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Untold Physio Stories - You Sleep How Again? - themanualtherapist.com


We've talked about it before and this won't be the last time. For difficult cases it takes a Physio Detective to figure out contributors to the patient's overall ecosystem. Sometimes they're doing things that can really sensitize the system and don't even realize it's out of the ordinary. Have you ever had a similar case? Let us know by reaching out on social media!




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[RESEARCH] What Are We Missing? Prone MRI vs. Supine MRI in Low Back Pain Patients - theManualTherapist.com


Goal of the Study?

It is not uncommon to encounter remarkable pain patients with unremarkable MRI findings in clinical settings. Conventional MRI is done laying down, facing up (supine) in a recumbent and off-loading environment. This group of researchers out of The University Hospital Sanitas La Moraleja in Madrid, Spain, wanted to compare supine (face-up) MRI to prone (face-down) MRI in lower back pain patients to see the difference in the MRI findings.

 

Why are they doing this study? 

Posture does matter in most cases of lower back pain. Patients complain of symptom exacerbation in different positions like sitting, laying down in particular positions, standing, walking or bending. However, the standard, thought to be the ‘gold standard’, is supine MRI. However, this position often relieves a patient’s back and/or leg pain symptoms. In this research study published in Pain Physician1 the group of researchers wanted to see if there were MRI changes to the spine when the patients were laying face down vs face up.

 

What was done in this study?

Nineteen low back pain sufferers, with a mean age of 48.7 years old, with an average numerical pain scale of 6.5 out of a scale of 0-10. They looked at radiological findings and the changes related to disc bulging, ligamentum flavum buckling and/or thickening. The researchers also looked at varying grades of spondylolisthesis and facet joint subluxations resulting in foraminal stenosis. In other words, they were looking at how much the vertebra slid and how much more narrow the exiting holes became when the patients lay on their stomachs instead of laying on their backs.

spondylolisthesis

What did they find?

Four patterns of changes were seen when people were imaged on their stomachs rather than their backs. They found that in over 50% of the people, disc problems were only seen in the prone position. They saw 52.6% of cases showing increased thickness in the ligamentum flavum in the prone position that was otherwise not seen in the supine position. They also saw varying degrees of listhesis (slippage of vertebrae) and facet joint spacing differences in 26.3% of those laying on their stomach compared to those lying on their backs.

 

Why do these findings matter?

This simply designed study has revealed postural anatomical changes related to the imaging position. This would seem obvious from a layman’s standpoint; however, medicine has relied so much on supine MRI imaging as the gold standard position to investigate pathoanatomical findings. There is very often a clinical disconnect between a patient’s symptoms and the associated pathology seen in MRI, likely because MRI imaging has been standardized to be taken belly-up. Many spine problems are missed or misguided in treatment approaches if a proper assessment (including appropriate MRI positioning) is not conducted. Research like this allows a better match of pathoanatomical findings and the associated treatments.

 

At Dynamic Disc Designs, we create dynamic human anatomy models showing a dynamic disc that changes shape and position with different postures as well as the ligamentum flavum thickening under extension. Explore how you can connect a patient to their postional symptoms with a ddd model.


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Gut Biome Linked with Alzheimer's: What do PTs Need to Know? - theManualTherapist.com


By Dr. Sean M. Wells, DPT, PT, OCS, ATC/L, CNPT, CSCS, Cert-DN

Alzheimer's Disease

Physical therapists (PTs) play a crucial role in helping patients and caregivers in the management of Alzheimer's disease (AD). Alzheimer's disease is a chronic neurodegenerative disease that slowly destroys a person's memory, personality, and physical functioning. Currently there is no none cure, so often PTs are left with help patients try to maintain as much physical and cognitive functioning as they can. The costs associated with managing patients with AD are projected to be over $2 Trillion dollars by 2030 -- yes, trillions!

Promising News

While there's much doom and gloom there is also hope: diet and the gut biome. A major, and first of its kind, study out of Edith Cowan University has established a genetic link between AD and several gut-related disorders. In the Nature Communications Biology Paper, the authors analysed large sets of genetic data from AD and several gut-disorder studies – each of about 400,000 people. The results were that people with AD and gut disorders have several genes in common, which could lead to earlier identification of AD and possible gut-brain axis treatments down the road. While gut disorders may not be causal, due to obvious limitations of the study's design, it can prove to be valuable for clinical management and future research. 

Cholesterol

One other significant finding from the study was the connection between cholesterol and AD. Prior observational studies has shown a connection between high amounts of dietary and serum cholesterol in the development of AD; however, this study highlights evidence that high cholesterol can transfer into the central nervous system, resulting in abnormal cholesterol metabolism in the brain. Furthermore, the other gut conditions, like H. Pylori infections, can further worsen fat metabolism, which can further worsen cholesterol metabolism in people at risk for AD. The authors of the study state the importance of using statin drugs and dietary modifications as ways to reduce serum cholesterol. 

Physical Therapy Bottomline

 Some DPTs may say: "So what can I do about this?" The answer is fairly simple at this point, as there is more research that needs to be done before we have bedrock clinical research outcomes. First, PTs need to screen for gut disorders. As part of our examination we're supposed to do a review of systems -- how many times do you ask about about stomach, bowel, or bladder issues? Getting patients to registered dieticians and/or gastroenterology sooner may help them control their irritable bowel syndrome, undiagnosed Crohn's, or GERD. Second, physical therapists need to support patients that are on statins to stay on statins. In an ideal world patients should eat a predominantly plant-based or true Mediterranean diet to keep their cholesterol as low as possible; however, sometimes patients can't make this change or they have familial hypercholesterolemia, one of the most common genetic disorders in general practice. As such, PTs need to discuss family history, recommend patients to stay on statins, and refer them to the primary care physician for continued management of the hypercholesterolemia. Lastly, we as PTs need to talk more about diet! Encourage patients to dump the junk, focus on fruits and vegetables, and limit their saturated fat intake, which comes mostly from excessive animal product consumption. In the end, stopping AD may not be possible, but preserving function and quality life is obtainable.


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If you like what you see here then know there is more in our 3 board-approved continuing education courses on Nutrition specific for Physical Therapists. Enroll today in our new bundled course offering and save 20%, a value of $60! 


Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

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Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. 
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Untold Physio Stories - Someone Loves Their Recreation - themanualtherapist.com


Can you have too much recreation and not enough work? Can you be too compliant? Some very diligent people really take the home exercise program to the next level! Erson discusses a case where stress relief added up to some lumbar stress.


Untold Physio Stories is sponsored by


Helix Pain Creams - I use Helix Creams in my practice and patients love them! Perfect in combination with joint mobs, IASTM and soft tissue work. Use code MMT2 to get your sample and get an additional revenue stream for your practice. Click here to get started.


Check out EDGE Mobility System's Best Sellers - Something for every PT, OT, DC, MT, ATC or Fitness Minded Individual


My PT Insurance - Insurance just got easier. check out the self employed and employed plans. Easy sign up and coverage that follows you wherever you practice in the United States. Save $20 if you sign up using our link.



Keeping it Eclectic...

[RESEARCH] Natural Disc Height Narrowing Does Not Help With Cervical Spondylolisthesis - theManualTherapist.com



Goal of the Study?

Disc height narrowing is thought to incur stabilization over time as discs dry out and age. However, in this study1, the researchers were curious to investigate the cervical spine as most previous knowledge of degenerative spondylolisthesis has been performed in the lumbar spine. The cervical spine is structurally different compared to the lumbar spine and has been trickier to ‘fix’ in the case of cervical spondylolisthesis. Often disc height loss will stiffen spinal motion segments, but these researchers were curious about whether the degenerative cascade seen in aging would naturally stabilize as the disc loses height.

Why are they doing this study? 

Cervical instability, or dynamic cervical spondylolisthesis, is a common problem for many. This is identified when a cervical vertebra will slip more than 1.8mm on its adjacent vertebra, most often seen in the frontal plane during flexion-extension motion. According to Kirkaldy-Willis’s work on the lumbar spine, a degenerative cascade will naturally stabilize over time. However, the cervical spine appears to behave a little differently. And because these unstable motion segments in the cervical spine contribute to ongoing pain for many, the researchers wanted to see if disc height narrowing stabilized the unstable motion segments naturally. In other words, if left alone, do cervical spines naturally become more stable over time?

 

What was done in this study?

The researchers looked retrospectively at 731 patients who underwent routine radiographs, including cervical flexion-extension x-rays. Additionally, each subject underwent CT or myelogram-CT. The researchers used a 2mm translation of one vertebra on another as an unstable spondylolisthesis. Of the 731 subjects, they identified 101 cases revealing cervical spondylolisthesis. Of these 101 cases, 68 demonstrated anterior translation, while 40 cases slipped posteriorly. If more than two levels were found to translate more than 2 mm, these cases were considered unique and not used and excluded from the data set. Two spinal surgeons evaluated disc height loss by comparing discs of the spondylolisthesis level and grading the disc height compression on a grade scale of 0-4. A zero grade indicated no height loss, a grade 1 indicated 25-50% loss, a grade 3 indicated 50-75% loss, and grade 4 indicated greater than 75% loss of disc height.

 

What did they find?

Disc height narrowing did not reduce the degree of slippage, which was opposed to what the researchers suspected. The researchers found that disc height narrowing was a risk factor for cervical spondylolisthesis. They also found that anterior slippage had more variation compared to posterior translation. Interestingly, disc height narrowing did not have as much effect on increasing the slippage when the translation was posterior compared to anterior.

 

Why do these findings matter?

Cervical spondylolisthesis appears to be different than what has been thought to occur naturally over time in the lumbar spine. Because these findings showed that the natural degenerative changes of the cervical spine did not stabilize the already moving motion vertebra in the cervical spine, time cannot be counted on to help cervical problems related to cervical spondylolisthesis. Solutions focussing on maintaining disc height should be considered in the future as disc height loss encroaches on the spinal canal and intervertebral foramen of the cervical spine.

 

At Dynamic Disc Designs, we create dynamic human anatomy models showing the dynamic disc height loss as it relates to the spinal spacing where nerves reside. Helping patients understand their own anatomy with the postures and activities they perform to maintain disc health is at the roots of our company. Consider taking patient education to the next level with a dynamic disc model.

Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

Learn more online - new online discussion group included!


Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. 
  • NEW - Online Discussion Group
  • Live cases
  • webinars
  • lecture
  • Live Q&A
  • over 600 videos - hundreds of techniques and more! 
  • Check out MMT Insiders
Keeping it Eclectic...

Untold Physio Stories - Ankle Sprain Jinx - theManualTherapist.com



Even though we often preach about PT negativity and avoiding nocebo during patient visits, it can slip out and happen to the best of us! Listen in as Erson describes how he jinxed a patient and friend about his sprained ankle.

Untold Physio Stories is sponsored by


Helix Pain Creams - I use Helix Creams in my practice and patients love them! Perfect in combination with joint mobs, IASTM and soft tissue work. Use code MMT2 to get your sample and get an additional revenue stream for your practice. Click here to get started.


Check out EDGE Mobility System's Best Sellers - Something for every PT, OT, DC, MT, ATC or Fitness Minded Individual


My PT Insurance - Insurance just got easier. check out the self employed and employed plans. Easy sign up and coverage that follows you wherever you practice in the United States. Save $20 if you sign up using our link.



Keeping it Eclectic...
Does Arthritis Cause Low Back Pain? - theManualTherapist.com


๐Ÿ‘€Does Arthritis Cause Low Back Pain?๐Ÿ‘€
[RESEARCH] Toe Flexor Strength and Balance - theManualTherapist.com


Toe Strength and Balance in 60’s +

INTRO:
The substantial role of large muscle groups in balance is recognized, such as:
  • Trunk
  • Hips
  • Knees
  • Ankles
However, significance of the toe flexor muscles is less well understood. 10 toe flexor muscles contribute to motion of the foot.

Extrinsics:
  • Flexor digitorum longus
  • Flexor hallucis longus

Intrinsics:
  • Abductor hallucis
  • Adductor hallucis
  • Flexor hallucis brevis
  • Flexor digitorum brevis
  • Flexor digiti minimi brevis
  • Lumbricals
  • Interossei
  • Quadratus plantae

Poor toe flexor muscle strength has been implicated in:
  • Poor postural balance
  • Injury risk
Quinlan et al. (2020), systematically reviewed the research to establish if toe flexor strength related to static and dynamic balance.

RESULTS:
9 studies with over 2200 participants met inclusion criteria. In each study, participants were over sixty years of age, and over 73 % of them were female.  All studies showed direct, proportional, and significant correlations between toe flexor strength and postural balance.

CLINICAL SIGNIFICANCE:
Toe flexor strength contributes to improved postural balance for people over the age of 60. Including specific Toe Flexor Exercises into workouts can have a positive effect on balance

LIMITATIONS:
  • No study was found/included for a younger population group
  • Primarily observational studies
SOURCE:
Quinlan et al. 2020. The evidence for improving balance by strengthening the toe flexor muscles: A systematic review. Gait and Posture, 81, pp. 55-56.

Dalton Urrutia, MSc PT

Dalton is a Physical Therapist from Oregon, currently living and running the performance physiotherapy clinic he founded in London for Grapplers and Strength & Conditioning athletes. Dalton runs the popular instagram account @physicaltherapyresearch, where he posts easy summaries of current and relevant research on health, fitness, and rehab topics. 
Want to learn more or contact him?
Reach out online:
@Grapplersperformance

Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

Learn more online - new online discussion group included!


Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. 
  • NEW - Online Discussion Group
  • Live cases
  • webinars
  • lecture
  • Live Q&A
  • over 600 videos - hundreds of techniques and more! 
  • Check out MMT Insiders
Keeping it Eclectic...