Is this not evidence based practise in its purest form?

I for one am very grateful for his dedication and commitment to the profession and hope he retains a watchful eye in his final place of rest..

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2010. | Permalink | No comment | Add to del.icio.us
Post tags: cyriax, diagnostic classification, Geoff maitland, Kaltenborn, Maitland, manual therapy, manual therapy concept, movement diagrams, semi-permeable brick wall

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I’ve recently been reflecting on the clinical relevance of evaluating end-fee in clinical practice. The issue arose from  a conversation about interpreting patient response to manual therapy and whether “useful clinical change” was being achieved. Changing end-feel is certainly part of the manual therapists armory and needs to be considered in conjunction with range of motion as a measure of effectiveness. However in situations of established degenerative change the clinical objective may be to improve tolerance of static positions (typically lying in spinal conditions) and in these cases improving end-feel is often the key criteria in reducing symptoms without tangible range changes.

Conversely, failure to alter end- feel is a poor prognostic indicator and one where the clinician must be vigilant.

Knowing when not to treat is also a skill we must embrace.

I’ve included a refresher summary below of the issues associated with end-feel in spinal examination.

Different sensations of movement barriers can be perceived according to the tissues limiting motion, the anatomical region, and pathological change.  Cyriax describe a number of characteristic End-feels

1. Bone to bone
2. Spasm
3. Capsular feel
4. Springy block
5. Tissue approximation
6. Empty feel

Kaltenborn summary of end-feel

1. Normal soft end-feel due to soft tissue approximation
2. Normal firm end-feel due to capsular ligamentous stretching
3. Normal hard end-feel (bone to bone)

In pathological states the variations may be:

1. A firm less elastic feel (indicative of scar tissue or shortened connective tissue)
2. An elastic less soft end-feel (indicative of increased muscle tone)
3. An empty end-feel (patient limits movement prior to resistance)

(This is indicative of inflammation, serious pathology or fear avoidance behaviour)

ACCESSORY MOVEMENT

In order to allow physiological movement joint surfaces undergo combinations of rotation and translation.  These characteristics are determined by the shape of the joint surfaces, the ligament us and capsular tension and the inherent bony structures.

When a concave surface moves on a convex the direction of translation (slide) is in the same direction as that of the motion (rotation).  When a convex surface moves on a concave the translation is in the opposite direction to the motion.

Manual Examination

Objective: to determine the presence presence of vertebral motion (somatic) dysfunction.

Passive Physiological Intervertebral Motion (PPIVM’s)

Passive Accessory Intervertebral Motion (PAIVM’s)

Functional Technique

Flexion / Extension

- segmental range

- total range

Side flexion / Rotation

- segmental range

- total range

- coupled motion

- position dependent

Correlation of active movement , PPIVM’s & PAIVM’s to define diagnosis and prescribe optimal treatment strategies.

Saggittal plane motion: nutation / counternutation

Range:

Intra-pelvic motion a function of:

Inominate position (functional test in Siting)

Sacral position

Spinal position

Manual Examination Techniques

Physiological Motion

Lumbar flexion

Lumbar extension

Lumbar side flexion

Lumbar rotation

Lumbar shear

Accessory Motion

PA’s

Unilateral’s

Transvers’s

In combined positions

Positional assessment:

ASIS

PSIS

Iliac Crest

Standing hip flexion test

Standing hip extension test

Positional assessment:

Sacral base

Inferior lateral angles

Accessory glide

Shear (stress) test

Enjoy the clinical challenge

David

Gertzbein, S. D., R. Holtby, et al. (1984). “Determination of a locus of instantaneous centres of rotation of the lumbar disc by moire fringes.” Spine 9(4): 409-413.

Gertzbein, S. D., J. Seligman, et al. (1985). “Centrode patterns and segmental instability in degenerative disc disease.”  Spine 10(3): 257-261.

Loeble, W. Y. (1967). “Measurement of spinal posture and range of spinal movement.”  Annals of physical medicine 9: 103-110.

McFadden, K. D. and J. R. Taylor (1990). “Axial rotation in the lumbar spine and gaping of the zygapophyseal joints.”   Spine15(4): 295-299.

Panjabi, M., I. Yamamato, et al. (1989). “How does posture affect coupling in the lumbar spine.”  Spine 14(9): 1002-1011.

Pearcy, M. (1984). “Is there instability in spondylolisthesis.”  Spine 10(2): 175-177.

Pearcy, M., I. Portek, et al. (1984). “Three-dimensional x-ray analysis of normal movement in the lumbar spine.”  Spine 9(3): 294-297.

Seligman, J. V., S. D. Gertzbein, et al. (1984). “Computer analysis of spinal segmemt motion in degenerative disc disease with and without axial loading.”  Spine 9(6): 566-573.

Stokes, I. A. F. (1986). Three dimensional biplanar radiography of the lumbar spine. Modern Manual Therapy, London, Churchill Livingstone.

Stokes, I. A. F., D. G. Wilder, et al. (1981). “Assessment of patients with low back pain by biplanar radiographic measurement of intervertebral motion.”  Spine 6(3): 233-239

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | No comment | Add to del.icio.us
Post tags: ACCESSORY MOVEMENT, Characteristics of End-feel, Clinical Assessment, Convex - Concave rule, End-feel, Kaltenborn, lunbar spine, manual therapy, pelvis, poor prognostic indicator, si joint, useful clinical change

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Tennis Elbow is one of those conditions where cautious prognosis is wise until we see the response to treatment over one or two reviews.  The propensity for chronicity in this area is well known to both therapists and patients alike.  Associated with this resistance to treatment is a wide variety of treatment techniques employed (always a warning sign).  One of the biggest challenges clinically is demonstrating improved pain response during individual treatment session’s.

Specific clinical markers for tennis elbow

Resisted wrist extension

Resisted supination,

Resisted elbow flexion

Resisted finger extension

Grip strength

all provide a cluster of easily quantifiable measures to determine improvements in function or reductions in elbow sensitivity.

Of course the first important issue to recognise is that not all lateral epicodylitis is the same phenomena and in reality spans a spectrum from …

Pathological Spectrum

Common extensor tendon insertion pain

Myofascial irritation of the forearm supinators and wrist extensors

Radioulnar joint dysfunction

Peripheral entrapment neuropathies at the lateral elbow

Biceps insertion

Tendenopathies

Elbow joint pathology.

This spectrum of pathologies is likely associated with the variations in provocation testing which we observe clinically but nonetheless does give us direct feedback on the effectiveness of our interventions.

Treatment Strategies

Using anti-inflammatory modalities such as ultrasound, interferential, laser and TENS rarely produce an objective improvement in measurable function within a treatment session.  Whilst the merits of employing anti-inflammatory measures as part of the management strategy seem reasonable, their merits are usually not directly measurable but would fit in the category of “useful things” to include in the management.

commonly utilised around the area of irritation can sometimes induce a local analgesic effect resulting in measurable change in objective measures.  Experience suggests a variable response, often indirectly measured over time rather than within sessions and  with significant potential for causing irritability in the presence of a neural component to symptom patterns.

Manual therapy – anteroposterior mobilisation of the radial head, elbow extension and medial glide of the olecranon are accessory joint motions which should be routinely assessed both for mechanical characteristics and symptom provocation.  When these are contributory factors one can generally expect an observable change on test re-test within a treatment session.

Neural mobilisation – this is a large topic in its own right but in the presence of neural sensitivity direct nerve mobilisation techniques have an important role in desensitisation.  The clinical challenge of course is actually producing a nerve desensitising effect from mechanical treatments.  There is the potential to produce increased neural sensitivity particularly if the mechanical aspects of the nerve interface throughout the length of the upper limb have not been adequately screened and addressed.

SNAGS

Brian Mulligan’s work has been pioneering in this regard and seat belt gliding techniques to produce lateral distraction around the elbow give very direct and immediate feedback with regard to reduction of symptoms – particularly if grip test is used as the provocation measure.

In recent years my preference has been to use a grip dynamometer as an objective measure, apart from the obvious benefit of providing a numerical scale of feedback it appears that patients who still have symptoms on grip strength do find it difficult to quantify improvement just simply by arbitrarily clenching a fist.  Therefore the numerical scale can be quantified in relation to maximum pain tolerance and therefore would give fairly indisputable feedback with regard to response to treatment.

Invasive Management

Of course the alternative is steroid infiltration which would also appear relatively arbitrary if Cochrane Reviews are considered. It’s  many years since I have seen surgical interventions in this area but would be interested to know if any of our readers have had experience -positive or negative with this approach?

Let us know by leaving a comment.

Enjoy the clinical challenge.

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | 3 comments | Add to del.icio.us
Post tags: accessory joint motions, anteroposterior mobilisation of the radial head, anti-inflammatory, clinical markers for tennis elbow, Cochrane Reviews, Common extensor tendon insertion pain, Deep transverse friction, elbow extension, grip dynamometer, Grip strength, laser, lateral epicodylitis, manual therapy, medial glide of the olecranon, nerve desensitising, Neural desensitisation, Neural mobilisation, prognosis, Resisted elbow flexion Resisted finger extension, Resisted wrist extension Resisted supination, SNAGS, surgical interventions, Tennnis Elbow, TENS, Treatment Strategies, treatment techniques, ultrasound

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symptoms

behavioural characteristics

regional distribution

temporal characteristics

responsiveness to pharmacological intervention.

Many patients are diagnosed as Migraine sufferers but  do not fit the classical ” migraine with aura” classification and are then classified as “atypical migraine without aura”.

While many of these patients can identify specific triggers (alcohol, dairy products, chemical irritants, ambient lighting, fatigue and dehydration many are unable to determine triggers.

Unfortunately, many chronic migrainuers develop “Tension type headache” or alternatively “chronic daily headache”

Physiotherapists dealing with this type of caseload commonly find a multitude of clinical signs in the cervical & thoracic spine together with TMJ dysfunction.

The clinical challenge is to determine the relevance of co-existing physical signs and the prioritisation of legitimate targets to treat.

The pain producing structures may be….
Articular

Myofascial

Neural

Common mechanisms may precipitate sensitisation of these structures

Such as

postural adaptation

occupational factors

ergonomics

previous musculoskeletal history

and the clinician must prioritise the primary target tissue.

Often this is influenced by clinician bias as to whether they utilise a manual therapy approach, a general exercise regime, a specific muscle imbalance protocol, myofascial techniques or dry needling.

The direction for future research into cervicogenic headaches needs to look at the testing and interpretation of musculoskeletal clinical signs which are frequently associated with headaches in order to establish clinical prediction rules and a clinical efficacy protocol for the management of these challenging patients.

Share your experiences with fellow clinicians by adding your comments below.

Enjoy the clinical challenge

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | 2 comments | Add to del.icio.us
Post tags: cervicogenic headache, manipulation, manual therapy, migraine, physiotherapy, TMJ

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