Thursday, July 31, 2008


Example 1: Last month I received a female patient (58 years) of B/L hip OA with extreme capsular tightness to a degree you can call fibrous ankylosis. This patient had left side affected first. On examination lt. Side showed more deformity than rt. Side.
Example 2: Yesterday I received another female patient (71 years) who was treated by me 3 months ago for left sided OA hip. This patient has developed similar features on the Rt side of her hip. My examination revealed typical capsular pattern.
Now the question is can we predict the outcome of the other hip if one of the hip is affected by OA? Vossinaskis IC et al has the same question. They examined the anteroposterior radiographs of the pelvis of 95 white patients with unilateral idiopathic (56 patients) or secondary to congenital hip diseases (39 patients) OA. The other hip was free from symptoms (pain or limping) at the initial examination and without radiographic evidence of OA; it was what we call a "normal" hip.
They evaluated 2 parameters:
a. the type of osteoarthritis of the involved hip and
b. the range of four radiographic indices of the contralateral hip:
1) The weight-bearing surface,
2) The acetabular angle,
3) The Wiberg's center-edge angle, and
4) The neck-shaft angle.
The conclusions drawn from this study are as follows:
1. Patient with idiopathic OA of one hip is at increased risk of developing OA in the other hip.
2. The outcome of the other hip cannot be predicted only on the basis of the evaluation of its radiographic indices.
3. Among the different indices, weight-bearing surface seems to have a strong influence toward the development of OA.
For researchers: for this type of study involving predictive question, regression analysis is used. This group of researchers has used a special technique called Logistic regression analysis. Logistic regression analysis showed that the presence of idiopathic OA in one hip had a statistically significant effect on the development of OA on the other hip (p <>

Tuesday, July 29, 2008

Exercise, diet & cholesterol

Abnormal cholesterol metabolism, including low intestinal cholesterol absorption and elevated synthesis, is prevalent in diabetes, obesity, hyperlipidemia, and the metabolic syndrome. Diet-induced weight loss improves cholesterol absorption in these populations, but it is not known if endurance exercise training also improves cholesterol homeostasis. Wilund KR et al (2008) examined this, by measuring circulating levels of campesterol, sitosterol, and lathosterol in 65 sedentary subjects (average age = 59) with at least 1 metabolic syndrome risk factor before and after 6 months of endurance exercise training. Their data indicated that exercise training reduces plasma cholesterol despite increasing cholesterol absorption in subjects with metabolic syndrome risk factors.

Monday, July 28, 2008

ICT in large Cervical spine disc prolapse

Many claim that the use of intermittent cervical traction’s role is redundant. But according to a research paper by a group of Swedish physical therapists (In journal of manipulative physical therapy,2002) cervical spine traction could be considered as a therapy of choice for radiculopathy caused by herniated disks, even in cases of large-volume herniated disks or recurrent episodes.
They described the use of intermittent cervical traction in managing 4 patients with cervical radiculopathy in large-volume herniated disks. All 4 patients had neck pain radiating to the arm. The clinical examination was typical in all cases for radiculopathy of cervical origin. Magnetic resonance imaging (MRI) of the cervical spine revealed large-volume herniated disks in all patients.
Their treatment consisted of intermittent on-the-door cervical traction. Complete symptom resolution for each patient occurred within 3 weeks. One patient who had an episode of recurrence 16 months after the first treatment was successfully managed again with cervical traction and physiotherapy.
In my personal experience I also regard ICT as a great modality in managing cervical spine prolapse cases. But I also think we should have more number of cases in a RCT format to validate our experience.

Wednesday, July 23, 2008

Few points on diagnosis of spinal pain

Most spinal conditions are benign and self-limiting. For diagnosis the following are used: history, physical examination, and special studies, including diagnostic imaging, diagnostic blocks, and facet and sacroiliac joint injections.
1. In general, there is much more evidence on diagnostic procedures for the low back than there is for the neck.
2. With regard to the history, a number of factors can be identified which can assist the clinician in identifying sciatica due to disc herniation or serious pathology. With regard to the physical examination, the straight-leg raise is the only sign consistently reported to be sensitive for sciatica due to disc herniation, but is limited by its low specificity.
3. The diagnostic accuracy of other neurological signs and tests is unclear.
4. Orthopaedic tests of the neck, such as Spurling's or the upper-limb tension test, are useful to rule a radiculopathy in or rule out, respectively.
5. In patients 50 years of age or older, plain spinal radiography together with standard laboratory tests are highly accurate in identifying underlying systemic disease; however, plain spinal radiography is not a valuable tool for non-specific neck or low-back pain.

Tuesday, July 22, 2008

efficiency of traction over mechnical neck disorders- a review of 2008

According to a review in Cochrane Graham N et al (2008) currently literature does not support or refute the efficacy or effectiveness of continuous or intermittent traction for pain reduction, improved function or global perceived effect when compared to placebo traction, tablet or heat or other conservative treatments in patients with chronic neck disorders.

Monday, July 21, 2008

Truth about muscle flexibility

Magnussion P et al reported:
With stretching:
1. With repeated stretches muscle stiffness declined, but returned to baseline values within 1 hour.
2. Long-term stretching (3 weeks) increased joint range of motion as a result of a change in stretch tolerance rather than in the passive properties.
Where as strength training resulted in increased muscle stiffness, which was unaffected by daily stretching.
The effectiveness of different stretching techniques was attributed to a change in stretch tolerance rather than passive properties.
Inflexible and older subjects have increased muscle stiffness, but a lower stretch tolerance compared to subjects with normal flexibility and younger subjects, respectively.

The inverse relationship of osteoporosis and osteoarthritis!!

The similarity of etiology:
The etiology of osteoporosis (OP) and osteoarthritis (OA) is multi-factorial: constitutional and environmental factors, ranging from genetic susceptibility, endocrine and metabolic status, to mechanical and traumatic injury, are thought to be involved.
The differences:
1. The anthropometric differences of patients suffering from OA compared with OP are well established. OA cases have stronger body build and are more obese. OA cases have increased BMD or BMC at all sites. OA cases not only have higher apparent and real bone density, but also wider geometrical measures of the skeleton, diameters of long bones and trabeculae, both contributing positively to better strength and fewer fragility fractures.
2. Not only is bone quantity in OA different but also bone quality, compared with controls and OP cases, with increased content of growth factors such as IGF and TGFbeta, factors required for bone repair.
3. Furthermore, in vitro studies of osteoblasts recruited from OA bone have different differentiation patterns and phenotypes. These general bone characteristics of OA bone may explain the inverse relationship OA-OP and why OA cases have fewer fragility fractures.

Sunday, July 20, 2008

Effectiveness of exercise on fatigue associated with cancer

Fatigue is well recognized as a side-effect of cancer and its treatment. Medical consultants advised people with cancer to rest if they felt fatigued. More recently a number of studies suggested physical exercise as a helpful tool in reducing the fatigue that is associated with cancer. Cramp F et al reviewed the effect of physical exercise on fatigue related to cancer. Twenty-eight studies were included in their review. Result of this review suggested that physical exercise can help to reduce fatigue both during and after treatment for cancer. However it is non clear what is the best type or intensity of exercise for reducing the symptom of fatigue.

Saturday, July 19, 2008

Time to publication- how important time lag is?

I have never written on research methodology in my site. For young researchers I would like to present the following summary of a recent article by Hopewell S et al.

Hopewell S et al’s methodology review was to assess whether the time taken to publish the results of clinical trials is influenced by the statistical significance of their results (time-lag bias). If clinical trials with positive findings are stopped earlier than planned and published quicker than those trials with null or negative findings, then new interventions might be mistakenly assumed to be effective.
Their review shows that trials with positive results are published sooner than other trials. This has important implications for the timing of the initiation and updating of a review, especially if there is an association between the inclusion of a trial in a review and its publication status. It is of particular concern when one considers reviews containing only a small number of studies.

Electro therapy in mechanical neck pain disorder

According to Kroeling P et al’s review of evidence of electrotherapy on mechanical neck disorders
1. Low or high frequency pulsed electromagnetic field (PEMF) compared to placebo, provides immediate post treatment pain relief only for chronic MND, acute whiplash (WAD) (Limited evidence of benefit)
2. Direct and modulated Galvanic current compared to other treatments for pain in acute, subacute, chronic occipital headache (Unclear or conflicting evidence)

3. Iontophoresis compared to other treatments for pain, RTW, and self-assessment of overall outcome in acute, subacute WAD (Unclear or conflicting evidence)

4. TENS compared to placebo for pain in acute WAD, chronic MND (Unclear or conflicting evidence)

5. PEMF compared to placebo for medium or long term effect on pain, patient assessment of improvement, ADL in acute WAD, chronic MND (Unclear or conflicting evidence)
6. Diadynamic current compared to placebo for reduction of trigger point tenderness in chronic MND with radicular findings, cervicogenic headache (Limited evidence of no benefit)
7. Permanent magnets compared to a placebo for pain in chronic MND (Limited evidence of no benefit)
8. Electric muscle stimulation compared to a sham control for pain in chronic MND (Limited evidence of no benefit)

Thursday, July 17, 2008

Predicted postoperative FEV1- not correct to use!!!

Predicted postoperative FEV1 is the most widely used parameter in preoperative risk calculation in the screening of patients for lung resection surgery.
Recent evidences have suggested that predicted postoperative FEV1 is not a reliable predictor of postoperative cardiopulmonary complications because of the fact that the resection of a portion of lung in patients with obstructive disease determines only a minimal loss.
The FEV1 measured on the first postoperative day may be 30% less than predicted postoperative FEV1.

Is there any swelling of tendons in tendinopathy???

Tendinopathy is a painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Current data support the use of eccentric strengthening protocols.

Cystic fibrosis & BMD

Cystic fibrosis is associated with low total proximal femur BMD. According to Dodd JD et al (2008) exercise appears to influence total proximal femur BMD more than lumbar spine BMD in Cystic fibrosis. Exercise rehabilitation programs focusing on peripheral strength training may benefit those Cystic fibrosis patients with low total proximal femur BMD.

Sunday, July 13, 2008

anterior knee pain- current defination

MannG et al defines anterior knee pain as following:
1. Anterior knee-pain syndrome would best be defined as a painful condition that arises in or around the patellofemoral joint and is insidious in onset and bilateral, with no macroscopic gross pathology.
2. Anterior knee pain as a descriptive term would define the need to search further for a specific cause of pain, because neither patellar cartilage damage nor malalignment would necessarily be correlated to pain.
3. The examining physician should be aware that specifically in adolescents the higher chance would be that, eventually, no clear-cut pathology would be found; thus, great caution should be taken before diagnosing anterior knee-pain syndrome as existing unilaterally.
It could be claimed, following the above, that as opposed to the term "anterior knee pain," the term "anterior knee-pain syndrome" is an exclusion diagnosis that can be applied after macroscopic pathology has been ruled out.

Calcific tendinopathy

Calcific tendinopathy is a condition may present with severe pain. Usually in the supraspinatus tendon a chalky white deposit is seen on a radiograph. Recent Physiotherapy articles recommend local hyperthermia in this condition.
A case study by De cesare A et al found; microwave diathermy (hyperthermia) at 434 Mhz three times a week for four weeks to be very effective. The radiographs ware negative after one month. 1 year follow ups ware highly satisfactory assessed by SPADI

Saturday, July 12, 2008

Importance & injuries of Posterio-Lateral corner of knee

The structures within the posterolateral corner of the knee have recently been "re-discovered" providing a very important role in maintaining the stability of the knee. The posterolateral aspect of the knee is stabilized by a complex anatomy of osseous, myotendinous and ligamentous structures. It plays an important role in the stabilization of the knee at low angles of knee flexion. Advanced biomechanical studies have brought additional understanding of both the anatomy and the function of posterolateral structures in knee stabilization and kinematics.
Injury to the posterolateral corner is not common but neither is it rare; it is usually damaged in combination with rupture of one of the cruciate ligaments in direct and indirect trauma to the knee. The posterolateral corner has been shown to play a role in the prevention of varus angulation, external rotation, and posterior translation. The potential for long-term disability from these injuries may be related to increased articular pressure and chondral degeneration. The failure of the reconstruction of cruciate ligaments may be due to unrecognized or untreated posterolateral corner injuries. Increasingly MRI is used to study the injuries pertaining to this area.

both are required!!

sedentary habit produces many ill effects on musculo-skeletal & cardiorespiratory system. both skeletal muscles and cardiac muscles can work in a wide range of contractile activity. cardiac contractility in many ways depends on rate & style of musculoskeletal contraction.
the challenge thrown by sedentary habits however is mono directional make both (musculo-skeletal & cardiorespiratory system) of them UNI-PACED. sacrificing the entire fringe of contractile activity & trading it for sedentary individual comfort makes us prone to loss of many functional capacities more importantly it makes us vulnerable to many diseases.

Friday, July 11, 2008

Physical therapy of migraine- prudent or result of persuation of studies of methodological error!!!

Some migraine patients find that regular exercise helps in reducing the frequency of headache attacks. Currently many headache experts are recommending exercise in migraine. However, most of these recommendations refer to some anecdotal reports or observational studies in literature stating that regular exercise can reduce the frequency and severity of migraine.
Busch V et al investigated whether recommendations for exercise in migraine are based on sufficient data to cope with requirements of an evidence-based modern migraine therapy. The review summarizes
1. Some results are controversial regarding the efficacy of sports intervention in migraine.
2. The majority of studies did not find a significant reduction of headache attacks or headache duration and only indicate a reduction of pain intensities in migraine patients due to regular exercise.
3. The grade of recommendation of exercise in migraine based on evidence based medicine (EBM)-criteria is presently B-C. But due to methodological limitations, the available data are insufficient for a final statement on this topic.

Undetected hangman's fracture in a patient referred for physical therapy for the treatment of neck pain following trauma- Be careful Blogs!!

The following are 2 case reports by Ross MD et al published journal of physical therapy & journal of orthopedic and sports physical therapy. (Evidence: diagnosis level 4)
These case report describes a patient referred for physical therapy treatment of neck pain who had an underlying hangman's fracture that precluded physical therapy intervention. Read the following minutely so that you can pick up clues for your own practice.
Case study 1: This case involved a 61-year-old man who had a sudden onset of neck pain after a motor vehicle accident 8 weeks before his initial physical therapy visit. Conventional radiographs of his cervical spine taken on the day of the accident did not reveal any abnormalities. Based on the findings at his initial physical therapy visit, the physical therapist ordered conventional radiographs of the cervical spine to rule out the possibility of an undetected fracture.
The radiographs revealed bilateral C2 pars interarticularis defects consistent with a hangman's fracture. The patient was referred to a neurosurgeon for immediate review. Based on a normal neurological examination, a relatively low level of pain, and the results of radiographic flexion and extension views of the cervical spine (which revealed no evidence of instability), the neurosurgeon recommended that the patient continue with nonsurgical management.
Case Study 2: This case involved a 73-year-old woman who had a sudden onset of neck and left upper extremity pain after a fall 15 days prior to her initial physical therapy visit. Conventional cervical spine radiographs completed 1 day prior to her initial physical therapy visit were negative for a fracture. However, several components of this patient's history and physical examination were consistent with a condition for which physical therapy intervention would not be indicated until more definitive cervical spine diagnostic imaging had been completed; more specifically, the physical therapist was primarily concerned about the possibility of an undetected fracture. The referring physician was contacted and immediate magnetic resonance imaging was requested, which revealed a type II fracture of the odontoid. Thirty-four days after her fall, the patient underwent a C1-C2 fusion.
1. In patients with neck pain caused by trauma, physical therapists should be alert for the presence of cervical spine fractures. Even if the initial radiographs are negative for a fracture, additional diagnostic imaging may be necessary for a small number of patients, because they may have undetected injuries that would necessitate medical referral and preclude physical therapy intervention.
2. When evaluating patients with neck pain who have a history of cervical spine trauma, it is important that physical therapists understand the clinical findings associated with cervical spine fractures, as these findings provide guidance for the use of cervical spine diagnostic imaging and medical referral prior to implementing physical therapy interventions.

Thursday, July 10, 2008

WHY such difference ?

The effects of eccentric exercises on Achilles tendinopathy are not similar in athletic and non-athletic sedentary populations. According to Sayana MK et al Eccentric exercises, though effective in nearly 60% of our patients, may not benefit sedentary patients to the same extent reported in athletes.
In my opinion any body in physical therapy practice confirms the statement. WHY such difference exists?

A lymphatic decongestive machine

Ridner SH et al reported a home-based self operated lymphatic decongestive machine called Flexitouch system (developed in USA ,Tactile Systems Technology, Inc.) helps to reduce the following:
1. Participants' use of professional manual lymphatic drainage (MLD) therapy,
2. Self-MLD, and
3. Bandaging
A high degree of adherence is reported in the usage of this equipment by both cancer and non-cancer patients. Healthcare professionals should facilitate communication among members of the lymphedema treatment team.

Wednesday, July 9, 2008

comments on sciatic nerve release by marc heller, DC

have you seen the manual therapy video of Marc Heller, DC
the technique is excellent but be cautious!
1. do not use it in acute & subacute manifestations
2. read the course of sciatic nerve again
3. understand the meaning of each step of the manipulation
finally i would recommend that it should be used after the normal SLR is re-gained in a prolapseIVD. i found it responds well to conditions producing restriction of glide where the root constituting the sciatic nerves are not impinged within the TV foramina.

size of pillows

literature exsists on all of the following:
1. big pillows causing neck pain
2. no pillows causing neck pain
3. moderate sized pillow easing neck pain