The Musculoskeletal Wrangler in Wonthaggi, Victoria | Medical and health

The Musculoskeletal Wrangler

Locality: Wonthaggi, Victoria

Phone: +61 3 5672 5866

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24.01.2022 Mechanisms of physio treatment (simplified) . What mechanisms are you trying to harness with your choice of treatment? . Bialosky et al. (2018) have done a great deal of work investigating manual therapy (as an example intervention), in order to assist clinicians in conceptualising its plausible underpinning mechanisms in clinical practice. ... . MECHANISMS: Neuro-physiological (eg: descending inhibitory modulation, local tissue or nervous system changes etc.) . Psychological (eg: expectations, beliefs) . Biomechanical (eg: joint mobilisation, mechanical tissue changes etc.) . IMPRESSION: Realistically, there’s probably going to be a combination of each mechanism at play at different times in different contexts. I still always try to ask myself the above question when I’m justifying the use of a specific treatment modality, and when predicting the mechanisms underpinning the expected outcome. . MW . Reference: Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unraveling the mechanisms of manual therapy: modelling an approach. Journal of Orthopaedic & Sports Physical therapy,2018;48(1):8-18. See more

22.01.2022 Central sensitisation Part 4: treatment options . Nijs et al. (2021) provide an update regarding the latest discoveries around ‘central sensitisation’. .... DEFINITION: ‘Central sensitisation’ can be defined as the amplification of neural signalling within the central nervous system, which leads to heightened pain sensitivity in an individual. . TREATMENT SUMMARY: In some patients, central sensitisation can be maintained by peripheral input, and hence ‘bottom-up’ treatments (that address the source of this input) can normalise a patient’s pain processing. . In contrast, in other patients whose central sensitisation is maintained relatively independent of peripheral drivers, it may be important to address their central factors (ie ‘top-down’ approach) such as, catastrophizing, fear-, unhelpful pain beliefs etc. . TREATMENT OPTIONS: Pharmacological: Antidepressants Anticonvulsants NOT opioids . Non-pharmacological: Physiotherapy (manual therapy, education and exercise) Psychological interventions (aimed at improving self-efficacy, decreasing catastrophizing) Pain neuroscience education (to improve beliefs and coping strategies) . ALL treatment approaches should be patient-centered and individually-tailored. . . Part 5: Emerging concepts and literature . MW . Reference: Nijs J, George SZ, Clauw DJ, Fernandez-de-las-Penas C, Kosek E, Ickmans K, Fernandez-Darnero J, Polli A, & Curatolo M. Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine. Lancet Rheumatology,2021; https://doi.org/10.1016/ S2665-9913(21)00032-1 See more

21.01.2022 Have you considered your patient may be experiencing ‘perceived injustice’? . It’s a poor prognostic indicator for many MSK pain conditions. . MW

21.01.2022 Psychologically-informed physiotherapy Graded Activity (GA) (part 2/2) . Coronado et al. (2020) provide an editorial paper that reviews the recent literature on graded activity. .... RESULTS: 7 randomised controlled trials (n=570) were retrieved that investigated the effects of ‘graded activity’ on groups of patients with chronic low back pain or chronic whiplash-associated disorder. Most forms of GA took place over several weeks or multiple-day workshops. . CONCLUSIONS: Graded activity as a standalone intervention or in conjunction with pain education interventions were equally as effective as other forms of exercise at improving short- and long-term disability. . Graded activity is a common-sense approach to restoring an individual’s functional capacity! . MW . Reference: Coronado RA, Brintz CE, McKernan LC, Master H, Motzny N, Silva FM, Goyal PM, Wegener ST, Archer KR. Psychologically informed physical therapy for musculoskeletal pain: current approaches implications, and future directions from recent randomized trials. Pain Reports,2020;5:e847. See more

20.01.2022 Central sensitisation Part 3: prognosis . Nijs et al. (2021) provide an update regarding the latest discoveries around ‘central sensitisation’. .... DEFINITION: ‘Central sensitisation’ can be defined as the amplification of neural signalling within the central nervous system, which leads to heightened pain sensitivity in an individual. Central sensitisation is NOT a clinical condition; but rather, the underpinning mechanisms of many pain conditions. . PROGNOSIS: Patients with evidence of central sensitisation are more likely to experience: Higher severity pain and disability, and for longer durations Poorer response to treatment, and hence poorer outcomes and greater dissatisfaction . SUMMARY: Patients with ‘central sensitisation’ are more likely to have a worse prognosis than those without! . Part 4: Treatment . MW . Reference: Nijs J, George SZ, Clauw DJ, Fernandez-de-las-Penas C, Kosek E, Ickmans K, Fernandez-Darnero J, Polli A, & Curatolo M. Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine. Lancet Rheumatology,2021; https://doi.org/10.1016/ S2665-9913(21)00032-1 See more

20.01.2022 Thoracic spine exercise prescription MOTOR CONTROL (Part 3/5) . A recent narrative review and systematic review by Heneghan et al. (2020) collated the data of 2348 sources of various ‘evidence’ to classify exercises for the thoracic spine. .... The authors also divided ‘motor control’ exercises into ‘functional’ and ‘non-functional’, as well as ‘static’ and ‘dynamic’, and further into: . SPINAL DISSOCIATION: (eg: bird dog; wall squat) . SEGMENTAL MOVEMENT CONTROL: (eg: flexion/extension control quadruped etc.) . WHOLE-BODY COORDINATION (eg: woodchop/chop & lift etc.) . LIMITATIONS: Again, there is currently a lack of evidence that suggests the thorax exhibits proprioceptive or motor control deficits, and subsequently, there is a lack of evidence that investigates the effectiveness of such exercises. . CONCLUSION: Thoracic spine ‘motor control’ exercises are underpinned by nothing more than a theoretical basis NOT evidence! The jury is still out regarding their effectiveness! Motor control exercises can be classified in terms of whether they encourage the maintenance of a ‘neutral’ spine, or whether they encourage segmental spinal movement, or whole body coordination. . MW . Reference: Heneghan NR, Lokhaug SM, Tyros I, Longvastol S, Rushton A. Clinical reasoning framework for thoracic spine exercise prescription in sport: a systematic review and narrative synthesis. BMJ Open Sport & Exercise Medicine,2020;6:e000713. See more

20.01.2022 How often do you incorporate ‘individualised’ assessment items with your patients? . Never Rarely Sometimes... Often Always . MW See more

19.01.2022 Ergonomic sit-stand workstations (part 3/4) . A randomised controlled trial by Ognibene et al. (2016) collated the data of 46 office workers with at least 4/10 low back pain (in the last 3 months) to determine the effectiveness of sit-stand workstations on reducing low back pain. .... QUALITY: This paper was considered LOW quality with HIGH risk of various biases. . CONFLICT: This paper was NOT funded by the ergonomic sit-stand provider. . INTERVENTION: Sit-stand workstation implemented for 12 weeks. . CONTROL: No intervention . PRIMARY OUTCOME: Low back pain (0-10 scale) Self-reported disability (Roland Morris Questionnaire) (Measured at 0 & 12 weeks) . ISSUE: Participants were undergoing concurrent treatments for their low back pain! . RESULTS: Sit-stand workstations did NOT significantly reduce low back pain OR self-reported disability within groups or between groups. . CONCLUSIONS: This low quality RCT provides data to suggest sit-stand stations do NOT reduce low back pain or self-reported disability (even in conjunction with various other treatments) . MW . Reference: Ognibene GT, Torres W, von Eyben R, Horst KC. Impact of a sit-stand workstation on chronic low back pain: Results of a randomized trial. JOEM,2016;58(3):287-293. See more

19.01.2022 Thoracic spine exercise prescription STRENGTH (Part 5/5) . A recent narrative review and systematic review by Heneghan et al. (2020) collated the data of 2348 sources of various ‘evidence’ to classify exercises for the thoracic spine. .... The authors classified strength exercises as those that augmented rapid force production (power), and were also sub-divided into static and dynamic. . STATIC (Stiffness) . DYNAMIC (Power) . CONCLUSIONS: Thoracic strengthening exercises can be characterised by those that augment stiffness development, or those that augment power development. . OPINION: There appears to be an awful lot of cross-over between ‘work capacity’ exercises and ‘strengthening’ exercises. It seems the fundamental difference between the two relates to the parameters and intended outcomes of each (ie: endurance vs. power). . MW . Reference: Heneghan NR, Lokhaug SM, Tyros I, Longvastol S, Rushton A. Clinical reasoning framework for thoracic spine exercise prescription in sport: a systematic review and narrative synthesis. BMJ Open Sport & Exercise Medicine,2020;6:e000713. See more

18.01.2022 Back pain don’t take it lying down! . Remember the Australian advert campaign in the late 90’s? . It provided the simple, accurate messages like:... Back pain is common Back pain is rarely serious and rarely requires surgery Keeping active (with gentle exercise) is the best solution! . O’Keefe et al. (2019) suggest a call to action for the Australian government to re-visit such a campaign to reduce the ever-increasing disability rates associated with the misconceptions of low back pain! . Research strongly suggests it is our beliefs systems that can be the leading contributor to the disability associated with low back pain. . In essence, if we are fearful of back pain and avoid activities because of it, we are much more likely to be disabled by it. . MW . . References: O’Keefe M, Maher CG, Stanton TR, O’Connell NE, Deshpande S, Gross DP, O’Sullivan K. Mass media campaigns are needed to counter misconceptions about back pain and promote higher value care. British Journal of Sports Medicine,2019; 53(20):1261-1262. . https://sites.google.com//scottis/australian-back-pain-ads See more

17.01.2022 Neurological recovery following lumbar nerve root compromise Early vs. delayed decompression surgery . A recent retrospective cohort study by Nakashima et al. (2020) collated the data of 60 patients with lumbar nerve root compromise to compare the neurological function of those who underwent decompression surgery early versus late. .... POPULATION: Patient records from 2 hospitals were reviewed 20 had early surgery (<72hr; average 0.8 days) 40 had surgery late (>72hrs; average 117 days) . OUTCOMES: Manual muscle test (MMT) at 2-years follow-up Japanese Orthopaedic Association (JOA) score . RESULTS: 90% and 80% of each group achieved >4/5 MMT, respectively 80% and 45% of each group achieved >5/5 MMT, respectively JOA scores were significantly better in the early stage group (90% vs. 69%) . IMPRESSION: Both of these outcome measures are highly subjective, and seeing as assessors were not blinded when assessing them, this paper is underpinned by a reasonable degree of performance bias, and should be interpreted with caution. . CONCLUSIONS: Ultimately, at 2-years follow-up, patients that had decompression surgery early or late appeared to score pretty similarly in terms of myotomal strength. It begs the question if decompression surgery is needed for some of these patients JOA scores need to be conducted by a blinded assessor to yield more valid results. . MW . Reference: Nakashima H, Ishikawa Y, Kanemura T, Kato F, Satake K, Ito K, Ito K, Ando K, Kobyashi K, Ishiguro N, Imagama S. Neurological function following early versus delayed decompression surgery for drop foot caused by lumbar degenerative diseases. Journal of Clinical Neuroscience,2020;72:39-42. See more

16.01.2022 Spin The misrepresentation of data, often skewed towards strengthening research findings. . A recent overview study by Nascimento et al. (2020) collated the data of 66 low back pain systematic reviews to investigate the incidence of spin. .... RESULTS: 80% of the systematic review abstracts included within the study presented with some form of spin! . CONCLUSIONS: Read the whole paper, NOT just the abstract! . MW . Reference: Nascimento DP, Gonzalez GZ, Araujo AC, Moseley AM, Maher CG, Costa LOP. Eight in every 10 abstracts of low back pain systematic reviews presented spin and inconsistencies within the full text: an analysis of 66 systematic reviews. Journal of Orthopaedic & Sports Physical Therapy,2020;50(1):17-23. See more

15.01.2022 Research authors can spin their data! (Spin = the misrepresentation of data, often skewed towards strengthening research findings or persuading readers) ...A recent consensus paper by Yavchitz et al. (2016) recruited 122 clinicians and researchers to try classify the types of spin commonly found in systematic reviews and meta-analyses. Of the 39 types of spin they deliberated, the 3 broad categories most applicable to systematic reviews were: Misleading reporting (Eg: inadequate or incomplete reporting of methods, analyses or results) Misleading interpretation (Eg: misinterpretation of results) Inappropriate extrapolation (of results) (Eg: misleading title, conclusions, recommendations) Be vigilant of these issues! MW Reference: Yavchitz A, Ravaud P, Altman DG, Moher D, Hrobjartsson A, Lasserson T, Boutron I. A new classification of spin in systematic reviews and meta-analyses was developed and ranked according to the severity. Journal of Clinical Epidemiology,2016;75:56-65.

15.01.2022 Sit-stand workstations reduce sitting time (part 4/4) . A cluster RCT by Edwardson et al. (2018) collated the data of 146 office workers (37 clusters) to determine the effect of sit-stand workstations on various outcomes, namely sitting duration. .... INTERVENTION: Sit-stand workstation with advice (and 4 coaching sessions) over 12 months . CONTROL: No intervention . CONFLICT: No conflict of interest. . QUALITY: Moderate quality (6/10 PEDro score) . RESULTS: Sit-stand workstations significantly REDUCED daily sitting time by about 60-80min/day, and INCREASED standing time by about 60min/day. across 3-, 6- and 12-months! All other outcome measures remained insignificant (eg: stepping time, activity levels, MSK discomfort, absenteeism, job satisfaction etc) . CONCLUSIONS: Sit-stand workstations clearly reduce the amount of sitting time among office workers which is great, but that’s all they’ve been shown to do! . MW . Reference: Edwardson CL, Yates T, Biddle SJH, Davies MJ, Dunstan DW, Esliger DW, Gray L, Jackson B, O’Connell SE, Waheed G, Munir F. Effectiveness of the stand more at (SMArT) work intervention: cluster randomised controlled trial. BMJ,2018;363:k3870. See more

14.01.2022 Psychologically-informed physiotherapy Graded Exposure (part 1/3) . For some people, pain can be quite a scary thing. When people are fearful of pain, or fearful of activities that cause pain, they can become progressively disabled by such fear in a perpetual cycle of fear and activity avoidance (fear-avoidance). .... Graded Exposure is a form of therapy designed to enable patients to confront activities or tasks that they are fearful of, and that they avoid. . GE may initially begin with having patients ‘rate’ their level of fear (eg: /10) toward particular activities. Then in collaboration with their therapist, they work through a step-by-step process involving careful and gradual exposure to activities with the least amount of fear, and progress toward activities that are more feared. . By gradually exposing someone to such activities, and providing positive reinforcement to successful completion, patients undergo a process of cognitive restructuring (challenging existing fears) and behaviour habituation (starting a new behaviour). Ultimately, the success of this intervention is likely mediated by increasing a patient’s self-efficacy, thereby reducing their pain-related fear and improving their functional capacity. . . . MW . Reference: Coronado RA, Brintz CE, McKernan LC, Master H, Motzny N, Silva FM, Goyal PM, Wegener ST, Archer KR. Psychologically informed physical therapy for musculoskeletal pain: current approaches implications, and future directions from recent randomized trials. Pain Reports,2020;5:e847. See more

13.01.2022 Psychologically-informed physiotherapy Graded activity (GA) (part 1/2) . Graded activity is a time-contingent approach to restoring a person’s physical capacity in a particular activity or task. .... Grading a person’s activity involves identifying an agreeable baseline level of function that can be performed, and designing an agreeable plan to progress that person’s function toward their eventual functional goal. This approach is generally NOT determined based on an individual’s pain, but rather time. . GA is designed to increase a person’s tolerance to a specific and meaningful activity, thereby increasing their physical function, and reducing their level of disability! . GA emphasizes the positive reinforcement of healthy/desired behaviours, and the negative reinforcement of unhealthy/avoidant/undesired behaviours (i.e.: operant conditioning). . Reducing a person’s avoidant behaviour can be mediated by reducing hypervigilance, pain-related fear and pain-catastrophizing! . . . MW . Reference: Coronado RA, Brintz CE, McKernan LC, Master H, Motzny N, Silva FM, Goyal PM, Wegener ST, Archer KR. Psychologically informed physical therapy for musculoskeletal pain: current approaches implications, and future directions from recent randomized trials. Pain Reports,2020;5:e847. See more

13.01.2022 What do patients want from their physio? . McRae & Hancock (2017) performed a cross-sectional survey; surveying 500 adult patients who were presenting to 1 of ...10 different physiotherapy clinics across Sydney (AUS). . As like any cross-sectional study, these patients varied in their demographic and clinical information, and hence, it took a ‘snapshot’ of the population attending physio. . Survey: Please indicate how important the following reasons were in your INITIAL decision to present to a physiotherapist for your CURRENT health condition - rated on a 5-point scale . Diagnosis Information and education Treatment for pain relief Treatment to improve function Prevention . Results: The majority of people thought ALL of these elements were at least quite important! . I wonder, if given a blank sheet of paper what participants may’ve said. . Conclusions: When given the 5 options above, most patients viewed ALL of them as quite important or extremely important, when it comes to what they wanted from their physiotherapist. . MW . Reference: McRae M & Hancock MJ. Adults attending private physiotherapy practices seek diagnosis, pain relief, improved function, education and prevention: a survey. Journal of Physiotherapy,2017;63:250-256. See more

11.01.2022 ‘Routine’ x-ray’s for spinal pain are NOT evidence based! . Referring patients for an x-ray of their spine is ONLY indicated in the presence of suspected red flags (serious pathology) OR Where the findings of that x-ray may impact the management of the patient!... Eg: bone cancer, nerve root compromise considering surgery, spinal infection, fracture. . It’s inappropriate, unnecessary and harmful for chiropractors, GPs and physio’s to be referring patients for x-rays to assess the structure or function of your spine (in the absence of suspected red flags). . A recent literature review by Corso et al. (2020) collated the data of 23 research papers to determine how clinically useful it is to refer patients for ‘routine’ x-rays (ie: in the absence of red flags). . OUTCOME: Clinical utility: to aid in diagnosis, prognosis or treatment, or that positively impacts patient outcomes . RESULTS: NO study to date has adequately demonstrated that referring patients for ‘routine’ x-rays of the spine is beneficial for diagnosis, prognosis, treatment or treatment outcomes. . CONCLUSIONS: STOP referring patients for unnecessary x-rays! . MW . Reference: Corso M, Cancelliere C, Mior S, Kumar V, Smith A, Cote P. The clinical utility of routine spinal radiographs by chiropractors: a rapid review of the literature. Chiropractic & Manual Therapies,2020;28(33). See more

10.01.2022 Manual Therapy & Therapeutic Alliance (Opinion piece) . We know from the highest level of evidence that forming a ‘therapeutic alliance’ with your patient can be a critical factor in enhancing patient outcomes. .... It certainly appears to have been the ‘flavour of the month’ among many online physiotherapy forums; and rightly so. . But since when did we make manual therapy exempt from enabling a therapeutic alliance? . We know from the highest level of evidence that manual therapy CAN have a positive impact on patient outcomes. And we also know that many of its mechanisms are likely ‘contextual’ in nature. . Do you not agree that a ‘therapeutic alliance’ is a ‘contextual’ factor in its very essence? . There’s been a hell of lot of physio’s ‘throwing the baby out with the bathwater’ when it comes to manual therapy and it’s harming the reputation of our profession! . MW See more

09.01.2022 Central sensitisation Part 5: Future directions and emerging concepts . Nijs et al. (2021) provide an update regarding the latest discoveries around ‘central sensitisation’. .... DEFINITION: ‘Central sensitisation’ can be defined as the amplification of neural signalling within the central nervous system, which leads to heightened pain sensitivity in an individual. . FUTURE DIRECTIONS: Emerging literature is aiming to identify, refine and characterise specific pain-PHENOTYPES among patients in order to better determine a patient’s susceptibility to developing central sensitisation, their prognosis, and their response to specific treatments. . More effort is required in order to increase the availability of, and expertise in using QST in clinic. . More research is also required to enhance our understanding of the effects and effectiveness of different treatment modalities, specific to an individual’s pain phenotype. . . MW . Reference: Nijs J, George SZ, Clauw DJ, Fernandez-de-las-Penas C, Kosek E, Ickmans K, Fernandez-Darnero J, Polli A, & Curatolo M. Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine. Lancet Rheumatology,2021; https://doi.org/10.1016/ S2665-9913(21)00032-1 See more

09.01.2022 Do ergonomic interventions prevent low back pain? (part 2/2) . A meta-analysis by Steffens et al. (2016) collated the data of 2 RCTs including >6500 participants to determine if ergonomic interventions can prevent an episode of low back pain. . POPULATION:... Office workers (Dutch) and postal workers (USA) . INTERVENTION: Ergonomic work-station set-up 1x 6hr session OR 2x 90min sessions . RESULTS: Ergonomic interventions alone DO NOT prevent an episode of low back pain (n=6644; 2 RCTs; moderate quality) . CONCLUSIONS: Ergonomic interventions alone (eg: work-station set-ups) DO NOT prevent low back pain, based on 2 large randomized controlled trials. . MW . Reference: Steffens D, Maher CG, Pereira LSM, Stevens ML, Oliveira VC, Chapple M, Teixeira-Salmela LF, hancock MJ. Prevention of low back pain: A systematic review and meta-analysis. JAMA Intern Med,2016;176(2):199-208. See more

08.01.2022 Manual Therapy & Pain Self-Efficacy (Opinion piece) . It is common belief among a portion of the physiotherapy community that providing a patient with manual therapy may negatively impact on their pain self-efficacy; that is their ability to cope with, and be confident to manage themselves despite pain. .... In other words, some physio’s think patients can become ‘dependent’ on you as a clinician if you use manual therapy. . Did you know there is currently NO research that actually supports this notion? . While we should all recognise the limitations of manual therapy, we should also acknowledge when our own beliefs and biases have yet to be proven. . MW See more

08.01.2022 Central sensitisation Part 2: Assessment and diagnosis . Nijs et al. (2021) provide an update regarding the latest discoveries around ‘central sensitisation’. .... DEFINITION: ‘Central sensitisation’ can be defined as the amplification of neural signalling within the central nervous system, which leads to heightened pain sensitivity in an individual. . Central sensitisation is NOT considered a clinical condition or syndrome; but rather, the underpinning mechanisms of many pain conditions. . ASSESSMENT FINDINGS: Subjective information: Widespread, disproportionate and unpredictable/non-mechanical pain and hyperalgesia Sleep and memory problems, and concentration difficulties Sensitivity to various sensory stimuli (incl. light & odour) Stress as an aggravating factor A score of >40/100 on the Central Sensitisation Inventory (CSI) questionnaire . Objective information: Quantitative sensory testing (QST): Mechanical and thermal hyperalgesia Allodynia Altered conditioned pain modulation (ie: temporal summation) . SUMMARY: The assessment of ‘central sensitisation’ is complex and imperfect. There are many challenges in formulating a diagnosis of central sensitisation, and so currently, it is based on the sum of all relevant clinical information (ie: a clinical diagnosis). . . Part 3: prognosis . MW . Reference: Nijs J, George SZ, Clauw DJ, Fernandez-de-las-Penas C, Kosek E, Ickmans K, Fernandez-Darnero J, Polli A, & Curatolo M. Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine. Lancet Rheumatology,2021; https://doi.org/10.1016/ S2665-9913(21)00032-1 See more

08.01.2022 Psychologically-informed physiotherapy Graded Exposure (part 2/3) . Coronado et al. (2020) provide an editorial paper that reviews the literature on graded exposure. .... RESULTS: Only 1 randomised controlled trial (n=49) as retrieved that investigated the effects of ‘graded exposure’ on a group of patients with chronic pelvic pain. This was just one arm of a multimodal intervention including manual therapy and pain education, and was compared to manual therapy on its own. Graded exposure was performed over a 45-minute session each week for 6-weeks, and was aimed at targeting each patients’ 5 most feared activities. . LIMITATIONS: Obviously the findings of this literature should be interpreted with caution due to its small sample size, and the multidimensional nature of the interventions investigated. . CONCLUSIONS: Based on this limited available literature, ‘graded exposure’ as part of a multimodal physiotherapy intervention was significantly more effective than manual therapy alone at reducing pain and disability among patients with chronic pelvic pain. . ‘Graded exposure’ within the field of physiotherapy is a common sense approach to enabling patients to overcome their fears of pain or painful activity. . MW . Reference: Coronado RA, Brintz CE, McKernan LC, Master H, Motzny N, Silva FM, Goyal PM, Wegener ST, Archer KR. Psychologically informed physical therapy for musculoskeletal pain: current approaches implications, and future directions from recent randomized trials. Pain Reports,2020;5:e847. See more

08.01.2022 Thoracic spine exercise prescription MOBILITY (Part 2/5) . A recent narrative review and systematic review by Heneghan et al. (2020) collated the data of 2348 sources of various ‘evidence’ to classify exercises for the thoracic spine. .... The authors divided mobility exercises into ‘functional’ and ‘non-functional’, which represents loaded/weight-bearing and partial weight-bearing exercises, respectively but these concepts are highly subjective. . LIMITATIONS: There is NO evidence to date that investigates the effectiveness of thoracic spine ‘mobility’ exercises! Most of the exercises detailed within this paper are resourced from social media - FYI - Social media is NOT evidence! . CONCLUSIONS: Thoracic spine ‘mobility’ exercises are underpinned by nothing more than a theoretical basis NOT evidence! The jury is still out regarding their effectiveness! . OPINION: Not all thoraxes are stiff! Sometimes ‘tight is right’! ‘Mobility’ exercises might NOT be the most effective way to address mobility . MW . Reference: Heneghan NR, Lokhaug SM, Tyros I, Longvastol S, Rushton A. Clinical reasoning framework for thoracic spine exercise prescription in sport: a systematic review and narrative synthesis. BMJ Open Sport & Exercise Medicine,2020;6:e000713. See more

07.01.2022 Adolescent knee pain Tomato: Tomato? . Whether its Osgood-Schlatters (growing pains) or patellofemoral pain (PFP), adolescents get better with activity modification and targeted rehabilitation! .... Rathleff et al. (2019; 2020) demonstrated that among 51 adolescents with growing pains, and 151 adolescents with knee-cap pain, the majority improved in the short-term and long-term with activity modification and targeted rehab. . INTERVENTION: Activity modification (graded activity and pain monitoring) Progressive home-based ‘knee strengthening’ exercises . RESULTS: For most measures, and for most individuals, this intervention regime resulted in clinically-significant benefits for self-reported pain and function, strength and performance, and patient satisfaction! - in the short-term AND in the long-term! . IMPRESSION: In the context of the two types of knee pain, it seemingly doesn’t matter what the inherent diagnosis or pathology is; the intervention can remain the same! . CONCLUSION: Consider adopting the abovementioned interventions when managing adolescents (and adults?) with knee pain! . MW . References: Rathleff MS et al. Activity modification and load management of adolescents with patellofemoral pain: a prospective intervention study including 151 adolescents. The American Journal of Sports Medicine,2019;47(7):1629-1637. . Rathleff MS et al. Activity modification and knee strengthening for Osgood-Schlatter disease: a prospective cohort study. The Orthopaedic Journal of Sports Medicine,2020;8(4). DOI: 10.1177/2325967120911106 See more

06.01.2022 Thoracic spine exercise prescription WORK CAPACITY (Part 4/5) . A recent narrative review and systematic review by Heneghan et al. (2020) collated the data of 2348 sources of various ‘evidence’ to classify exercises for the thoracic spine. .... ‘Work capacity’ is a term best synonymous with endurance exercise. . The authors again divided ‘work capacity’ exercises into ‘functional’ and ‘non-functional’, as well as static and dynamic, and: . PILLAR CONDITIONING: (The ability to maintain a STATIC thoracic spine against load) . SEGMENTAL CONDITIONING: (The ability to DYNAMICALLY control the thorax against load) . CONCLUSIONS: ‘Work capacity’ exercises largely fit under the ‘umbrella’ of ‘core-stability’-type exercises and they can plausibly be divided into exercises that promote STATIC thorax control or DYNAMIC thorax motion control. . MW . Reference: Heneghan NR, Lokhaug SM, Tyros I, Longvastol S, Rushton A. Clinical reasoning framework for thoracic spine exercise prescription in sport: a systematic review and narrative synthesis. BMJ Open Sport & Exercise Medicine,2020;6:e000713. See more

05.01.2022 ***FLASHBACK ...To the positive and negative prognostic indicators for lumbar discectomy surgery . . MW

04.01.2022 Did you know pain self-efficacy is a MEDIATOR between pain and disability? . Did you know your patient’s expectations are a MODERATOR for the effects of your treatment? . MW

03.01.2022 Ergonomic sit-stand workstations (part 1/4) . BACKGROUND: Excessive sitting and physical inactivity are considered health risk factors for various chronic diseases (eg: T2DM, heart disease). Hence, why the sit-stand workstations have a plausible theoretical basis. ... . But what research do we have on sit-stand workstations? . A systematic review by Agarwal et al. (2020) collated the data of 8 studies to determine the effectiveness of sit-stand workstations on reported musculoskeletal discomfort. . POPULATION: Pain-free office workers . RESEARCH: 6 cross-over designs (n=159) 1 cross-sectional (n=24) 1 RCT (n=47) . INTERVENTION: Various parameters for sitting and standing duration, ranging from 10min/5min to 1hr each, to alternate days sitting/standing, to free choice between sitting/standing. . OUTCOME: Musculoskeletal discomfort . IMPRESSION: Collectively speaking, this research ISN’T going to tell us a great deal. The findings of this paper will be unlikely to assist in our understanding of the effectiveness of ergonomic sit-stand stations for office workers with or without pain. . ISSUES: Some of the studies were funded by the ergonomic sit-stant workstation provider (huge conflict of interest!) Study sizes are very small, and the quality of the research has not been assessed. The intervention parameters and follow-up duration are far too variable/inconsistent between studies. The outcome measures are inconsistent between papers, and are not validated. . CONCLUSIONS: This paper is trying to draw conclusions by comparing apples with oranges (among other problems). The effectiveness of sit-stand workstations remains unknown based on this research. MW . Reference: Agarwal S, Steinmaus C, Harris-Adamson C. Sit-stand workstations and impact on low back discomfort: a systematic review and meta-analysis. Ergonomics,2020;61(4):538-552. See more

03.01.2022 Psychologically-informed physiotherapy . Psychologically-informed physiotherapy is blended approach that combines psychological strategies within a physiotherapy treatment model for the management of patients with musculoskeletal pain. . Coronado et al. (2020) provide a recent literature review that highlights the many types of psychologically-oriented interventions, and examines the existing evidence that underpins them.... . Graded activity (GA) Graded exposure (GE) Cognitive-behavioural therapy (CBT) Acceptance and commitment therapy (ACT) Stress inoculation training Pain-coping skills training Pain neuroscience education . . In this series, I am going to dive into the current rationale for each of these interventions, their application and implications, and the existing literature that underpins them. . MW . Reference: Coronado RA, Brintz CE, McKernan LC, Master H, Motzny N, Silva FM, Goyal PM, Wegener ST, Archer KR. Psychologically informed physical therapy for musculoskeletal pain: current approaches implications, and future directions from recent randomized trials. Pain Reports,2020;5:e847. See more

03.01.2022 Thoracic spine exercise prescription Overview (Part 1/5) . A recent narrative review and systematic review by Heneghan et al. (2020) collated the data of 2348 sources of various ‘evidence’ to classify exercises for the thoracic spine. .... 4 classifications emerged (incl. 38 different specific exercises): . MOBILITY . MOTOR CONTROL . WORK CAPACITY . STRENGTH . The principles/clinical reasoning, evidence and examples of which will be presented in this 4-part series. . MW . Reference: Heneghan NR, Lokhaug SM, Tyros I, Longvastol S, Rushton A. Clinical reasoning framework for thoracic spine exercise prescription in sport: a systematic review and narrative synthesis. BMJ Open Sport & Exercise Medicine,2020;6:e000713. See more

02.01.2022 Ergonomic sit-stand workstations (part 2/4) . A randomised controlled trial by Graves et al. (2015) collated the data of 47 pain-free office workers to determine the effectiveness of sit-stand workstations on reducing workplace sitting time (among other things). .... QUALITY: This paper was considered low quality with high risk of various biases. . CONFLICT: This paper was NOT funded by the ergonomic sit-stand provider. . INTERVENTION: Sit-stand workstation implemented for 8 weeks with self-selected parameters (based on each individuals' preference) . CONTROL: No intervention . OUTCOMES: Ecological momentary assessment (EMA) time spent sitting, standing, walking measured every 15 minutes over a 5-hour period (Mon-Fri). Musculoskeletal discomfort (0-10 scale) (Measured at 0, 4, 8 weeks) . RESULTS: Sit-stand workstations significantly reduced sitting time (>100min/day on average) Sit-stand workstations did NOT reduce MSK discomfort within groups or between groups . CONCLUSIONS: This low quality RCT provides data to suggest sit-stand stations significantly reduce sitting duration among office workers, though its impact on reducing MSK discomfort in an asymptomatic population is insignificant (no surprise). . MW . Reference: Graves LEF, Murphy RC, Shepherd SO, Cabot J, Hopkins ND. Evaluation of sit-stand workstations in an office setting: a randomised controlled trial. BMC Public Health,2015;15:1145. See more

02.01.2022 STAR method of reflection (Opinion piece) . For patients with chronic or persistent pain conditions, much of what we try to do as physiotherapists, is to evoke behavioural change through promoting self-monitoring and self-regulating processes and strategies. .... When trying to empower patients with these skills, do you ever employ the ‘STAR’ method of reflection? . SITUATION: what happened? (eg: a recent pain flare up) . TASK: why or how did it happen? (eg: recent relative increase in provocative activity) . ACTION: how did you handle the situation? (eg: implemented self-management strategies such as pacing, mindfulness etc.) . RESULT: what was the outcome? (eg: a sense of control over pain, and subsequently a relative decrease in pain) . I’d say its structured reflective practices like this that might be able to enable patients to learn more about their chronic or persistent pain, and how to best manage it. . MW See more