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Untold Physio Stories - Correcting an Ipsilateral Lumbar Lateral Shift - themanualtherapist.com


If you have ever seen a lumbar patient with a true lateral shift, you would know they're not the easiest or straight forward patients. An ipsilateral lumbar lateral shift usually has poor outcomes. If it's actually discogenic and you have to shift away from the side of symptoms (they are shifted toward the pain instead of away) to correct the shift, this could make the disc protrude or herniate worse. In the 200th episode of Untold Physio Stories, Erson goes over the problem solving he used to treat an ipsilateral lateral shift case he saw recently.

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Should PTs Use a New Model for Weight Loss? - themannualtherapist.com


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

For decades the predominant model that dictated weight gain, loss, or maintenance was the energy balance model (EBM). The EBM is rooted in one of the basic laws of thermodynamics. It goes without saying that food contains energy and it is typically measured in a unit known as calories (kilocalories in the dietary world). As a person consumes food it provides energy to do work such as exercise, activities of daily living (ADL), physical therapy, basic living functions, or even sport. Energy can come from recently consumed food or stored energy (e.g. fat, glycogen, or protein) from previously eaten food. 

Clinicians often explain weight loss to patients as “calories-in versus calories-out” or CICO, which directly relates to the EBM. In brief, CICO helps rehab professionals to explain to clients the balance between the energy coming into their body versus the energy they expend: too much food coming in and not enough expenditures means weight gain, while too little food or excessive exercise means weight loss. Simple, right?

Well, a new model of weight maintenance has been postulated which focuses on the consumption of carbohydrates and their interaction with hormones. The carbohydrate-insulin model (CIM) asserts that our obesity epidemic has only worsened with greater emphasis on CICO and that we as clinicians ought to focus more on reducing refined carbohydrates. The alternative paradigm proposes that increasing fat deposition in the body—resulting from the hormonal responses to a high-glycemic-load diet—drives a positive energy balance. In other words, consuming highly refined carbohydrates can increase fat deposition and alter hormones that further drive more fat mass gain.

What’s the evidence for this new alternative paradigm and how should it impact Doctors of Physical Therapy (DPT)? Let’s take a quick glance at the data and see what’s really happening.

The CIM model weighs heavily on a notion known as glycemic load (GL). A GL can be calculated based on the quantity and glycemic index (GI) of a food. Thus, a meal with only a few bites of a white bread has a relatively low GL versus a meal with a giant bowl of refined pasta. Starchy vegetables like potatoes and cassava, while not refined, may also deliver a high GL if eaten on their own or in very large quantities. 

Why does the GL matter? Well, according to the new CIM it is this GL which drives an post-prandial anabolic state. In this anabolic state we see an increase in insulin secretion, suppression of glucagon secretion, and facilitation of a glucose-dependent insulinotropic polypeptide (GIP)-dominant incretin response. Initially, after a large GL meal, these hormonal factors help with absorption. However, eventually this strong anabolic state may drive a significant release of glucose from the liver and muscles. Such a release of glucose from the liver and muscles may trigger the central nervous system to activate a hunger response. Studies show that a hunger response from the CNS often drives individuals to seek out rapid energy sources of food (e.g. more refined carbs). And so goes the cycle, purportedly, that a person eats refined carbs → gets hungry → eats more refined carbs with obesity being the end product. Here’s a representation of the CIM from Ludwig et al 2021:



Data to support CIM is still evolving. Authors of a recent review by Ludwig et al provide evidence against EBM, limited evidence supporting CIM via trials, but cite evidence supporting many of the hormonal notions above in animal and lab modeling studies. Ludwig et al do go further by providing arguments against the CIM but with the intention of refuting such arguments. Many of the arguments are sound but leave the reader open with much interpretation as nutrition science has many facets, is multifactorial, and often full of confounding factors.

One big factor I see as a limitation of the CIM is that most dietary guidelines do not support the consumption of highly refined grains. Other organizations, such as the American Heart Association and the American Diabetes Association, put recommended limits on added sugar in much of their literature. The 2020 Dietary Guideline for Americans (DGA), while rife with industry influence, also discourages the consumption of refined grains. As such, our guidance and clinicians already engage and educate clients on reducing their refined carbs and added sugar intake. Palatability of such foods is addressed by Ludwig et al, but I argue that many of these foods are consumed out of convenience, due to lacking food supplies (e.g. food deserts), and/or familial patterning with meals/snacks. I agree with the authors that palatability of foods can be changed -- it takes time, exposure, and education! 

Another severe limitation with the publication is the underlying bias of the ketogenic diet. Currently the evidence supports the use of the keto diet for epilepsy. Keto has grown in popularity, partially because of short term weight loss studies and success stories, and the fact that the food can be very tasty (lots of fat!). Adding excessive fat can be detrimental to the gut biome and potentially have other untoward effects (e.g. heart disease from excess saturated fat). Moreover, many keto dieters struggle with bowel movements and micronutrient deficiency due to the lack of fiber and variety of foods. As such, I question whether the authors, such as Gary Taubes, have financial ramifications for publishing a CIM article. Afterall, there are huge financial gains for developing a model for weight loss that helps to support a diet (keto) that is sold in your books, subscriptions, and diet programs.

My final perspective on the CIM is that it still comes back to energy balance. While refined carbohydrates may alter hormones which drive more refined carbohydrate consumption, there still exists the will to change this behavior, eliminate the refined carbs in the diet, and avoid or reduce the weight gain over time. Physios working in wellness or with clients wanting to lose weight should educate their patients to avoid purchasing refined grains and sugars. Have your clients stick with a variety of whole plant based foods and they will feel full thanks to the fiber, lower GL, and small bits of protein. I completely agree, along with many other dietary guidelines, with Ludwig et al in that quality of food matters. However, the food quality does not change the laws of thermodynamics. 

In my opinion, we do not have sufficient evidence for PTs and rehab professionals to incorporate the CIM as the best weight loss model available. I think Ludwig et al have detailed a feedback mechanism for why people may repeatedly consume refined foods, which drives a positive calorie balance and weight gain, but they didn’t derive a whole new paradigm for weight loss. The CIM is merely EBM plus a feedback mechanism -- calories in, calories out!

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!

 



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5 Symptoms of Cervicogenic Dizziness - themanualtherapist.com


There are a range of symptoms and variety of potential descriptions of cervicogenic dizziness. Cervicogenic Dizziness symptoms can vary from one person to another and still carries the weight of controversy.

The description of dizziness, including a sensation of spinning and/or dysequilibrium is common (Krabak et al 2000Kalberg 1996).  It has even been described generally as dizziness that may be associated with headache, cervical pain, nausea, cold sweats and/or nonspecific complaints (Morinaka 2006).

With that said, the following are the top 5 symptoms of Cervicogenic Dizziness.

  1. Lightheadiness
  2. Drunkenness
  3. Unsteadiness
  4. Feeling of imbalance
  5. Room spinning

It is highly recommended to exclude other sources of dizziness prior to making a diagnosis of cervical origin. We recommend using the Optimal Sequence Algorithm, a detailed subjective and objective screening process.

There are some fine details in symptom and presentation characteristics between several types of dizziness. The differential diagnosis can mean a difference between referring out or greenlight to treat in an outpatient setting.

If benign disorders of the dizziness are found, then the patient could have a double entity, which is both a vestibular disorder and cervical disorder. That is why the patient’s symptoms may vary or change between several of the descriptors above.

CERVICOGENIC DIZZINESS COURSES AND CERVICAL VERTIGO COURSES

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the entire weekend includes the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” and treat through the “Physio Blend”. 

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

via In Touch PT


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[RESEARCH] Evaluation Is Treatment for Low Back Pain - themanualtherapist.com


Goal of the study?

In this study,1 the purpose is to investigate if the physical therapy (PT) evaluation process of history taking and physical exam results in a meaningful change for patients with low back pain (LBP), even before implementing treatment interventions. 

 

Why are they doing this study?

Low back pain (LBP) is the most widely reported musculoskeletal disorder globally and has significant healthcare expenditures. In the US, LBP accounts for 25% of outpatient physical therapy (PT) visits, with an estimated 170,000 people daily seeing a PT for this issue. 

With a shift toward a biopsychosocial model, more focus has been put on the therapeutic alliance (TA) and its impact on patient outcomes. TA is essentially the working social connection between a patient and clinician, blending clinical skills, verbal and non-verbal communication, a sense of warmth, collaboration, and trust. There is increasing evidence that TA and trust play a significant role in patients’ pain outcomes before any formal treatment is started.

 

Evaluation

 

What did they do?

This observational study included 34 patients with LBP with/without leg pain who went to four different outpatient PT clinics over a 3-month period. They had one PT at each site do the history taking and physical exam, and a different PT does the outcome measurements. Before the examination, all participants completed a demographic survey, disability index, and outcome measurements, including pain (low back and leg; numeric pain rating scale – NPRS), fear-avoidance beliefs (FABQ)Pain catastrophization (PCS), lumbar flexion, nerve sensitivity – pressure pain thresholds (PPT). After completing this pre-assessment, history taking and physical exams were done on each patient. 

All data were analyzed using statistical software.

 

What did they find?

This study found that for patients with LBP, the process of history taking and a physical exam had a significant therapeutic effect regarding fear-avoidance, pain catastrophization, movement and sensitivity of the nervous system. However, while some changes met or exceeded clinically significant differences, these were not correlated to physical exam duration and perceived connection by the PT.

Following history taking, the authors also found that NPRS for leg pain, PCS, trunk flexion, and PPT measurements showed a significant change from the initial intake. While adding a physical exam generated some improvement, only active trunk flexion and PPT for the low back were significantly improved compared to the measurements after history taking alone. Overall, they found that history taking resulted in the most significant changes seen in the evaluation process. The authors suggest that in line with existing research, this finding may result from the fact that history-taking happens at first contact and therefore provides an opportunity for a connection to alleviate patient fears and establish a TA. 

They did not find that the PT’s connection with the patient altered changes in pain or function.

 

Limitations?

The main limitation of this study is the study design. Being observational, the findings cannot speak to any causal relationships between the changes and outcome measures. Additionally, as there were no strict controls on the history taking and physical exam, with each PT doing them their own way may have affected the findings.

 

Why do these findings matter?

Understanding what factors provide the most significant treatment outcomes for patients with LBP can help address patient pain and function and reduce overall healthcare costs.


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Greater Trochanteric Pain Syndrome - themanualtherapist.com


Greater Trochanteric Pain Syndrome

INTRO:

Greater trochanteric pain syndrome (GTPS) is a general term used to describe disorders of the peritrochanteric space, including:
  • Trochanteric bursitis.
  • Abductor tendon pathology.
  • External coxa saltans.

GTPS is a common cause of lateral hip pain and tenderness. While GTPS is seen in all age groups, it most commonly affects patients between 40-60 years old. While conservative treatment is effective for most patients with GTPS, many demonstrate symptoms refractory to physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and corticosteroid injections (CSIs). Accurate diagnosis of the specific etiology of GTPS and the degree of gluteal tendon injury are critical to guiding appropriate treatment.

Pink et al. (2021), systematically reviewed the research and highlighted the clinical and radiographic findings that can differentiate GTPS from other causes of lateral hip pain and guide management.

RESULTS:

Clinical Tests:
  • Tenderness to palpation over the greater trochanter (Sensitivity 80%; Specificity 47%)
  • Pain with abduction against resistance (Sensitivity 38%; Specificity 93%)
  • Pain with internal rotation against resistance (Sensitivity 44%; Specificity 93%).
  • Pain with single leg stance (Sensitivity 38%; Specificity of 100%)

Abductor tendon tears often present with abnormal gait and weak hip abduction.

Differential Diagnoses:
Intraarticular sources include:
OA, avascular necrosis, labral tears, FAI, femoral neck stress fractures, and loose bodies.

Extra-articular causes include:
Lumbar stenosis, and meralgia paresthetica.

CONCLUSIONS:

GTPS encompasses a spectrum of pathologies and diagnosis can be challenging. Proper evaluation relies primarily on careful clinical examination. Traditional nonoperative management with activity modification, physical therapy, NSAIDs, and CSI remains the mainstay of treatment. In chronic symptoms operative techniques have demonstrated excellent outcomes.

SOURCE:
Pianka et al. 2021. Greater trochanteric pain syndrome: SAGE Open Medicine Volume 9: 1–12.

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SOURCE:
Dattilo et al. 2020. Effects of Sleep Deprivation on Acute Skeletal Muscle Recovery after Exercise. ACSM

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

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Top 3 Tips for Geriatric Rehab and Nutrition - themanualtherapist.com


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

Exercise is certainly medicine but what if we could do more for our older adult clients? As physical therapists (PTs), occupational therapists (OTs), or personal trainers we strive to push our clients with the best exercise selection and most evidenced-based techniques to improve our clients’ strength, balance, and function. But what if all we are doing is for not because of a client’s poor diet? 

I have seen this time and time again in my clinical practice: a client enters my practice, I examine them and find weakness and balance deficits; we begin a program of resistance training, balance and neuromuscular work, and notably see little change in their function. As I dive deeper into their lifestyle factors (e.g. sleep, stress management, and nutrition) I find they don’t eat enough, drink too much alcohol, and consume overly processed foods devoid of essential nutrients.  Could these factors be the elements holding some of our older adults back from improving better rehabilitation outcomes? Let’s look at some examples and evidence connecting nutrition with geriatric physical therapy and rehabilitation.

Physiologically, older adults' sense of taste and smell diminish with age. Moreover, other factors such as dental changes or pain with mastication, swallowing problems, or GERD may further drive an older adult away from consuming enough food. As a result we often see older adults not enjoying food as much as they did when younger. Not consuming sufficient energy can drive catabolism and, if sustained, drive sarcopenia (muscle mass loss secondary to aging). We also know that data supports the consumption of slightly higher protein intake in older adults. Typically the FDA recommends 0.8g/kg body weight/day of protein for most adults, but some older adults may gain muscle mass and mitigate some bone loss with protein levels slightly higher than this (e.g. 1.0g/kg body weight/day). Having more muscle mass can equate to better functional scores on the Timed Up and Go (TUG), Five Time Sit to Stand (FTSTS), and balance metrics. Rehab professionals can help their patients by asking a client about their diet and trying to understand why an older adult may be undereating. If it is due to a sense of smell or taste, then consider encouraging the use of aromatic spices as another method to improve the smell and taste of food. If it is swallowing or dentition, then consider a referral to a Speech Therapist (SLP) or dentist -- helping them get food into their bodies is essential!

Alcohol is another underestimated portion of an older persons’ diet that can negatively impact their rehab outcomes. Older adults may use alcohol to cope with a loss of a loved one, as a means to control shakes or tremors, or as an aid to meet social requirements. Alcohol is a central nervous system depressant, which data show can translate to more falls, higher rates of depression, and can drive neuroinflammation. Discussing alcohol consumption with older adults during therapy is important. Many mentees and students of mine are utterly surprised at how many and how much alcohol their clients consume once they start asking. Several evidenced-based alcohol assessment tools exist: I encourage Doctors of Physical Therapy (DPTs) to use these tools in their physical therapy practice to screen for referrals to alcohol cessation programs or professionals.

Our final discussion point centers around the high consumption of processed foods. Several NIH studies have shown that ultra processed foods are linked with greater rates of obesity and morbidity. As rehabilitation professionals we know that obesity makes movement difficult and data show it also promotes inflammation. Multiple comorbidities reduce an older patient’s successful rehab prognosis, as well as decreasing their quality of life. Ultra processed foods like potato chips, white-bread sandwiches, and sugary fruit drinks offer little nutrients but lots of calories. Malnutrition is certainly a risk with some older adults and this can be easily detected with the MNA-SF screening tool (it’s very  easy to use). Referrals to a registered dietician (RD) is a must in possible malnutrition cases. In addition, sarcopenic obesity, where an older adult loses muscle but gains fat mass, can often present in older adults unknowingly. Individuals with sarcopenic obesity often present without looking thin or atrophy due to the fat mass gain; however, PTs will notice they are weak and cannot perform functional movements with ease. Doctors of Physical Therapy and other rehab professionals need to educate patients on reducing their consumption of processed foods. Detecting junk food consumption is easy using the fruit and vegetable screener or a 3 day diet assessment. Advocating for quality, whole-foods in hospitals, nursing homes, and rehab facilities is also in the wheel-house of rehabilitation professionals. Referrals to RDs should also be considered a mainstay for PTs, especially if multiple comorbid conditions exist. 

After all, what’s the point in all your skilled services and the patient’s hard work if it all gets sidelined by crappy food?

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!


Via Dr. Sean Wells - Nutritional PT



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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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