6 FACTS EVERY PHYSIO NEEDS TO KNOW ABOUT LUMBAR DISK HERNIATIONS

Fact & Fiction around lumbar disc herniations

Hardly any musculoskeletal topic has received as much media coverage as herniated discs and probably every person knows some family member or neighbor who has had one. At the same time, a lot of misconceptions have been spread about the topic and a lot of patients suffering from low back pain fear that they herniated a disk. We’ve decided to aggregate the research surrounding lumbar disc herniations to separate facts from fiction:

Anatomy of an intervertebral disk

 

 

 

 

 

 

 

 

 

An intervertebral disc consists of strong fibrocartilage designed for shock-absorption and is firmly anchored into the vertebral bones above and below by the vertebral end plates. Furthemore, it is surrounded by strong ligaments, so there is absolutely no way a disc can slip.

 

Disk Herniations

Herniations are broadly defined as a localized or focal displacement of disc material beyond the limits of the intervertebral disc space. The disc material may be the nucleus, cartilage, fragmented apophyseal bone, annular tissue, or any combination thereof. First of all, the presence of disc tissue extending beyond the edges
of the ring apophyses, throughout the circumference of the disc, is called ‘‘bulging’’ and it’s not considered a form of herniation. 

There are 3 categories of disc herniations: We are talking about a disc protrusion if the greatest distance between the edges of the disc material presenting outside the disc space – so the D-line- is less than the distance between the edges of the base of that disc material extending outside the disc space, which is presented by the B-line.

In an extrusion, the D-line is bigger than the B-line:

And in a sequestration - which is a subclass of a disc extrusion -the extruded disc material has no continuity with the disc of origin:

 

Prevalence of disk herniations in healthy subjects

Table fromBrinjikji et al. (2015)

It’s important to realize that disc protrusions are very common, also in healthy people. A famous study by Brinjikij et al. (2015) showed that almost one third of 20 healthy year olds have a disk protrusion. The numbers increase with age up to 43% at the age of 80, so almost every second person without low back pain has a herniated disk. Disk bulges are even more common by the way with 84% at the age of 80. So even if your MRI scan does show a bulging or protruding disc you should realized that these findings are completely normal and much like “gray hair from the inside”. Pain is complex and cannot be explained by an MRI scan alone.

 

What are risk factors to suffer from a lumbar disk herniation?

Let’s see what the evidence says about risk factors to be hospitalized due to a lumbar disk herniation irritating a nerve root:
In a chinese study Zhang et al. (2009) report that family history so genetic predisposition was by far the biggest risk factor. This was followed by lumbar load at work and strenuous work, while regular physical exercise and sleeping on a hard bed were both protective. Furthermore, a study in Swedish construction workers (Wahlström et al. 2012) and two systematic reviews with meta-analysis revealed that smoking (Huang et al. 2016), obesity and overweight (Shiri et al. 2014) as well as being taller than 1 meter 90 or 6 foot 3 are further risk factors.
An interesting literature review by Belavy et al. (2016) showed an increased risk for lumbar disc herniations in astronauts after return to earth. They concluded that the most likely cause thereof was a swelling of the intervertebral disc in the unloaded condition. Conclusion: Intervertebral disks need load to stay healthy. Not surprisingly, studies from Bowden et al. (2018) and Belavy et al. (2017) also show that physical activity, particularly vigorous activity, and running are beneficial to maintain intervertebral disc health.

 

What is the course of a symptomatic disk herniation?

Okay, so let’s say you or your patient are one of the unlucky ones who experience sciatica from a herniated disc pressing on a lumbar nerve root. How long does this take to heal? In a Dutch study by Vroomen et al. (2002), 73% of patients showed major improvement at 12 weeks without surgery. On long-term Konstantinou et al. (2018) found a less positive course with 55% of patients reporting improvement of sciatica after 12 months.
For some reasons, a lot of patients assume that having a disc herniation is something they will have to live with for the rest of their lives. However, a study by Elkholy et al. (2019) followed 9 patients with lumbar disc herniations and sciatica. Spontaneous resorption of the herniated disc was found in ALL patients in a mean time of around 9 months, while they recovered way earlier with a mean of roughly 6 weeks. This shows again that you can recover although you still have a hernia, so structure is just one component of many influencing someone’s pain experience. By the way, larger and/or sequestrated discs were associated with an even faster resorption. A meta analysis from Zhong et al.(2017) confirms these findings showing that spontaneous resorption was reported in 66% of patients across eleven different studies.

 

Management options

So a herniated disc and sciatica do not necessarily mean that you need to get surgery. In the Netherlands about 5-15% of patients with lumbosacral radicular syndrome end up getting surgery (NHS Standaard Radiculair Syndroom). But how effective is surgery? A systematic review by Jacobs et al. (2011) showed that conservative treatment and surgery are equally effective after 1 and 2 years. The only advantage that surgery might offer is a faster pain relief for patients with 6-12 weeks of radicular pain. However, other options for pain relief should be considered first such as NSAIDs, weak opioids or epidural injections, like the NICE guidelines from the UK suggest.
While surgery or just time usually improves a patient’s leg pain, a lot of patients we see do not improve their back pain. Probably the main role for us as clinicians in these cases is education and re-assurance (possible by showing them our video) and by helping patients to regain confidence in their backs. This can be done be achieved with a graded activity or graded exposure programs to challenge specific movement-related fears such as bending over. If you need some inspiration for that, check out our video in the top right corner.

Alright, this was our posts on facts and fiction around lumbar disc herniations. Comment down below if you still have any questions or if you were surprised about actual evidence around a couple of persistent myths. A lot of this information and much more can be found on our online course on the spine.

ATTENTION THERAPISTS WHO WANT TO INCREASE THEIR CONFIDENCE IN TREATING PATIENTS WITH LOW BACK PAIN

How to Massively Improve Your Knowledge about Low Back Pain in the Next 5 Days for FREE

5 absolutely crucial lessons you won't learn at university that will improve your care for patients with low back pain immediately without paying a single cent

How knowledge about statistics will make you a better evidence-based physio

Statistics is one of the most confusing topics for physios and physio students. Most probably this is due to the fact that we care more about people and health than we care about math, right?

dafuq_statistics-265x300

Well, I get that you are more interested in assessing your patient properly, good handling and the latest treatment methods, but I gotta tell you that you need to know the statistical values of a special test and even numbers about prevalence, pre-test and post-test probablilities of questions you ask your patients during your whole anamnestic process!
I would even dare to say that without the knowledge of the above-mentioned numbers, you will have no clue how much value you can put on certain questions you ask your patient (and the answers thereof) and you will perform special tests without really knowing what a positive or negative outcome will tell you.
When I see or hear that a physio performs a special test like the Thessaly test for meniscus lesions, it is positive, and they are 100% sure afterwards, that their patient has a meniscus lesion, it makes me cringe!
PLEASE STOP DOING THAT!

That´s why I urge you to to continue reading my post in which I will try to give you an insight into how you can and should use statistics to become a better physio and how that knowledge increases your awareness of your clinical reasoning process!

In general, you will start with your screening, then your anamnesis, followed by basic assessment. On the basis of the information you got during the aforementioned parts, you are forming your hypotheses that you would either like to confirm or reject.  This is where sensitivity and specificity come into play. So let´s first have a look at what sensitivity and specificity are! The easiest way is to watch the short video we have made a while ago:

So to sum it um again: A negative outcome in a 100% sensitive test can rule out the disease (SnNOut) and a positive outcome in a 100% specific test can rule in the disease (SpPIn).
With the two mnemonics SnNOut and SpPIn it´s relatively easy to put these two concepts into practice.
Most of the time, you will get a better grasp on their definition and what they actually are if you are able to calculate these values using a 2×2 table. Watch our next video, which will show you how to do the calculation part:

Unfortunately, in real life there are hardly any 100% accurate tests, which is why you will have a lot of false positive and false negative results . On top of that, sensitivity and specificity tell us how often a test is positive in patients who we already know have the disease or not. In practice, we however do not know wether our patients have a certain condition or not. What we rather do in practice is to interpret the results of a positive or negative test.
You usually want know what the probability is that the patient actually has the disease with a positive outcome and how high the probability is that a patient does not have the disease with a negative outcome.
These values are called positive predictive value (PPV) and negative predictive value (NPV), also called post-test probabilities. You guessed it – we have another video that explains these values with the help of the 2×2 table and shows you how to calculate these values:

Now, like mentioned in the video PPV and NPV are a great tool if you have a good idea about the prevalence of your patient group and if this prevalence is identical with the the prevalence of the RCT, where you have gotten your statistical values from for a specific test in the first place. If this is not the case, PPV and NPV become pretty much useless.
Imagine how the pre-test probability of an anterior cruciate ligament (ACL) rupture changes in different settings: For example, the prevalence of patients with an ACL tear in a general practice will be much lower than in a sports clinic that is specialized in knee injuries. The higher the prevalence, the higher your PPV and the lower your NPV will be.
Maybe well make a video on that as well in the future, but it´s important to remember that we need a better value than the PPV and NPV, which is where the likelihood ratios come into play.

The likelihood ratio combines both sensitivity and specificity and tells us how likely a given test result is in people with the condition, compared with how likely it is in people without the condition. Watch the following video about likelihood ratios and how you can calculate them:

In the example we used the Lachman test, which one of the most accurate tests that is out there in clinical practice, but let´s look at our beloved Thessaly test and how our example plays out there:
According to Goossens et al. (2015) the Thessaly test has a sensitivity of 64% and a specificity of 53%, which results in a LR+ of 1,36 and a LR- of 0,68. As you can already see, these values are pretty close to LR = 1, which tells us that they will change the probability that a person has a meniscus lesion very little. To apply these values to our example of our ACL tear case, we know that ACL tears are often accompanied by meniscal tears. Although our patient does not report about any locking or catching sensations, we estimate our pre-test probability at about 30%.
Our nomogram will look like this:

nomogram_thessaly

Based on the (more accurate) calculations we end up with the following post-test probabilities:
– Pre-test odds: Prevalence/(1-prevalence) = 0,3/(1-0,3) = 0,43
– Post-test odds (LR+): 0,43 x 1,36 = 0,58
Post-test probability (LR+): post-test odds / (post-test odds+1) = 0,58/(0,58+1) = 0,37 (so 37%)
– Post-test odds (LR-): 0,43 x 0,68 = 0,29
Post-test probability (LR-): post-test odds / (post-test odds+1) = 0,29/ (0,29+1) = 0,22 (22%)

So with a positive Thessaly test, you have increased your chances of a mensical lesion from assumed 30% to 37% and with a negative Thessaly test you have decreased your chances to 22%.
See why I am freaking out if people perform a test and then they assume that their patient definitely does or does not have a certain condition?! And this is all based on an assumption of the pre-test odds, which most people even forget to take into consideration!

If you want to perform multiple tests, say you want to add the Anterior Drawer test in our ACL example, you will base your pre-test probability on the post-test probability of the Lachman test. So in case of a positive Lachman, you will start with a pre-test probability of 95% and with a negative Lachman you will start with a pre-test probability of 19%.
While most tests either have a positive or negative outcome, there are also test clusters with multiple outcomes. So if you take the cluster of Laslett for example, for 2 out of 5 positive tests you will end up at an LR+ of 2.7, for 3/5 at an LR+ of 4.3 etc.

statistics

Be aware though, that with a very high pre-test probability, another test has little value and it is better to start your treatment. The same is true for a very low pre-test probability in which case you don´t test and also do not treat the condition.
As an example, if a patient presents to you with sudden onset of low back pain, neurological symptoms in both legs, problems with micturition and saddle anesthesia, you would be pretty sure that this patient has cauda equina syndrome, which is a red flag and requires urgent surgery. So if you are say 99% sure of your diagnosis, a straight leg test (SLR) with a LR- of 0.2 will decrease the post-test probability to 95%, which is still very high and you would still want to send this patient for surgery.
In turn, if the test was positive, you would probably go from 99% to 100% certainty, so why bother testing in the first place, especially if this is an urgent referral for surgery?

The same is true for a very low pre-test probability. If a patient presents to you without radiating pain below the knee, the chance of this patient for radicular syndrome due a disc herniation is very low, say we assume 5%. So what would happen in this case if you performed the SLR with a LR+ of 0.2? You would end up at a post-test probability of 10% and if the test is negative the post-test probability would have decreased to maybe 4%. So if you are almost certain, that a patient does not have a certain disease, why test it in the first place?
Of course, in practice the decision to do a certain test always depends on various factors such as costs, severity of a disease, risks of the test etc.

Now let´s get back to what I claimed in the beginning, that statistical values help you to evaluate the outcome of your questioning during your patient-history taking.
In fact, every question can be seen as a special test, in which the answer (yes or no) will either increase or decrease the probability that a patient has a certain condition.This is also the reason why a thorough anamnesis is most of the times more important than special testing, because you are basically performing a series of special tests in a row,
if you are a good clinician who knows how to form a hypothesis based on your patient’s answers.

So let´s take another example: How does a positive answer to the question about prolonged use of corticosteroids influence the chance of a spinal fracture?
According to Henschke et al. (2009), prolonged use of corticosteroids has a positive LR+ of 48.5. The prevalence (pre-test probability) of a spinal fracture presenting to primary care can be estimated between 1%-4% according to Williams et al. (2013) in patients who present with low back pain.
So with prolonged corticosteroid use, we will end up with a post-test probability of 33% although we assumed only 1% of prevalence in this example calculation.
I think it´s fair to say that this question about corticosteroids should always be asked in the screening procedure for spinal fractures!
Now let´s take a look at another red flag that is commonly used in the screening for malignancy in patients with low back pain: Insidious onset of low back pain.
According to Deyo et al. (1988, I admit this is a pretty old study) the LR+ for this question is 1.1. According to Henschke et al. (2009) the prevalence of malignancy in patients with low back pain is even lower than 1%, but we will calculate with this 1% just for simplicity.
So the red flag insidious onset increases the post-test probability of malignancy as the cause of low back pain from 1% to exactly 1,1%. I think we can agree that this red flag should be kicked out of any guideline in which it is listed.

I know this was a long post and congratulations and respect if you made it till here! My goals were to give you an explanation about how to work with statistical values like sensitivity, specificity, PPV, NPV and especially the likelihood ratios and to make you aware about their importance in your whole physiotherapeutic process.
It would be fantastic if you could take the prevalence of a certain hypothesis into account with your future patients, have an idea about the impact of your anamnestic questions on the pre-test probability and if you could properly evaluate the power of your special testing.

statistics-make-me-moist

Feel free to ask questions in the comment and to share this blog post if you found it helpful!

Thank you for reading!

Kai

References:
Goossens P, Keijsers E, van Geenen RJ, Zijta A, van den Broek M, Verhagen AP, et al. Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study. J.Orthop.Sports Phys.Ther. 2015;45(1):18-24, B1

Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P, Irwig L. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst.Rev. 2013;(2):CD008686. doi(2):CD008686.

Williams CM, Henschke N, Maher CG, van Tulder MW, Koes BW, Macaskill P, et al. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane
Database Syst Rev 2013;1:CD008643.

Clinical Pearls and Advice From a Young PT to Even Younger PTs

I must have read a lot of different blogposts in the last year, but certainly one of the greatest was Jarod Hall’s “Clinical Pearls and advice from a young PT to even younger PTs”.

Can’t agree enough on most of the points! My number one advice would also be to learn as much as possible as fast as possible about pain!

@Our more experienced followers: What would you be the number one thing you would recommend a young physio?
Let us know in the comments!


Having been out of school just shy of 2 years it might be hard to believe I have the ego to write a post giving advice to anyone or educating on clinical pearls. Maybe it’s my naivety or just or an embodiment of the wonderful illustration that depicts the relationship between how much you think you know and how much you actually know.

how much I think I know

However, I truly feel that I have been lucky enough to be plugged into and learn from some extremely smart clinicians (whether they realize I have been learning from them or not). One of my professors in PT school always said that there was an immense learning curve during your first year of clinical practice. I would have to say that it was an indescribable understatement in my own personal growth as a health care provider. The following is a short list of information I wish I knew/understood when I started practicing, and that I’ve had to learn the hard way.

  1. Learn AS MUCH AS YOU CAN about pain science and the biopsychosocial model AS FAST AS YOU CAN!
  1. Listen closely and carefully to your patient and they might just tell you exactly what is wrong and even how to fix it. Stop thinking about every test you should do and every movement you should evaluate while the patient is telling you their story. Earnestly listen to them because you are often the first person that has. 80-90% of your diagnosis comes from the history you take.
  1. STOP cranking on and cramming your patient’s total knee replacement right after surgery. They certainly aren’t limited in ROM due to massive amounts of scar tissue a few weeks after a surgery. They are in pain and have muscle guarding as well as fluid in the knee restricting movement. Honey will catch the fly in this case. Try gentle ROM, Contract relax, grade 1-2 joint mobs (not 3-4), light IASTM to the quads. If their knee really is burdened with scar tissue doesn’t it make more sense to have them exercise and move anyway? They can mostly likely put a lot more force through their knee into new ROMs that you can with your hands.
  1. Stop basing everything you do and the way you think off of a patient’s x-ray or MRI. We now know and have a plethora of evidence that tissue damage often does not correlate to pain presentation. Imaging is important, but we need to talk patient’s off of the I have DDD/DJD cliff and onto the you don’t have to be in pain because of you imaging ride.
  1. Use manual therapy and modalities if you must, as a means to get a patient to do MORE active therapy, not become passive and falsely reliant on your magic sound wand or massage.
  1. Do not be afraid to question your instructors. In school or on clinical affiliations. They can be wrong, and you may have something to teach no matter how high their position.
  1. Learn about the tissue homeostasis model and think about it during your treatments. A vast amount of the patients we treat in the outpatient patient setting have overuse injuries that have led to degenerative tissue pathology. To truly “heal” these patients we need to know how to appropriately load their tissues to stimulate healing. Learn the “sloptimal zone of loading”
  1. This bullet goes along with number 6. Learn to use isometrics! They can be very powerful for pain relief, improving motor unit recruitment, and loading tendons to simulate collagen synthesis.
  1. Stop over complicating evaluation and treatment. With a doctoral education, I know there can be pressure to “find” all sorts of asymmetries that need correcting and give patients fancy bosu body blade exercises to demonstrate some sort of face validity, intelligence, and value. Yet, the vast majority of those asymmetries, leg length discrepancies (if you are even able to get close to accurately diagnosing them), forward head rounded shoulder postures, increased lumbar lordosis, etc rarely actually have anything to do with your patient’s pain. Very often your patients sit in prolonged positions and don’t move/exercise much at all through the day. Merely getting them moving in safe and progressive manner can be incredibly powerful.
  1. No, everyone doesn’t have a rotated pelvis and please stop correcting all of the theoretical innominate torsions. The end.
  1. Learn and become skilled in some basic manipulation techniques. I know many people may disagree with this, and yes I know the research surrounding manipulation techniques and their questionable benefit over other manual therapy treatments very well. However, the fact still remains that many of the patients that walk through your door will have had a manipulation done on them before. They likely even experienced resolution of a painful condition. It doesn’t matter if the technique fixed them or not if they THINK it fixed them. There is power in using a technique that a patient strongly believes will help. Not to mention there is increased theatrical placebo with audible joint pops. Just make sure you explain to the patient that you are NOT putting anything back into place and that the benefits of the treatment are likely due to global or possibly local neurophysiologic effects.
  1. Give patients small manageable home exercise programs that require very little if any equipment. A skilled therapist can make exercise easy and convenient for a patient, because we all know there is no way they will do it if it has 10 exercises, takes an hour, and they need dumbbells, swiss balls, therabands, and foam rollers. Not to mention if they are doing that much at home with good form and independently why in the world do they need to see you?
  1. Learn to use repeated motions as a way to decrease nervous system sensitivity/threat perception, decrease pain, and improve ROM for additional exercises.
  1. Stop chasing fads! They come and they go all in good time. Learn how to critically think and use evidence to guide your clinical decision making.
  1. Remember that there are 3 pillars of evidence based practice. Patient expectation, research/evidence, and clinical experience. They are all important, but you have to remember that evidence should dictate changes to your practice even if it goes against your personal experience as it is very easy to have a cognitive bias and overlook the shortcomings of your previous methods.
  1. GET ON SOCIAL MEDIA!!!! And I don’t mean to post funny cat pictures or follow Lady Gaga. Get on social media and follow the plethora of intelligent people out there regularly posting evidence based blogs, posting research ahead of print, and engaging in clinical discussions that can convey years and years of knowledge and experience……ok well you can post some cat pictures as long as they’re funny.funny cat pic

I know you and the cat are probably thinking along the same lines, but thank you for taking the time to read this far. This is a short list and will definitely be expanded on many times over. Just remember to stay hungry for self-improvement. It helps you, your patients, and our profession.

Jarod Hall, PT, DPT, CSCS

Part 2: Clinical Pears and Advice From a Young PT to Even Younger PTs

We hope you enjoyed last weeks blog article about “Clinical Pearls and Advice from a young PT to even younger PTs” from Dr. Jarod Hall. If you did, check out the second part of his article!
You can find Jarod’s Blog on: http://drjarodhalldpt.blogspot.com


After a little brainstorming and time to ponder on the meaning of life I came to the conclusion that I left out a few good bits of advice in my first post. I know what you’re thinking… “the first one wasn’t half bad, but things always go downhill when they make a sequel!”

shark funny shark funny 2

 

Hopefully that isn’t the case! The following is a short update to the list of information I wish I knew/understood when I started out. My goal is to take the information I’ve learned from the brilliant minds in PT and pass it down without the years of struggle it usually takes in-between, so the profession can continue to push further and further forwards to gain the respect it deserves. So, without further ado I present to you part two of my list:

  1. I’ve found that it can be very powerful to ask your patient what THEY think they need to get better. Sometimes they will say “that’s what I’m here to see you for!” which leaves the floor open for you to pull out your best game as a clinician. However, sometimes they will tell you that “I feel weak here and I think I need X” or “if I could just figure out how to work on Y I know that would help me out”. Then you have a wonderful situation of being able to give the patient a treatment you are positive they have buy in to while simultaneously selling them on other interventions that you know may be physiologically what would benefit them most.
  1. It just isn’t possible for us to be super specific with our mobilizations and manipulations like you were taught in school so stop worrying about PPIVMs and PAIVMs. Research has shown that experienced therapist can’t even accurately palpate the same level with acceptable reliability, and manipulation techniques have been shown to disperse force over several vertebral levels as well as cavitate on both sides. The effects of manual therapy are most likely much more generalized than they are specific based on current research. I’ve written a post on this topic here. So, as my most recent student said “Damn, I’m sure glad you told me this, because now I know I’m not crazy for feeling like the worst physical therapist ever when we were asked to palpate all of this in class and I couldn’t!!!”
  1. Use as much body contact as you possibly can with your patients while doing manual techniques such as PROM on their shoulder. Too often I see therapists, especially young ones, holding a patient’s arm like it’s the crank on an old school water well instead of getting in close and making them feel safe with their arm in your hands.

old water pump

What’s the point in even doing PROM if the patient is guarding so bad you can’t even get close to their available end range because they aren’t comfortable and are guarding. Use as many points of contact as you can to support them and allow them to fully relax.

  1. It would probably be a good idea to stop spending so much time manual muscle testing every single motion on every patient that walks through your door. I know you probably had an entire class on goniometry and MMT, but in reality it wastes time you could spend evaluating the way a patient actually moves, building your therapeutic alliance, or educating them on their condition. Are there times in which MMT is a good idea? Sure, but on the whole its way over sold….and incredibly subjective after a 3+ anyway.
  1. Try using extrinsic cueing vs intrinsic cueing. Instead of telling a patient with hip adduction and femoral internal rotation during squatting/landing to keep their knees in line try telling them to screw their feet into the floor (engage external rotation at the hips) or split an imaginary line in the floor underneath them as they squat. A trick that I’ve used several times that works well is to use a mirror and dots on a patient’s knees for extrinsic visual feedback. Instruct the patient to keep the dots from falling in towards each other. Or in the case of a 16 y/o cheerleader with PFPS and significant valgus collapse on her R side during landing with her cheer jumps, you could use smiley faces on her knees and tell her to not let them look at each other when she lands (true story and worked great).
  1. Learn what a nocebo is, and try your hardest to avoid creating a situation in which there is a nocebo effect. Stop using the words like herniated, bulging, punched, worn out, degenerated, etc and replace with irritated, sensitive, threatened by “x” direction instead. These replacement words give the impression of a transient problem to the patient. A problem that CAN and WILL get better
  1. Stop telling people their core is unstable… Odds are it’s not… Core stabilization has been shown to be no better than general exercise for low back pain in a plethora of studies. Not to mention the potential nocebo effect of patients picturing a weak, wobbly, wimpy spine. Try instead thinking about exercises for low back pain in categories of those that decrease threat perception (repetitive motions, nerve glides, positioning), those that explore new movements (prone on elbows, cat-camel, pelvic tilts, etc), and those that get the patient moving and load/challenge the system (squats, deadlifts, reverse hyper, cable resisted rotations, etc).
  1. Fascia isn’t magical- it’s an interesting tissue and most likely plays a role in pain/dysfunction occasionally, but it certainly is not the panacea that it has been made it out to be in recent years…. Oh yeah and you can’t release it like you’ve been so adamantly taught. Even the “father of fascia” has grown weary of all the hype and marketing ploys surrounding it.

“I am so over the word ‘fascia’. I have touted it for 40 years — I was even called the ‘Father of Fascia’ the other day in New York (it was meant kindly, but…) — now that ‘fascia’ has become a buzzword and is being used for everything and anything, I am pulling back from it in top-speed reverse. Fascia is important, of course, and folks need to understand its implications for biomechanics, but it is not a panacea, the answer to all questions, and it doesn’t do half the things even some of my friends say it does.”

-Tom Meyers (father of fascia)

  1. If a muscle feels really “tight” it is rarely actually the muscle that has limited mobility. Most often this feeling of tightness is due only to a perception the central nervous system has based on input from the periphery. It could be muscle weakness, decreased neural mobility, or protective guarding based on perception of threat such as joint hypermobility. Decrease the threat or strengthen the tissue and you decrease the perceived tightness. I regularly work with professional ballet dancers, who let me assure you are not tight in any way. However, they regularly come to me with complaints of hip, ankle, calf, neck, etc tightness. They report that they feel tight and restricted in their movements, yet they can move beautifully through ranges of motion most of us could never dream. Neural mobilization techniques as well as positioning a muscle in a slacked position with a firm, but not painful, pressure usually work wonders to decrease the perceived threat and “tightness” that these dancers come to me for.
  1. The number one thing you can do for your injured runner patient is to get them on a well-rounded strengthening program….period…a stronger system can sustain more force with less breakdown.
  1. For runners with chronic problems such as medial tibial stress syndrome or PFPS (number one and two running injuries) simply cueing to shorten their stride length and increase cadence can make a huge impact. This will get their foot strike more directly underneath them and help to decrease ground reaction forces distally and increase work load proximally to the bigger stronger muscles. Shoot for a cadence higher than 160bpm.
  1. Forefoot striking usually increases force distribution to the foot, ankle, and calf while mid to rear foot strike patterns transmit more forces to the knee and hip. Changing strike pattern occasionally can be good for allowing different tissues to “rest”.
  1. Patient reported comfort is currently the best advice we can give regarding shoe choice for decreasing running related injuries
  • Mündermann A, Stefanyshyn DJ, Nigg BM. Relationship between footwear comfort of shoe inserts and anthropometric and sensory factors. Med Sci Sports Exerc. 2001;33(11):1939-45.
  • “Shoe inserts of different shape and material that are comfortable are able to decrease injury frequency. The results of this study showed that subject specific characteristics influence comfort perception of shoe inserts.”
  • Ryan MB, Valiant GA, Mcdonald K, Taunton JE. The effect of three different levels of footwear stability on pain outcomes in women runners: a randomised control trial. Br J Sports Med. 2011;45(9):715-21.
  • “The findings of this study suggest that our current approach of prescribing in-shoe pronation control systems on the basis of foot type is overly simplistic and potentially injurious.”
  • Knapik JJ, Trone DW, Swedler DI, et al. Injury reduction effectiveness of assigning running shoes based on plantar shape in Marine Corps basic training. Am J Sports Med. 2010;38(9):1759-67.
  • “This prospective study demonstrated that assigning shoes based on the shape of the plantar foot surface had little influence on injuries even after considering other injury risk factors.”
  • Nielsen RO, Buist I, Parner ET, et al. Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study. Br J Sports Med. 2014;48(6):440-7.
  • “The results of the present study contradict the widespread belief that moderate foot pronation is associated with an increased risk of injury among novice runners taking up running in a neutral running shoe.”
  • In addition, the incidence-rate difference/1000 km of running, revealed that pronators had a significantly lower number of injuries/1000 km of running of -0.37 (-0.03 to -0.70), p=0.03 than neutrals.

  

  1. Based on current research those who “over pronate” while they run actually have a lower risk of running related injuries….yes you read that right. See above study in #12
  1. If you are interested in working with runners, learn who Chris Johnson and Tom Goom are and follow them ASAP. Zeren PT and the runningphysio.
  2. Explain pain to a patient in terms of a home alarm system. The alarm goes off if it senses danger, just as the brain produces pain in the event it perceives a threat. During persistent pain the trigger on the alarm system can become very easy to trigger. Instead of someone needing to break a window to set the alarm off, the wind only needs to blow on the grass in the front yard. Just the same, instead of tissue damage occurring or something physically being “wrong” to cause pain, the smallest movements can set off the alarm system and cause one to unnecessarily experience pain. This analogy tends to be a great ice breaker into talking deeper about pain sciences with patients.
  3. To take the alarm system analogy a step further, it can be used to explain spreading pain or pain in other locations of the body. If you were out of town and your house alarm went off and you weren’t there to turn it off, it’s likely that it would end up waking your neighbors. Similarly if the alarm system in the body is consistently ringing, it is likely that you could “wake your neighbors” and begin to experience pain in a wider area than the original area, or even in old injury areas that the brain has previously developed a neurotag to elicit pain.
  4. Explain whiplash injuries to patients as several small ankle sprains in their necks. Nothing super scary to worry about. Most patients have had an ankle sprain and healed just fine from it with no residual pain. Confidence and reassurance of improvement is more important than anything you can do early on for a patient after a whiplash injury.
  5. Try EVERYTHING you possibly can to get a patient out of pain within 3 months of their whiplash injury as those that have pain at three months almost always still have pain at 2 years…long after tissue has healed. Research shows that between 30-40% of patients with whiplash injuries progress into persistent pain. These people need our help and DEFINITELY need pain science education because you can be assured that their nervous systems are wound up.
  6. Based on the current evidence “Trigger points” may or may not (much more likely not…at least in the traditional definition) exist so stop explaining to your patients that they all have a million trigger points. Even the originators, Travell and Simons couldn’t agree on trigger point location with accuracy closer than a 3.3-6.6cm inter-rater error. I’m not blatantly saying there is no such thing as a trigger point right now, but I am saying that if there is, it isn’t quite so clear cut like the basic explanations we have been taught. If it does exist, it likely has much more to do with some sort of PNS and/or CNS sensitization due to threat perception that leads to local neurophysiological changes in a certain grouping of peripheral nerves. Therefore, IF (and this is a big if) needling works beyond a strong placebo, specific needle placement into a trigger point is probably not necessary. If there are effects of needling, they are likely to be much more about a global change in the nervous system than a localized neuromuscular junction. (This is a personal opinion based on current understanding with the literature. Feel free to disagree!)
  7. Challenge your patients, especially your older patients. Don’t fall into the yellow theraband trap! Their systems can still adapt and they might surprise you in what they can do. Better yet, they may surprise themselves!
  8. If you want to make a name in your community be different. Don’t be the same old tired PT that goes on autopilot. Be different by educating your patients. Education makes patients invest in their rehab, understand why they are doing what you have advised, and have a reason to do exercises. This leads to better improvements and more referrals. Word travels faster than you may think.
  9. This one may ruffle some feathers, but I strongly advise that you try your hardest to be healthy and in relatively good shape. Now I’m not talking about getting your Arnold on or anything, but research shows that it may take less than one second for individuals to make their first impression of you based on appearance. Interestingly, it also shows that it is surprisingly hard to change the immediate conclusion that has been drawn. It could be much easier for a patient to buy stock in the exercises you prescribe if it appears you know a thing or two about exercise and can easily perform whatever you are asking of them. This same premise is illustrated when everyone goes up to the jacked guy in the gym with phenomenal genetics for workout advice when he may or may not know half as much as the skinny guy in the corner working his butt off. It can be seen again when celebrities give health advice. Jenny McCarthy= ‘nuff said. Just because they look good and have the public eye on them people take what they say as gospel. Sadly, at the end of the day you may be able to get through to your patients a little easier if you look the part.
  10. There is no list of inherently “bad” exercises. There are certain exercises that certain people should not perform due to injury, lack of mobility to complete said exercise, anatomic variance, or poor control during that exercise. But just because an exercise is bad for one or a few people doesn’t mean it is for everyone. The body is a dynamic system that steadily adapts to safe progressive overload over time. Deadlifts aren’t bad, squatting deep isn’t bad, shoulder press isn’t bad, crunches aren’t evil, good mornings aren’t ripping your back in half, knee extensions aren’t bad. They just need the requisite mobility, control, and progressive load.
  11. Stop making your patients do all sorts of exercises on an upside down bosu. It doesn’t increase EMG and as no specificity to carry over to anything “functional” in life. That old staple of specificity of training is still very important. Build strength and practice the actual skill to improve performance.

WTF swiss ball

  1. When returning an athlete to sport after ACL reconstruction a single leg hop or Ybalance is not specific enough to do on its own. Athletes get tired and fatigue leads to break down in control. Fatigue the hell out of them to simulate a game situation and then test them for a better glimpse into how they may actually look after returning to sport.
  2. Don’t hang your hat on the VBI positional testing to make you feel comfortable and like you checked a box on a cervical patient. The VBI positional testing is mediocre at best and could actually stress the vertebral artery to a greater degree than HVLAT. A solid history regarding symptoms and cardiac history is much more important when screening the cervical spine before intervention.
  3. If you are interested in strength and conditioning learn who Brad Schoenfeld, Bret Contreras, Andrew Vigotsky, and Chris Beardsley are.
  4. If you are interested in nutrition find Alan Aragon, James Fell, and Spencer Nadolsky
  5. Finally, I strongly encourage you to learn to like good beer. Everyone knows all good PTs like craft beer…and you know, networking and stuffs

 

craft beercraft beer 2

 

Thanks again for reading! I would love to hear people’s feedback regarding these “pearls”.

-Jarod Hall, PT, DPT, CSCS

The Upper Traps, over assessed, over blamed & very misunderstood!

This is a reblog from Adam Meakins Blog: The Sports Physio | Simple, practical honest advice

The upper traps get a lot of blame and are commonly released, massaged, dry needled and what not during physiotherapy treatment,
while the middle and lower traps receive a lot of attention during training, because they are commonly weak.
According to Adam’s view, the reason why the upper traps become tight is because they are weak and thus should be an integral part
of the strength training regime instead of just releasing them!

Are you still massaging the upper traps or have you already started training them? Read the article that will give you a different perspective on the role of the upper traps!!!


There is a strong culture within physiotherapy to blame a specific structure, be it a muscle, ligament, nerve, fascia etc etc when things are sore and painful for our patients. The Upper Trapezius muscle is one such structure that gets an awful lot of blame, but unfairly and incorrectly in my opinion.

I regularly hear physio’s telling patients that this muscle is too tight or ‘over active’ and so the cause of their neck or shoulder pain. I hear them explaining how they can feel or see that this muscle is knotted and tense, and explain how it needs to be released, loosened and stretched. I also see and hear many therapists choosing exercises to help reduce upper traps activity, by focusing on the Lower Traps to restore the balance between them.

Well I argue the exact opposite approach is needed.

Most, if not all the painful upper traps I see are weak and long, not tight and short, and yes they can ‘feel’ tight and tense, but they ‘feel’ this way because they are over loaded due to being weak. Hence we don’t need to be stretching or massaging these muscles, we need to be giving strengthening exercises, which is completely alien and counter intuitive for some.

I argue that weak inefficient Upper Traps are often the culprit for a lot of shoulder and neck pains, and I argue that most Upper Traps need to be strengthened a lot more, a lot, lot more.

However lets first look at the anatomy and function of the Upper Traps to help us understand it better. The Trapezius muscle is a large flat muscle that is found down the side of your neck and top of your shoulders. Its the most superficial muscle of the upper back and runs from the base of your skull, along to the tip of your shoulder, all the way down to the middle of your back, see image below.

It is commonly described as having three separate portions, the upper, middle, and lower fibres. These sections are often described in the text books as having differing functions on the action of the shoulder blade (the scapula). The lower fibres are described as depressing it, the middle fibres retract it, and the upper fibres elevate and upwardly rotate it.

However, this is a very simplistic way to look at any muscle function. Firstly, no muscle works in isolation, all muscles work in synergy with others, and one muscle certainly doesn’t work in isolated parts, they tend work as a whole unit, albeit with some parts working harder than others during different movements.

How a muscle affects movement is also not just due to its insertions and origins, but also the orientation and angle of its muscle fibres. This is what Johnson and Bogduk looked at in the Trapezius muscle in their 1994 paper here.

What they found questioned the commonly held thoughts and explanations of how the Trapezius functions. But despite this paper being over 20 years old these findings are still not that well known and so many myths about the Traps still exist.

Johnson and Bogduk found that the angle and orientation of the upper fibres of Trapezius are unable to create ANY significant elevation of the scapula when the arm is in neutral. They also showed that the upper fibres need the co-ordinated assistance of the lower and middle fibres to upwardly rotate the scapula, highlighting that they do not function in isolation. They also found that the Trapezius muscle is insufficient to rotate or elevate the Scapula alone, instead it is its coupled action with the Serratus Anterior that does.

The action of the Serratus Anterior pulling the scapula laterally around the chest wall at about 30° of arm elevation is when the lower Trapezius muscles fibres first start to resist the movement, which then starts to cause the scapula to tilt into upward rotation. Once this upward rotation of the scapula has started then the upper Trapezius fibres further assist in its upward rotation and elevation.

The Upper Traps only really contribute to Scapula upward rotation and elevation once the arm is in slight abduction!

This not well known fact I think has some big implications on the exercises and movements given by physios and trainers that are thought to influence Trapezius muscle activity. For example does standard shrugging or hitching actions when the arm is in neutral target the Upper Traps as Scapula upward rotators? Not very much it seems, if at all.

Errrr, what…..!!! Shrugs don’t work the Upper Traps!!!

Well they do, anyone who has shrugged will tell you they do. But its only really when the arm is in > 30° of abduction and the scapula has already started to rotate do they really kick in!

With the arm in a neutral position, the other thing to consider is another key scapula elevator muscle that is working, the appropriately named Levator Scapulae. However, as the Levator Scapluae attaches onto the medial superior pole of the scapula, so it also creates downward scapula rotation, usually the exact opposite movement we are looking to achieve in a lot of shoulder problems.

Now what about studies showing ‘over activity’ in the Upper Traps and suggesting that we need to reduce it for shoulder problems such as research done by Ann Cools et al 2007.

Well as much as I really respect and admire the work Ann Cools and her colleagues over in Belguim have done, I think in regards to the Upper Trapezius they could be mistaken, and partly to blame for all this anti Upper Traps culture in physiotherapy.

Firstly, these studies look at upper Trapezius activity using surface electromyography or EMG, which is a useful tool, and I do like EMG research as it aids my exercise prescription and clinical reasoning by giving me an insight into a muscles level of activity. But they do have issues, and they are not infallible to error, and the information taken from such studies has to be used with caution.

For example despite normalisation procedures designed to limit the effect of cross talk between other muscles when using EMG equipment, there is always some, especially with surface EMG, and I suspect at the point often used for reading upper Trapezius activity it also picks up the Levator Scapulae. I have a suspicion that the Levator Scapulae cross talk maybe producing the so called high EMG readings from Upper Trapezius.

I also think the EMG readings of the Upper Trapezius can be ‘misinterpreted’ as high or ‘over active’ in those with shoulder pain and dysfunction due to another forgotten and overlooked action of this muscle!

A primary role of the Upper Trapezius is to distribute loads away from the neck.

The majority of the Upper Trapezius muscle fibres actually attach to the distal third of the clavicle and due to the orientation of these fibres, when they contract they rotate the clavicle medially. This rotation of the clavicle strongly compresses the sternoclavicular joint, and this is a rather useful action.

In fact it’s a bloody marvelous action and is probably the most beneficial and often overlooked action of the Upper Traps.

The compression of the sternoclavicular joint by the upper Trapezius allows forces and loads from the arm and shoulder to be transferred away from the neck, passing them down through the collar bone, into the sternum, rib cage and axial skeleton. Pretty damn useful, and maybe good to know for those with neck issues?

How many physios give Upper Traps strengthening exercises for those with neck pains or problems?

As I said, nearly all the upper Trapezius I see clinically are long and weak, struggling to upwardly rotate the Scapula efficiently. It is this struggling of a weak and fatigued muscle that I also think causes the ‘over active’ readings on EMG studies.

So instead of stretching, rubbing, poking sore and painful Upper Traps, lets get them stronger, more resilient, more robust.

It just seems daft to me to ask a muscle that wants to lift and elevate the scapula AND off loads the neck to work less! Of course get the Lower Traps and Serratus Anterior working, but why not ALSO get the Upper Traps to stronger as well! In my opinion and clinical experience when the Upper Traps become more resilient, more robust, more strong with exercise it only seems help those I see with shoulder and neck pains, not hinder them.

I regularly give out exercises and movements with an ’emphasis’ on strengthening the Upper Traps to patients with long standing neck and shoulder problems who have tried everything else, such as manual therapy, postural correction, rotator cuff work, scapula setting etc etc… With some really good results.

Some examples of the exercises I use are over head shrugs see picture below (I sometimes prefer the elbow a little more flexed so the arm isn’t too high in elevation as this can be a bit uncomfortable or un-achievable in those with sub acromial pain or stiffness).

Another exercise that I often give is one I’ve lovingly called ‘Monkey Shrugs’ these are done by holding your arms down by your sides then sliding them up the side of your body, up to about waist height so your elbows are bent slightly out to the side. I then ask the patient to shrug from this position. This really targets the Upper Trap muscle as the scapula is already in slight upward rotation and the arm is in approx 30-45° of abduction.

Here is a link to some videos I have done of the monkey shrugs and overhead shrugs

Now these are just some of the Upper Traps targeted exercises out there and they may not be suitable for all, and there are other Upper Traps targeted exercises such as Wall Slides, Face Pulls, or even the good old Y or W lifts, which have all been found on EMG studies to get high Upper Traps activity.

In summary I hope I have given you some food for thought about the poor old Upper Traps muscle and that you will not be as quick to blame this poor misunderstood muscle quite so often, and think twice before you dive in so quickly with massage, stretches or needles!

And I hope that you can see that by actually strengthening and improving the function of the Upper Traps it could help a lot of neck and shoulder problems, and that you might consider giving Upper Trap focused exercises for your patients more often.

As always thanks for reading

Happy healthy exercising

Adam

PS: NEWS FLASH, since writing this piece over a year ago there has been some research here supporting my opinions on the upper traps, hoooraaah! Obviously I’m as biased as hell and I think it’s a wonderful paper but have a read for yourselves. It shows that a modified shrugging action , with the arm in approx 30° abduction creates better scapula upward rotation but also greater upper and lower traps activity… Damn I love being right… probably… possibly… ;0) !!!

ATTENTION THERAPISTS WHO STRUGGLE MANAGING PATIENTS WITH SHOULDER PAIN

2 Shocking Myth Bustings and 3 Knowledge Bombs to Increase Your Shoulder Game by 100% - For FREE!

What university doesn't tell you about shoulder impingement syndrome and scapula dyskinesis and how to massively level up your shoulder game without paying a single cent!