Complications associated with health interventions concentrate the mind when associated with debility or loss of life. In rehabilitation medicine, thankfully, as in most areas of modern healthcare in Canada these occurrences are few – though no less impactful when they do occur. Complications associated with neck manipulations are well publicised and give pause to manual therapy for patients with neck pain. A very cursory search of media reports purport to find many a bad outcome to these procedures. However, to advance safety in treatment of neck pain, meaningful research is needed that utilize both new and innovative approaches.

In March of 2017, I was with a team of spine researchers from the University of Alberta led by Dr. Greg Kawchuk that presented preliminary research findings on neck movements and positions and their impact on blood flow to the prefrontal cortex. The conference was an international gathering in Washington DC (DC 2017) that included spine researchers, spine physicians, physiotherapists and chiropractors. Our contribution highlighted work around screening tests that would exclude potential complications from neck manual therapy. We investigated whether eight basic neck movements in and of themselves altered changes in total blood volume in the prefrontal cortex. This area of the brain was chosen because of its importance in general executive function, and we used a relatively new investigative technique known as near infrared spectroscopy to monitor blood volume changes over the area. The investigative technique is essentially a light of specific wavelength that monitors changes in the hemoglobin molecule and their various concentrations associated with the neck movements. After testing 27 graduate students we were able to detect significant changes in blood volume with a combination of neck position and side of the cortex. Specifically, there was significant drop in blood volume with combined right-side flexion and extension, but the greatest reduction occurring was in full flexion. These are preliminary findings but may indicate the beginning of an effective screening device that could rule out those who might be “strokes in progress” when attending for neck treatment.

Notwithstanding, there remains in current practice many safe approaches to treatment of neck pain, particularly those treatments that emphasize postural correction and exercise.

Feedback is welcome – hercules.grant@rejuvenationhealth.ca

No Magic Bullet but Many Solutions
“New Thoughts on Rehabilitation”

The challenge of musculoskeletal injuries is in many ways similar to the various issues that confront other areas of modern medicine. They include the effects of an aging population, increased disease complexity, and the accompanying changes in the threshold of what is considered an acceptable treatment outcome. The important question is the reasonable comparison between the efficacy of various treatment approaches. Interestingly, numerous interventions in psychotherapy with very different treatment philosophies have very similar outcomes as per meta analysis (Wampold, 2015). Similarly, it is well known that in the musculoskeletal treatment of the low back, approaches as varied as exercise, education and manipulation have similar outcomes when subjected to randomized control trials (Keller et al., 2007).

To explain the similarity in outcome across various methods in physical therapies as well as psychological therapies, the “common factors” approach is a developing trend. This approach suggests that underlying factors common to the various therapies contribute more significantly to the outcome than the particular therapeutic technique itself. In a recent communication by Maxi Miciak PhD from the University of Alberta, she suggested that contextual factors such as the therapeutic relationship established between patient and practitioner provides a major portion of the outcome variance in physical therapy procedures. Some researchers (Keller et al) suggest that intangibles such as patient expectation and self-efficacy contribute up to four times more than the specific intervention itself.

Evidently successful physical rehabilitation will be an intersection of emotional factors and the particular physical therapy intervention. Actively building patient self efficacy through the therapeutic relationship such as clear goal setting and tactfully managing but elevating client expectations will likely enhance outcomes.

Psychiatry, Oct 14(3), 270-7.
Tschacher, W., Junghan VM, & Pfammator M. (2014). Towards a taxonomy of common factors in psychotherapy. Results of an expert survey. Clin Psychol Psychother 21(1) 82-96.
Keller et al 2007 Eur Spine J.
Miciak, M, Gross, D & Joyce , A. (2012). Scan J Caring 26; 394-403

 

Back School Program

Patient education as an integral tool in relieving and preventing back pain has been touted for many years. Yet for a variety of reasons this intervention is only widely used in the very large rehabilitation centres. Time constraints and an evolving funding model explain the absence from standard medical and therapy practice of widespread and dynamic patient education.

The value of “back schools” (a program of intense back care education, exercise and body mechanics advice) to control back pain was popularized in Sweden at the Volvo plant in the early 1970s. California Back Schools started shortly thereafter. At about the same time, the New Zealand physiotherapist Robin McKenzie initiated a revolutionary approach to treating “mechanical low back pain”.
Fast forward to where we are today. The efficacy of a concerted attempt at patient education and exercise training as the cornerstone of treating back pain is well known, yet strikingly underused in practice. A systematic review of the spine literature of 12 years ago (Hymans et al., 2005) reported moderately high evidence for this intervention in reducing pain and improving function in both the short and intermediate term. The back school results were reported to be more effective than placebo, manual therapy and other physical therapy type interventions. The findings also indicated that back school intervention resulted in less use of pain and anti-inflammatory medication. More recently, in a randomized controlled trial, the addition of back school intervention to a regular physiotherapy program was proven to be more effective than physical modalities alone (Sahin et al., 2011).

To be most effective in a modern clinical setting, the Back School program will have to adjust to the need for rapid dissemination of the most current information. Strategic use of lumbar stabilization exercises, patient training in self care, body mechanics and the improved general knowledge of back function will render the back school approach both cost effective and helpful in prevention and recovery. The new Rejuvenation Health Back School program utilizes a strong patient education focus. It also includes meaningful spinal muscle training along with established approaches to back care pioneered by McKenzie and Hamilton Hall.

Rejuvenation Back School has started sessions at our Terwillegar and West clinics and will begin at our Meadows location in mid June. We look forward to having your patients as a part of this exciting therapeutic approach. Please refer them to one of our three locations listed below for further information.

Lumbar Spinal Stenosis

The underlying causes of back and leg related symptoms are many. However spinal stenosis is one of the readily identifiable reasons for such symptoms and reportedly accounts for a three-fold increase in back and leg pain (Kalichman et al; 2009). Fortunately, these symptoms are amenable to a disciplined and concerted rehabilitation approach.

Narrowing of the spinal foramen may be congenital, but most often it occurs as a part of the cascade of events that accompany degeneration of the spine. Typically, these patients are in the 50’s and older age group with enlarged facets joints, narrowed lumbar discs and spurs that may narrow the foramen through which the spinal nerve exits. The resulting stenosis results in symptoms that mimic vascular insufficiency in the lower limbs thus limiting the patient’s level of physical activity.

Recent approaches using client education, intense physical training and spinal manual therapy have demonstrated significant improvement in symptoms and functional ability over an 8-week program. These programs (Amendolia et al; 2017), referred to as “Bootcamp programs” for spinal stenosis are having superior results compared to other approaches in enhancing the functional outcomes of these patients.

Rejuvenation Health Services Inc will be starting these programs at our Terwillegar clinic this fall. Please contact Hercules Grant PhD PT at this location for further information. hercules.grant@rejuvenationhealth.ca

An article published in the scientific journal, Spine in 2004, by Physical Therapist Audrey Long and Orthopedic Physician Ron Donelson clarifies the debate on whether the type of spinal movements matters to speed of recovery. In their study, these researchers determined whether previously validated low back pain subgroups responded differently to contrasting exercise prescriptions.

The multi-centred randomized controlled trial included 312 low back pain clients who were divided into subgroups depending on their responses to mechanical assessment of the spine. Each subgroup was characterized by immediate and clear response to movements of flexion, extension, side-bending or rotation. Each subgroup was then given a “directional preference” for one of these movements. In other words, there was pain relief while moving in that particular direction. These clients were randomly assigned to one of three groups. One group was given exercises that matched the directional preference; another group was given exercises that moved in an opposite direction to directional preference, while the final group was given exercises with no specific directional preference. One third of the subgroups who were performing exercises opposite to the directional preference and no particular directional preference withdrew from the study due to increase in pain. The subgroup performing exercises that matched directional preference completed the study with significant reduction in pain, medication use, work interference and disability (P<.0001). Consistent with prior evidence (notably Hamilton Hall – Back Doctor) standardized mechanical assessment can identify subgroups of clients. Matching exercise movements to directional preference, as determined by assessment, can result in significant improvement in disability scores, pain reduction and work outcomes. A physiotherapist with experience in this approach, notably the McKenzie approach, is trained to implement such a treatment regimen. Should you have any questions or concerns regarding this clinical brief, please contact Hercules Grant PhD.

FREE Winter Workshops

Low Back Pain – the Reflections of a Spine Rehab Leader

Among the foremost practitioners in the art and science of treating spinal pain is the renowned New Zealand physical therapist, Robin McKenzie. According to McKenzie, there are three (3) predisposing factors underlying the epidemic of back pain we observe in industrialized countries. The most important of these factors is the sitting posture. Sitting when unsupported reverses our lumbar curve placing important ligaments under full stretch. Additionally, a poor sitting posture in and of itself can produce pain even without trauma. Further, poor sitting postures will worsen and perpetuate existing back pain. Indeed most back pain patients complain of pain while sitting or rising from sitting. It has been well established that sitting in a kyphotic position (spine flexed), tends to increase intra-disc pressure in the lumbar region. Thus, poorly designed work stations conspire with the frequent and prolonged sitting position to dramatically increase the incidence of back pain.

Hand in hand with prolonged sitting is our second predisposing factor, a general loss in lumbar extension. According to McKenzie, significant loss of lumbar extension becomes apparent at age thirty. Without adequate training to prevent this trend, the loss of extension predisposes the spine to a kyphotic posture with concomitant increased disc pressure and compromised ligament length. With these adaptive changes, the threshold for stress to provoke pain is that much more readily reached.

The third predisposing factor in the epidemic of low back pain is the relative increased frequency of tasks requiring forward flexion of the spine. In analyzing our daily routine we see flexion with brushing the teeth, shaving, driving, sitting at the computer, leaning across the table, etc. It is safe to say that our routine mostly causes us to flex the spine and not to extend. Consequently, the sensible use of spinal extension in back care is what McKenzie refers to as the “beginning of a prophylactic concept”. Hence all treatment approaches should lead to recovery of extension as an integral part of the rehab strategy.

(For comments and feedback contact Dr. Hercules Grant, hercules.grant@ rejuvenationhealth.ca)

Blog Posts

Clinic Locations

Copyright 2016 Rejuvenation Health Services, All Rights Reserved

Our Clinics

Glenwood Clinic (West)
#203, 16028 100A Avenue, Edmonton, Alberta T5P-0M1
Phone: 587-524-9623  Fax: 587-524-9624

Terwillegar Recreation Centre Clinic
#1 2051 Leger Road, Edmonton, Alberta T6R-0R9
Phone: 780-431-9623  Fax: 780-431-9624

Meadows Recreation Centre Clinic
2704 17 Street, Edmonton, Alberta T6T-0X1
Phone: 780-465-9940  Fax: 780-465-9944

Stay Connected with Rejuvenation Health Services

Increased use of computers in the modern office has resulted in neck and shoulder girdle pain demanding more precise attention from therapists and physicians. The haste to offer relief to these workers is preceding the full understanding of the musculoskeletal function of this region of the body. In this regard, what differentiates computer workers with neck pain from similar workers with no pain is unclear.

A cross-sectional study in Spine (2008) explored aspects of neck function in female office workers. The salient aspects of the study were as follows.

Method: Eighty-five office workers were recruited from 333 survey participants investigated for neck pain risk. The inclusion criteria were symptomatic workers in a seated computer workstation situation for > 2yrs while working for > 4 hours per day. Workers with a history of neck surgery, trauma, fibromyalgia, cervical radiculopathy or systemic illness were excluded from the study.
Objective measures included neck range of motion, EMG activity of the anterior and posterior neck muscles while performing unilateral hand coordination tasks.

Results: Workers with neck pain had reduced rotation range of motion and increased activity in the superficial neck flexors. Additionally the coordination-type activity resulted in greater activity in the cervical extensors bilaterally. On completion of the task, the upper trapezius and dominant side cervical extensors and anterior scalenes demonstrated an inability to relax. In general there was a “linear relationship between the workers’ self-reported levels of pain and disability and the movement/muscle function changes”.

Conclusion: Neck dysfunction in this group of office workers represent possible altered muscle recruitment strategy to stabilize the head and neck during work-related activities. Therapies involving exercise and ergonomic advice that address changes in muscle function associated with this type of work are likely to have meaningful results in this population.

Adapted from Spine (2008), 33(5): 555-563.
Please provide feedback to Dr. Hercules Grant (Rejuvenation Health Services Inc)
Email: hercules.grant@rejuvenationhealth.ca

A 2009 communication on research of the injured shoulder by University of Alberta professor Judy Chepeha summarized the state of therapy for the non-surgical rotator cuff injury. These injuries represent an increasingly prevalent source of occupational restriction. Typically, the presentation is characterized by pain with above shoulder movements, shoulder weakness and a decreasing ability for day to day activities.

University of Alberta Rehabilitation Medicine researchers reviewed several studies that involved this patient population including randomized controlled trials (RCT) trials and cohort studies. The studies tended to include several treatment modalities in the same investigation and this may mask the real effect of some modalities. However, most notably, retraining muscles that act in concert with the rotator cuff (deltoid, pectorales and latissimus dorsi) had a statistically significant beneficial effect in restoring function when compared to no rehabilitation intervention. In another retrospective cohort study, a combination of steroid injection, physical therapy treatments and oral medication had superior results to physical therapy only.

This was consistent with the findings of yet another systematic review performed by Dewhurst (2010) of RCT trials. These trials showed that strengthening the muscles that control the scapula had significant beneficial effects on rotator cuff impingement. Vas et al. (2008) also demonstrated that a combination of single point acupuncture and physical therapy treatments had significant reductions in pain, improvement in functional abilities and reduction in medication use in this patient population. Similar results were noted in a blinded RCT that showed therapeutic exercise to be superior to electro-physical modalities in the treatment of rotator cuff tendinitis.

These studies are consistently demonstrating the value of a therapeutic exercise approach. The approach may be combined with steroid injection, in addressing the limitations produced by the partially torn rotator cuff when surgery is not an option. The findings indicate that an assertive approach to rehabilitation of these clients should have therapeutic exercise as its centre.

References
Dewhurst A. Musculoskeletal Medicine, 2010. 32(3): 111-116
Kuhn J.E. J Shoulder Elbow Surg, 2009. 18: 138 – 160
PT Alberta Newsletter, November, 2011
Vas J., et al. Rheumatology, 2008. 47: 887-893
For feedback contact Hercules Grant PhD at hercules@ualberta.ca

Most therapists or physicians have encountered the otherwise healthy patient with an episode of severe and unexplained low back pain. Often accompanied by an alarmed relative, the patient usually feels that a “kidney” ailment or worse is to blame. It usually turns out that the cause may be much more benign. An active trigger point in the quadratus lumborum muscle (QL) is often the source of pain. The increased activity in these focal points within the muscle may result from sustained poor posture such as bending and twisting while lifting, running on a sloped surface, or sleeping on a sagging and unfamiliar mattress.

As per Travell and Simons, myofascial trigger points are present in the majority of musculoskeletal pain disability cases. Their exact cause is unknown, but they are highly irritable circumscribed focal points of pain within the muscle or fascia that come to light with seemingly routine physical activity. In the case of QL, the underlying activity is often related to posture, given that this muscle is prominent in our normal upright posture. This muscle has three distinct parts which act as guywires for the lumbar spine maintaining spinal postural alignment for both trunk and extremity movements. Trigger points in this muscle are deep to the lumbar paraspinals and may go undetected with a superficial palpation of the back. Approaching the muscle in side-lying will more readily reveal the active QL trigger point(s).
Along with the extreme pain, the patient may report pain with coughing and sneezing with a need to support the trunk with the hands when walking or sitting. Practitioners are often concerned with the possibility of a protruded lumbar disc since pain may radiate to the groin, and even mimic a sciatic nerve distribution. Signs and symptoms may also resemble trochanteric bursitis. With the absence of any positive nerve irritability signs, treatment can proceed by directly addressing the trigger point from a side-lying position ensuring that the patient’s posture and activities do not result in further irritation of the trigger point. Postural correction, local therapies such as electro-therapy and manual therapy will be useful. However exploring the patient’s typical activities will offer clues as to how best prevent recurrence. Additionally, treatment for the contralateral side as well as for “satellite” trigger points in the gluteus medius is highly recommended. When the trigger point becomes less active treatment should be rounded off with conditioning to core and hip muscles.

For Feedback please contact Hercules Grant PhD (Rehabilitation Science) at hercules.grant@rejuvenationhealth.ca