The Week in Research Review, etc 12-24-18

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The Week in Research Review, etc 12-24-18 only had two posts to social media this week but hopefully two very helpful posts for your practice.

The back pain post was a repost from a previous time but I thought it was very important to share it again. I also put a new post from my YouTube channel where I discussed patellar mobility assessment for instability. Check the post out at the link here or below to see the full version.

Physical Therapy First to Treat Low Back Pain

[ICYMI} Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Frogner et al Health Serv. Res. 2018

The Week in Research Review, etc 12-24-18This study compared the differences in opioid prescription, health care utilization, and costs among patients with low back pain (LBP) who saw a physical therapist as the first point of care, at any time during the episode, or not at all.

Patients aged 18-64 years with a new primary diagnosis of LBP, living in the northwest United States, were observed over a 1-year period.

Patients who saw a PT first had:

  • a lower probability of having an opioid prescription (89.4 percent),
  • any advanced imaging services (27.9 percent),
  • and an Emergency Department visit (14.7 percent), yet 19.3 percent higher probability of hospitalization.

Interestingly enough, 80% of the patients in the sample had no PT at all. Furthermore, 8.7% saw a PT first and 11.5% saw a PT later (avg 38 days). The most common provider seen 1st was a chiropractor.

Assessing for Patella Instability

Assessing Patella Mobility

💥Assessing for Patella Hypermobility💥

This Instagram snippet shows how I assess a patient with suspected patella hypermobility who may have sustained a subluxation, dislocation or instability episode.

To see the full video at my YouTube Channel, click the link here!

Basically, we’re looking at how mobile the patella is when the knee is locked at full extension compared to when the knee is flexed to about 25 degrees.

Normally, the patella should become relatively stable when the knee is flexed to 25 degrees because it engages the trochlea groove.

In patients with underlying patella hyper-mobility, the amount of mobility with the knee slightly flexed will be similar to when the knee is in full extension (and not locked into the trochlea groove).

This is often the case when the patient’s trochlea groove is too shallow to offer bony stability.

The test should help the clinician gain a better understanding of the patient’s anatomical make-up and prognosis for the long term.

Check out the full video at my YouTube Channel.

The Week in Research Review, etc 12-17-18

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Not a lot this week…sorry folks. Focusing a bit more on other projects. The Week in Research Review, etc 12-10-18 included only 3 posts but they definitely made some waves. Especially my latest Instagram post on burn-out in the PT field. Check it out and chime in…it’s never too late to like a post and comment on SoMe.

When is it Safe to Drive after Orthopaedic Surgery?

💥OPEN ACCESS! 💥⠀

This study looked to comb the research to see the available data regarding when patients are safe to resume driving after common orthopedic surgeries and injuries affecting the ability to drive.


This is always the age old question as a PT or ATC (amongst the other disciplines) and this study may help to shed light and give a bit more concrete evidence.

Often times, our answer is ‘it depends’ and that is definitely true. Or we pass the ball to the doctor who did the surgery and try to buy time by waiting until that 1st post-op visit.

Or we just say you can’t drive because you’re still on pain meds…and that is definitely true! All of these factors may play a role but it seems as if the literature can help guide our answers a little better so I invite you to take a look to this OPEN ACCESS paper and keep it in your patient database.

It may help to guide a future patient’s independence after an injury.

Posterior Shoulder Stretching after a Surgery

The efficacy of stretching exercises to reduce posterior shoulder tightness acutely in the postoperative population: a single-blinded randomized controlled trial. Salamh et al Physiother Theory Pract. 2018.


This paper looked at acutely post-op shoulder patients (no repairs, just debridements) and followed their ROM horizontal adduction and internal rotation after the surgery.


Group 1 was assigned the supine sleeper stretch and shoulder pendulum exercises. Group 2 was assigned the standing horizontal adduction (cross-body) stretch and shoulder pendulum exercises. Group 3 (control group) was assigned and performed shoulder pendulum exercises only and asked to perform 10 clockwise or counter-clockwise pendulum exercises twice a day.

The study noted that ‘the horizontal adduction stretch is more effective 
at reducing acute posterior shoulder tightness in the postoperative shoulder population when compared to the supine sleeper stretch and no stretch at all.

Not surprised but wanted to share the information and maybe help someone use this for their clinical practice.
Not sure why they chose supine sleeper stretch versus sidelying sleeper stretch but most likely because of pain tolerance.

Traditionally, the sleeper stretch is performed in supine. It’s modified by having the patient rollback to potentially put the shoulder in a more comfortable position. We wrote a paper about this in JOSPT 2013 with @wilk_kevin and @toddrhooks

I’m still more of a fan of the horizontal adduction stretch and use it clinically every day for my shoulder patients.

Burn Out in Physical Therapy

Just said yesterday that I don’t post my tweets to IG but get like this one should be posted here too.

Not going to say much more than I already have.. maybe a future blog post or something.

Curious to hear the comments below too. Throw it all at me and I’ll try to write something up in the future.

The Week in Research Review, etc 12-10-18

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This week we’re still playing with formats and learning these Instagram changes. With that, in the week in research review 12-10-18, we discussed many topics that I wanted to share!

Surgery vs Physical Therapy for Carpal Tunnel Syndrome

Cost-Effectiveness Evaluation of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: Evidence From a Randomized Clinical Trial Fernández-de-las-Peñas et al JOSPT 2018.

This Level 1b study looked to evaluate cost-effectiveness differences of manual physical therapy versus surgery in women with carpal tunnel syndrome (CTS).

Performed in Spain, 120 women with a clinical and electromyographic diagnosis of CTS were randomized through concealed allocation to either manual physical therapy or surgery.

They concluded that manual PT including desensitization maneuvers of the central nervous system has found to be equally effective but less costly, i.e., more cost-effective than surgery for women with CTS.

From a cost-benefit perspective, the proposed manual PT intervention of CTS can be considered.

Interesting results but 2 obvious limitations to this study:
1️⃣No control group. What if the symptoms could spontaneously improve over time
2️⃣ They only looked at 1-year improvement and not short-term improvements. I would’ve liked to have seen 3 months and 6 months results as well to see the acute effects.

Not sure what to make of this study but it does seem as if a population of Spanish women may respond to Rx of CTS without surgical intervention.

This could be a huge cost/time saver for society!

Return to Sport Criteria and Reinjury Rates

The Association Between Passing Return-to-Sport Criteria and Second ACL Injury Risk: A Systematic Review With Meta-Analysis  Losciale et al JOSPT 2018.

Not going to lie, this study caught my attention because the results match my confirmation bias.⠀

I’ve been saying for years that hop tests, even combined with other tests, just don’t cut it.⠀

I wrote a blog post about this too for @mikereinold. This study, although with its limitations, did show that passing RTS criteria did not show a statistically significant association with risk of a second ACL injury. 

This review also determined that 12% of those who failed RTS testing suffered a graft injury, compared to 5.9% of patients who passed. 

It seems as if quadriceps strength measured via isokinetic testing or isometric testing may be an important factor to consider for RTS decision making.


Also, hamstring-quadriceps strength ratio symmetry should also be considered.

So with this review demonstrating that current objective criteria-based RTS decisions did not show an association with the risk of a second ACLI, how does this affect your practice?

Physical Therapy vs Knee Scope for Meniscus Tears

💥PT vs Scope for Meniscus Tear 💥
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Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Non-obstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial. van de Graaf VA et al JAMA Oct. 2018

Among patients with non-obstructive meniscal tears, PT was equal to arthroscopy for improving patient-reported knee function over a 24-month follow-up period. 

They went on to say that “Based on these results, PT may be considered an alternative to surgery for patients with non-obstructive meniscal tears.”

So basically, if there’s no bucket handle tear present that may be blocking joint range of motion, then it is highly encouraged that the patient #GetPT1st and not do surgery.

Without going out on a limb, I’d say this is a much more cheaper treatment option as well and would save society many costs associated with the surgery and lost time from work.

I do note a couple limitations: the surgical group did not get PT after surgery if they did ‘as expected’ but they could get PT to help improve their symptoms.

The PT group did pretty basic exercises although leg press, lunges, and balance type exercises were included.

Have you read this paper? It was a multi-center, randomized controlled trial performed in 9 hospitals in the Netherlands.

So, are we encouraged or surprised? Let me know by commenting below…thanks!

Shoulder Health Accessory Exercises

by @kieferlammi

Want strong and healthy shoulders!?

Shoulder strength is about more than pushing big lifts like strict pressing, push pressing, etc.

If you want a robust, healthy, well moving shoulder you should be including lower level drills that more specifically address scapular and RTC strength and control. –

I will always be a fan of traditional exercises like side like ERs, Prone Ys, Ts, etc.

Lately, I’ve thrown in more band work because it’s easy for me to do for higher volumes on a frequent basis and I enjoy the constant tension that the band provides. 

Give these two exercises a try:

✅ Band Front Raise Pull-Apart

✅ Band Overhead Y Raise

I find that these two do a great job of targeting my mid back and posterior shoulder without much compensation through a big range of motion.

Give them a try either in a warm-up for 1-3 sets of 10-15 reps or at the end of a training session for 2-4 sets of 10-25 reps depending on the difficulty of your band and your capacity. 

Should we Brace after an ACL Surgery?

  
 
 
 
 
 
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 [NEW BLOG POST]⠀ 💥Knee Bracing Immediately After an ACL Reconstruction 💥⠀ In this post, I review some recent Twitter, Facebook and Instagram discussions about the usage of a hinged knee brace after an ACL surgery.⠀ .⠀ You'd be surprised what I found in the literature and the differences that exist throughout the US and the world.⠀ .⠀ Go to my website <LINK in my BIO> and read/share with your friends/colleagues.⠀ .⠀ It was a bit eye-opening and I'm curious to hear what others have to say.⠀ .⠀ I still like to recommend a brace for my clients because it seems to give them an added security after a pretty painful surgery.⠀ .⠀ I typically keep them braced 4-6 weeks, depending on their quadriceps activity and if they can do an active straight leg raise without a lag.⠀ .⠀ Many others don't even bother bracing at anytime post-op, which was surprising.⠀ .⠀ What do you think? Read the blog post and let me know. Let's try to educate and come to a better consensus...thanks!⠀ .⠀ #kneerehab #knee #kneepain #kneesurgery #acl #aclsurgery #ROM #physio #physiotherapist #crossfit #exercise #deadlift #physiotherapy #physicaltherapy #physicaltherapist #athletictraining #athletictrainer #ATC #PT #teamchampion #dptstudent #lenmacpt #instagram
 
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You can also get to the blog post by clicking this link

Let me know what you think about this new blog post or any of my social media posts…thanks!

Knee Bracing Immediately After an ACL Reconstruction

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I recently came across a Facebook post that discussed bracing immediately after an ACL reconstruction and I was intrigued. I read some of the comments and chimed in with my observations and opinions.

In turn, a multi-platform discussion revealed many new details. I wanted to briefly share some of the research and the discussions that came up.

I was very impressed with the discussions by the way. They were very professional, grounded and level-minded.

No one got too emotional (typical of social media) and they really helped to educate and see both sides of the discussion.

What does the Research Say about Bracing after an ACL?

Again, I’m talking about post-op day 1 or as we like to say POD1 as clinicians.

Many people posted a 2007 systematic review that showed ‘no evidence that pain, range of motion, graft stability, or protection from subsequent injury were affected by brace use, thus supporting our hypothesis.’

Another study that kept showing up was a 2012 study in AJSM that said ‘Bracing following ACL reconstruction remains neither necessary nor beneficial and adds to the cost of the procedure.’

Wow! Two pretty high level studies that completely went against my 15+ years of experience.

More studies!

Another study in the Scandinavia Journal of Medicine and Science in Sports looked at brace versus no brace after an autologous patella tendon graft reconstruction. 

There were no differences either pre‐operatively or 5 years post‐operatively  between the groups in terms of the knee score (Lysholm), activity level (Tegner), degree of laxity or isokinetic peak muscle torque.

Keep in mind there are a ton of studies out there. This study in the Journal of American Academy of Orthopaedic Surgeons suggests ‘that functional bracing may have some benefit with regard to in vivo knee kinematics and may offer increased protection of the implanted graft after ACL reconstruction without sacrificing function, range of motion, or proprioception.’

I have NEVER seen a post-operative ACL patient without a brace immediately after surgery.

Instagram Story Poll will Decide It!

So, what’s the next obvious thing to do? Take it to instagram and see what they have to say?

So I did a poll in my story and the results favored immediately bracing after surgery which goes completely against the literature.

Poll Results- 63% say they use a brace after an ACL surgery
Instagram Poll Results for ACL Bracing

Pretty interesting and I’d say overwhelmingly confirmed my biases!

Twitter Discussion

I’m a big Twitter guy so it was only natural to hit up my peeps there to see what they had to say.

I started the Twitter discussion here and an awesome conversation continued between PT’s and MD’s that was so beneficial.

Regional Differences with Bracing

Midwest

It definitely seems that geography plays a huge role! Midwest PT’s and MD’s in St Louis, Minnesota (near Mayo) and Indianapolis (near Dr. Shelborne) were all opinionated. They advocated for NO BRACE.

West Coast

The no-brace crowd extended to the west coast a bit too but we took a curious stop in Colorado. One person said their doctors all brace their patients and limit weight-bearing to 25% for a period of time.

It surprised me to read this! I can maybe understand limiting WB after an ACL-meniscus repair but not for an isolated ACL reconstruction. 

Europe

Of note, it seems as if no one in Europe uses a brace immediately after an ACL surgery. Are we that far behind or naive to the literature?

Guess that topic will be for a different day!

For now, I wanted to share this discussion with people and hope to learn a bit more by it.

I know the docs ultimately have the final say. It really was interesting to see the regional differences.

For example, Sylvia Czuppon, a respected professor and researcher from Wash U. in St. Louis, had a 180-degree response from me!

She has basically only seen post-op patients without a brace.

Pretty funny, but it basically sums up our current medical practices.

This should be a lesson for all, especially the students and new grads.

Closing Thoughts

Keep an open mind, learn from the research and do what’s best for your patient!

I worked 11+ years in Birmingham, Alabama with some of the top sports medicine docs in the world. We always braced after an ACL reconstruction.

Same thing here in Boston where I get patients from Children’s Hospital, Mass. General Hospital and other top-notch hospitals.

Every single patient that I have ever seen has won a brace after surgery

With that, it was very interesting to see the results and the literature. It was equally interesting to see the responses.

People were stunned when they heard the other side of the story.

ACL rehabilitation is not easy…trust me. I’ve written bout this before right here. Check it out before you move on!

What do you see in your practice? Do your docs brace immediately after an ACL?

Let’s talk it out in try to come to a consensus. Again, education is the key and we can always do better.

The Week in Research Review, etc 12-3-18

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Hey everyone,  The Week in Research Review, etc for this week has a new look, compliments of Instagram’s new algorithm. Hope the new format doesn’t throw you too big of a curveball (maybe you’ll like it better), so here goes…

 

ACL Injury Rates Higher on Synthetic Turf than Natural Grass in the NFL

Preventing low back pain by @joegambinodpt

Female Soccer Players have a 5x Increased Risk of a Second ACL injury

Anatomy of the Proximal Humerus

ACL Injury Rates Higher on Synthetic Turf than Natural Grass in the NFL

 

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Preventing low back pain by @joegambinodpt

 

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A post shared by Lenny Macrina MSPT, SCS, CSCS (@lenmacpt) on

Female Soccer Players have a 5x Increased Risk of a Second ACL injury

 

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A post shared by Lenny Macrina MSPT, SCS, CSCS (@lenmacpt) on

Anatomy of the Proximal Humerus

 

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