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Calorie Restriction and Physical Therapy - themanualtherapist.com



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

Diet crazes come and go in the hopes to correct health issues and for weight loss. Many diets are merely fads, not backed by evidence, and/or offer only short-term solutions. One dietary pattern that stands out from the pack is calorie restriction (CR), especially in regards to data on longevity. I have 2 peer-review publications in the area of CR and intermittent fasting, so I can share both the data and experiences of this diet. Let's take a quick look at calorie restriction and what physical therapists (PTs) need to know!

Calorie restriction is a dietary regimen where a person consumes typically 25-40% less calories than usual. In order to accomplish this calorie deficit a person must know their total daily caloric needs over several days. Calculating 25-40% of this total calorie needs a client can then reduce their calorie content of each meal in order to hit their calorie deficit. Usually there is not a time restricted component, as seen with the newly popularized time-restricted feeding (TRF). The big focus is eating less throughout the entire day. 

To most Doctors of Physical Therapy (DPTs) it may seem obvious that eating less will promote a negative calorie balance and reduce body mass, but other physiological effects do occur under CR. The biggest side effect, as seen by countless animal studies, is lifespan expansion. Most data show that in as little as 30% CR many animal organisms, from rats, primates, to grasshoppers, will live extend life by anywhere from 25 to 50%! In fact, of all the diet fads and ridiculous supplements, CR has been consistency one of the only mechanisms researchers have found to extend life. Unfortunately, designing a trial for humans is not in the works, so transferring this lifespan extension data to humans is impossible at this time. Regardless, animal trials have shown lifespan extension as well as significant reductions in chronic diseases and body mass index, two factors that greatly affect mortality and morbidity. Take a look at the data from this recent Pifferi, F., Terrien, J., Marchal, J. et al. article focused on primates: 

 

It clearly shows the positive effects of CR on primates both from a lifespan as well as a lifestyle perspective (e.g. quality of life, chronic disease development, etc). Interestingly in this study, the researchers noted in the primates on CR a reduction in grey matter (white matter was intact). Fortunately those CR primates did not see any appreciable deficits in cognition in memory, so perhaps this grey matter loss is insignificant for them. The monkeys were scheduled to eat 30% less calories but actually obtained only 24% fewer calories over the study. While a primate study is not a human trial it does show promise for us as well opens our eyes to possible mechanisms.

Data do exist on positive short-term effects of calorie restriction and some of the possible mechanisms in humans. Probably the most robust recent human examination of CR in humans was the CALERIETM clinical trial. CALERIETM stands for the Comprehensive Assessment of Long term Effects of Reducing Intake of Energy and is lead by researchers at Duke and in combination with the NIH. The study included 218 young and middle-aged, normal-weight or moderately overweight adults who were randomly divided into two groups. People in the experimental group were told to follow a 25% CR diet for 2 years, while those in the control group followed their usual diet. Unfortunately, humans being humans, the participants only met a 12% calorie deficit for the 2 years of the study. Despite not reaching their 25% target, the subjects still loss 10% of body mass and had other positive health effects, as seen here from the 2019 Kraus et al Lancet article: 

Physical therapists should see that even a 12% CR induced improvements in blood pressure, blood lipid profiles, and metabolic status in humans. Such improvements could greatly reduce the risk of heart disease, renal failure, cancer, and other chronic but preventable diseases that plague our modern healthcare system. Moreover, could it be that reducing these chronic diseases help to extend life?

Possibly, let's take brief look at some of the mechanisms of CR. Understand the literature is thick with animal data and physiological mechanism for CR, with much of these factors DPTs would never measure in clinical practice. The CALERIE certainly provides compelling evidence in humans that a 12% CR diet significantly reduce chronic inflammation as measured by c-reactive protein (CRP). Less inflammation translates to less heart disease, stroke, and other chronic conditions. In animals studies, researchers have noted improvements in autophagy, a process where the human body cleans out damaged cells. Autophagy is vitally important for the brain and often occurs at night, especially when the body is fasted. Data correlates poor autophagy of the brain with certain neurodegenerative diseases. Other data show a clear impact on the metabolic and hormone systems under CR with a lowering of insulin like growth factor 1 (IGF-1), which associated with cancers. Another potential factor is that CR may alter the gut biome, which may help to control diseases states. Lastly, CR may exert an effect on our genes via Forkhead Box Protein O (FoxO), which may alter transcription factors and mutations. The mechanisms for CR are complex, context-specific, and need further analysis.

In the end, PTs should be aware that CR may benefit their clients but with some obvious caveats and limitations. First, it should be apparent that may humans struggle to follow a calorie reduced diet. We see this nearly everyday and even in major clinical trials. Second, CR diets are not appropriate for those developing (e.g. neonates) or severely ill (e.g. trauma). Most of these individuals need a positive calorie balance, not a negative one. Third, CR may induce bone loss and reduced aerobic capacity, but these could be mitigated through exercise prescribed by a PT! Fourth, CR may not be palatable to many but they might find other diets more palatable with similar outcomes (e.g. intermittent fasting, time restricted feeding, 5:2 fasting). Doctors of Physical Therapy need to educate their clients on the benefits, as well as the risk associated with CR, and work with a patient's primary care or dietician to optimize their diet for life!

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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[RESEARCH] A Cross-sectional Analysis of Persistent Low Back Pain Using Correlations Between Lumbar Stiffness Pressure Pain Threshold and Heat Pain Threshold - themanualtherapist.com


Goal of the Study?

In this primary research article1, the authors had two goals: (a) Determine and quantify the relationship between biomechanical and neurophysiology measurements in lower back pain patients and (b) examine if the correlations differ when considered regionally (lumbar back) or segmentally.

 

Why are they doing this study?

To improve our understanding of Lower Back Pain etiology, better non-invasive measurement tools and techniques must be established and quantified. 

 

What was done?

A sample of 132 patients of the Spine Centre of Southern Denmark who had persistent non-specific Lower Back Pain was measured for three different sensitivities: (a) global spinal stiffness (GS) using a VerteTrack Device which applied a rolling weight across the S1 and T12 spine; (b) deep mechanical pressure pain sensitivity threshold (PPT) using pressure algometer which applied bilateral pressure at each lumbar segment and (c) superficial heat pain sensitivity threshold (HPT) using a handheld thermode at the midline of each lumbar segment. 

A series of statistical tests were performed to determine if there were any correlations between these three quantitative sensory metrics: Global Stiffness (GS), Pressure Pain Threshold (PPT) and Heat Pain Threshold (HPT).

 

What did they find?

The correlation coefficients (R) for each pair of these three quantitative sensory metrics; GS, PPT and HPT were calculated and tested for statistical significance. 

  • Correlation between GS and HPT were found to be poor and statistically insignificant (R = 0.23)
  • Correlation between GS and PPT were moderate (R = 0.38) and statistically significant
  • Correlation between HPT and PPT were good (R= 0.53) and statistically significant

Unexpectedly, the correlation between GS and PPT was positive, meaning participants with higher global stiffness had a higher pressure pain threshold. The authors expected the reverse. They based their explanation of this unexpected relationship on the body’s adaptive mechanical protection system. Pain is considered a protective response and a stiffer spine is more resilient to applied forces and therefore can tolerate a higher pain threshold.

The other’s unexpected anomaly was that for the three QST’s measured, no differences were found between the individual lumbar segments. This indicates that patients with persistent LBP are probably less able to perceive lumbar stiffness reliably, perhaps due to “Cortical Smudging”, an overlapping of the cortical homunculus. 

 

Why do these findings matter?

Around four out of five people have lower back pain at some point in their lives. It’s one of the most common reasons people visit healthcare providers. To successfully evaluate both the extent of LBP and the effectiveness of any treatment plan, a reliable metric must first be established. This study is an attempt to use stiffness (GS), heat (HPT) and pressure (PPT) as this critical metric.

 

At Dynamic Disc Designs, we have developed models with varying lumbar stiffness to help in the education of the possible sources of back pain. This new research is important in establishing greater understanding of the causes and solutions of low back pain.

Check out the exclusive Blue Disc Dynamic Model, made exclusively for EDGE Mobility System here!



 

via Dr. Jerome Fryer - Dynamic Disc Designs 


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Untold Physio Stories - Fracture or Something Else? - themanualtherapist.com


In this episode, Erson talks about a recent young soccer player who was kicked twice in the calf. The antalgic gait, inability to WB or extend his knee, plus overall sensitivity to touch made him think of a fracture as a differential Dx. Listen in to find out what the result was.


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[RESEARCH] Rotator Cuff Tear - Surgery v. Conservative Rehab for 55+ - themanualtherapist.com


Rotator Cuff Tear - Surgery v. Conservative Rehab for 55+


INTRO:
Non-traumatic rotator cuff tear is a common shoulder problem which can be treated either conservatively or operatively. Kukkonen et al. (2021) investigated the difference between clinical and radiological 5 year outcomes in patients aged over 55 years.


METHODS:
180 shoulders with symptomatic, non-traumatic supraspinatus tears were randomly assigned to:
  1. Physiotherapy (Group 1)
  2. Acromioplasty and physiotherapy (Group 2)
  3. Rotator cuff repair, acromioplasty and physiotherapy (Group 3).
Primary Outcome:
Constant score.

Secondary Outcomes:
Visual analog scale for pain and patient satisfaction.
Radiological analysis included evaluation of glenohumeral osteoarthritis and rotator cuff tear arthropathy.

RESULTS:
The average tear size of the supraspinatus was 10 mm in all groups.

There were no significant differences in the average change of Constant score:
  • 18.5 points in Group 1
  • 17.9 points in Group 2
  • 20.0 points in Group 3.
There were no statistically significant differences in the change of visual analog scale for pain and patient satisfaction. At follow-up there were no statistically significant differences in the mean progression of glenohumeral osteoarthritis or cuff tear arthropathy between the groups.

CONCLUSIONS:
  • Operative treatment was no better than conservative treatment with regard to small non-traumatic single tendon supraspinatus tears in patients over 55 years of age.
  • Operative treatment does not protect against degeneration of the glenohumeral joint or cuff tear arthropathy.
  • Conservative treatment is a reasonable option for the primary initial treatment of this condition.
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SOURCE:
Kukkonen et al. 2021.
OPERATIVE VS. CONSERVATIVE TREATMENT OF SMALL NON-TRAUMATIC SUPRASPINATUS TEARS IN PATIENTS OVER 55 YEARS. Journal of Shoulder and Elbow Surgery

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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3 Factors That the Vestibular Therapist Should Know About BPPV and Stroke - themanualtherapist.com


During the differential diagnosis of a patient with vertigo or dizziness, it is pertinent that the clinician determine if the symptoms are benign / non-benign or central / peripheral.

This is our red light or green light system to treat or refer. This is by far the most important decision that comes out of a clinical evaluation and is especially important with neurological symptoms.

The most common benign cause of vertigo is benign paroxysmal positional vertigo (BPPV). There are specific subjective and objective findings that are crucial to ruling in BPPV in the dizzy patient.

A physical therapist trained in vestibular rehabilitation is well aware of these findings and do a splendid job at helping people! We are actually very good at differential diagnosis and use the latest research to help refine our clinical exam!

In some instances, patients who are having dizzy/vertigo symptoms seek out help from physical therapists with thought they are having BPPV but instead it is an early sign for a stroke. Early diagnosis and intervention are crucial for successful treatment in patients with acute ischemic stroke because prompt thrombolytic treatment improves outcomes. We also do not want to propel a spontaneous dissection through a mechanical input, such as with manual therapy, Dix-Hallpike testing or even range of motion.

In fact, ischemic changes affecting the vestibular artery in patients with BPPV could precede a full-blown ischemic stroke. These ischemic changes affecting the vertebrobasilar system could initially produce vestibular symptoms, such as BPPV.

Here are a three factors for the vestibular therapist to know about BPPV and stroke:
  1. The vestibular organs are vulnerable to ischemic obstruction. This is due to the “small creek” that finally lead to the organs from the anterior vestibular artery, which as we know, originate initially from the vertebral-basilar artery. Therefore, a disturbance of adequate hemodynamics to this region could indicate a disruption more proximal, such as in the vertebral-basilar artery.
  2. There are common risk factors associated with both BPPV and ischemic stroke. These can include osteoporosis, smoking, alcohol consumption, anxiety, cardiovascular disease and diabetes. Conditions such as obesity, cardiovascular disease, and diabetes are chronic diseases and related to stroke onset. Therefore, a correlation can be made that BPPV increases the risk of ischemic stroke.
  3. BPPV is recurrent and can lead to lifestyle changes. One lifestyle change can be physical inactivity. Physical inactivity following BPPV might increase the risk of an ischemic stroke. A sedentary lifestyle due to avoidance of activities from fear or provocation of vertigo/dizzy symptoms can occur in these patients over time. Our goal is to educate our patients to stay active with proper recommendations based off of the patient’s presentation. Our goal too is to get them better so they do not have impairments!
These are just 3 factors that we believe a vestibular therapist should be aware concerning ischemic stroke while treating a dizzy patient. Having this knowledge helps us go beyond the thinking of pathophysiology of cupulolithiasis and canalolithiasis. These factors can lead to knowledge of not only signs and symptoms associated with non-mechanical and mechanical causes of dizziness, but also education for our patients for the long term, especially for those with recurrent vertigo.

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

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Untold Physio Stories - Let's Review Those Exercises - themanualtherapist.com


In all of his initial evaluations, Erson goes over resets and any prescribed exercises 20-30 times minimum. When a patient gets relief from an end range loading reset, he makes sure they understand the how's and why's of the movements. When the same resets spontaneously start worsening the complaints after 2 weeks of relief, something is probably going wrong...

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Accuracy of ACL Special Tests - themanualtherapist.com


Accuracy of 3 ACL Diagnostic Tests


INTRO:
The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee. 

In America, estimates of ACL injury cases range from 80,000 to 250,000 per year, with approximately 100,000 of these patients undergoing ACL reconstruction surgery. 

The 3 primary diagnostic assessments of these manual tests are:
  • Anterior drawer test.
  • Lachman test.
  • Pivot shift test.
Hunag et al. (2016), performed a meta-analysis, looking at diagnostic sensitivity and specificity of the 3 assessments to evaluate the diagnostic accuracy of the anterior drawer, Lachman, and pivot shift tests. 

RESULTS:
  • 16 studies assessed the accuracy of the 3 tests for diagnosing ACL ruptures & met the inclusion criteria. 
  • Lachman test; most sensitive test to determine ACL tears (87.1%).
  • Pivot shift test; most specific test (97.5%) & has the highest positive likelihood ratios (LR+) of 16.00.
  • Lachman test has the lowest negative likelihood ratios (LR−) of 0.17. 
CONCLUSIONS:
In cases of suspected ACL injury:
  • Perform the pivot shift test, as it is very specific and has greater likelihood ratios in diagnosing ACL rupture. 
  • The Lachman test has favorable efficacy in ruling out a diagnosis of ACL rupture.
  • The anterior drawer test is the least proven of the 3 approaches in diagnosing ACL rupture.
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SOURCE:
Huang et al. 2016. Clinical examination of anterior cruciate ligament rupture: a systematic review and meta-analysis. Acta Orthop Traumatol Turc 2016;50(1):22–31 doi: 10.3944/AOTT.2016.14.0283.

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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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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  • over 600 videos - hundreds of techniques and more! 
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