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Re: ACHILLES INFLAMMATION AND PAIN
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Re: ACHILLES INFLAMMATION AND PAIN - May 3, 2006 10:10:00 AM
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chunkypuffin
Posts: 7
Joined: April 25, 2004
From: Wakefield, West Yorkshire, England
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Hi all,
not been on this site for a while so apologise for late entry to discussion. With regard to gingers lumbar treatment I too have had success with centrally directed treatments with certain patients. Think important area is good subjective assesssment and clinical reasoning to guide P/E and subsequent Rx. Jason, regarding EBM thought you may like the following 2 articles;
Seegers et al (2003).Enhancement of Angiogenesis by Endogenous Substance P Release and Neurokinin-1 Receptors During Neurogenic Inflammation. THE JOURNAL OF PHARMACOLOGY AND EXPERIMENTAL THERAPEUTICS. 306(1) p8-12
Alfredson et al (2003). Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis?
An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. Knee Surgery, Sports Traumatology, Arthroscopy. 11 p334-338
The second study notes the occurrence of angiogenesis present in an Achilles tendinosis patient group, while the first study notes that neuro-inflammation products can result in angiogenesis (admittedly this was a rat model so not direct evidence). This may explain why a spinal mobilisation technique, which will affect neural structures, may also affect distal inflammation and pain. Just a thought as I say, and I hope you guys can throw the debate around this regarding pro's and cons.
thanks for your thoughts
Craig
P.S ginger, about to start the Master of Manual Therapy course at UWA and note that it is one of only two to enable level 2 registration to your MPA. Given the high level of research coming out of Aus how come only two courses qualify? Any ideas?
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Re: ACHILLES INFLAMMATION AND PAIN - May 3, 2006 10:52:00 AM
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JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
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Craig-
Thanks, I'm familiar with the tendonosis concepts. Since eccentric training is biologically plausible and has good outcomes, I wonder why we rush to look centrally.
I fully understand neurogenic inflammation, but with extravagant claims of efficacy, a rather simplistic explanation, and a unidimensional treatment regimen, ginger and I are not likely to agree on much in this area.
I think certainly evidence is building in looking centrally for peripheral problems, and I encourage this in students, but it raises a red flag when someone is a bit too certain that he's right, and when claims are out of proportion to evidence and far exceed anything reported in the literature. Especially with zero evidence. While I don't doubt that there's something to it and it's plausible, at the end of the day we are left to take it for what it is...an unsupported claim of efficacy. I've heard a lot of those in my career, they don't impress me.
But perhaps that's just my scientific bias oozing out again...
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: ACHILLES INFLAMMATION AND PAIN - May 3, 2006 4:08:00 PM
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ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
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Hey Chunky, not connected in any real way to the course you mentioned , though I wish you all the very best with it. Not sure I'm able to give any usefull info on the level 2 registration issue either. Can you explain what this is a little further , Nari may be more able to offer insight there.
There will always be a number of rational evidence based thinkers who wait for the science to catch up before offering support for the new or the different. Not such a bad thing certainly. Just means they may not be at the vanguard themselves and are overly cautious. I'd rather plunge in with what I rationalise is both safe and effective than rely on literature alone to support my actions. Seems there is a culture of disaproval of the pragmatic outcome based proposals in favour of a strict adherence to the terminal absolutes provided by orthodoxy. Just as well there are those who are willing to give new ideas a thorough try rather than simply following academics.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: ACHILLES INFLAMMATION AND PAIN - May 4, 2006 3:29:00 AM
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JLS_PT_OCS
Posts: 1684
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From: USA
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I think that is a reasonable approach, ginger.
I don't dispute the well-reasoned application of what works pragmatically.
My issues are of claims of efficacy far beyond what exists in the literature and what may be at the limit of possibility, from a physiologic standpoint, coupled with a over-simplistic and one-dimensional rationale.
So, I question not the treatment, but rather the claimed effects of the treatment and the way in which it is presented both to patients and peers.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: ACHILLES INFLAMMATION AND PAIN - May 4, 2006 6:06:00 AM
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PHSPT
Posts: 119
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From: Oklahoma
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Yeah what he said!!
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Re: ACHILLES INFLAMMATION AND PAIN - May 4, 2006 6:22:00 AM
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PHSPT
Posts: 119
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From: Oklahoma
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Ginger,
It just baffles my mind that folks outthere are practicing with what feels right and not what is proven to work!
Can you imagine if a surgeon was to practice this way. hmmmmm... I think i'll approach the joint this way, not b/c its what works, but this way sounds better!!
Although the previous comment may have sounded far-fetched , it really is not.
I feel that if all the fields of medicine were to practice, without hard facts, we will all be predisposed to life threatening care. Thankfully not all of us practice in this way.
It is our duty as clinicians to provide the latest and most up to date care.
We need to stop this egocentric view, that we can fix all, do all, which sets up the stage for false, wacky medicine giving us clinicians a bad name.It is this type of mentality that plages chiropractors (not all!!) in the eyes of the medical community.
My 2 cents!!
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Re: ACHILLES INFLAMMATION AND PAIN - May 4, 2006 11:11:00 AM
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nari
Posts: 1568
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From: Australia
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In the field of medicine, there are often life and death issues; fiddling around with what seems to work would not be regarded as good practice.
However...we are not doctors dealing with potential mortality issues.
I don't believe, and most PTs would agree, that we can fix all and do all. If any of you are faced with someone whose symptoms do not seem to 'fit' the list of EBP "tools", do you then say "no,it's not in the evidence " and send them away? If EBP is rigidly adhered to, then, in extremis, this is what you would do. Is that good care?
Working from grass roots, from the CNS out, which I suspect Ginger is doing, is sound physiology, and as up to date as one can get. Even the folk at EIM are starting to recognise the brain. Concentrating on muscle and ligament and posture has some EBP backing, but fails to see the big picture. The patient population will get better with lots of sessions of musculoskeletal practice; but they could do better.
Somewhere in between is the way to go; and waiting for research to be done, for permission to treat our patients from the researchers, seems almsot unethical...It seems that many researchers are caught on the mousewheel of muscle and joints...
I'm sure this will raise the hackles of many; but working from the inside-out and top-down/bottom-up cannot harm, and has some spectacular results.
Why not?
Nari
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Re: ACHILLES INFLAMMATION AND PAIN - May 4, 2006 2:20:00 PM
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ginger
Posts: 658
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From: Melbourne Victoria
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It would seem clear PHSPT that your attitude and unwillingness to cross the floor into the uncertain ( at least for you ) without your hand held by the very orthodoxy I mentioned is holding you back . In the sense at least, that claiming the moral/ethical or in this case the safety high ground, is part of the culture of believing the academics rather than what evidence your own hands could easily provide.
To use your analogy of relating to surgeons, that choosing a professor of surgery ( an academic) over a working surgeon would be a bad one. I know I'd much rather have a pair of hands that can DO , than a pair that may have taken their attentions for a significant period away from the coalface to study and interpret and teach.
To suggest that academics have a better hold on the cutting edge of the world of musculoskeletal problem solving is a little bizzarre.
I'm reminded of the scout leading the pilgrims on the long journey into the wilderness, one night he comes back with great news, just over the next horizon is a fertile valley, where the cattle can safely graze he says ( tempting to add, "kimosabi" here ) , but the great white warrior prefers the map given to him by his superiors. Ans so they go on to suffer at the effects of thirst and hunger , then perish.
Jeez I got off on that tangent well enough , must read to my kids more often.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: ACHILLES INFLAMMATION AND PAIN - May 4, 2006 2:58:00 PM
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ginger
Posts: 658
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From: Melbourne Victoria
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While I have a few minutes this morning I thought I'd just re-establish my theme about this issue, that is, that one can not tell on the basis of symptoms alone, wether a sore, puffy , tender to palpate and stretch, achilles tendon has a local problem , or a referred , neurogenic lumbar soine related problem . One must reach a conclusion about cause by approaching the central ,( lumbar spine and sciatic nerve ) first.
No point describing how some eccentric exercises do quite well , while admitting that they don't always have the desired effect. While the potential to ELIMINATE this problem with a couple of carefull skillfully applied sessions of L5S1 mobs.
Now all you have to do is try it!
you can lead a horse to water.....
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: ACHILLES INFLAMMATION AND PAIN - May 4, 2006 4:29:00 PM
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PTupdate.com
Posts: 1474
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Some points to ponder:
1. Something that is in the literature, either proven or disproven, was once someone's whacky idea...perhaps it's a good thing they stuck with it
2. We all practice in some manner that is not supported by literature...either it was not proven, or the study that "disproved" it really was not that good. Or, we just do it in such a way that it works for us....the same reason that Nestle TollHouse cookies can taste so different depending on who made them, even though all the same ingredients were used.
3. More reasons why outcomes also need to be used in our practice. There are so many variables, that resolution of symptoms in "x" visits using some myriad of treatments may be another good way of looking at things.
Perhaps I'll use the ginger method of AP mobs on the next guy that comes across with the condition yet does not have insurance..."Let me treat your Achilles for 2 weeks doing lumbar mobilizations to see what happens. If you are cured, great. If not, I'll treat the foot in my usual method on the house"
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: ACHILLES INFLAMMATION AND PAIN - May 4, 2006 4:29:00 PM
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PTupdate.com
Posts: 1474
Joined: October 8, 2001
From: Pittsburgh, PA USA
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..............and then I'll send the bill to ginger
Duffy
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: ACHILLES INFLAMMATION AND PAIN - May 4, 2006 5:24:00 PM
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ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
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Every avalanch starts with a trickle John, It won't take you two weeks, unless you use the kid gloves with your mobs. The first treatment will yield powerful results if you follow my method. When the time comes by all means get in touch , I'll guide you as best I can. Good luck and I'm thrilled you've decided to let your hands do the talking.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: ACHILLES INFLAMMATION AND PAIN - May 8, 2006 8:19:00 AM
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PHSPT
Posts: 119
Joined: December 1, 2005
From: Oklahoma
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May be im thinking too hard here, but from a pathophysiological perspective doesnt sound as if it would bring any benefit.
Perhaps if I run into a wall ill look into alternatives. At this point Im able to produce positive results from conventional approaches.
Ultimately we all want the same thing, which is to return pnts back to their normal function. So...rock on! whatever works for you!
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Re: ACHILLES INFLAMMATION AND PAIN - May 25, 2006 5:10:00 PM
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PTdirector
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Joined: May 24, 2006
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If you are looking for science and physiology to back up the central effect on distal limb pain then I would guess many of you have taken the path that many physicians have taken. L5/S1 dermatomal distribution is in the calf area so I would not call it "referred" pain which is misinterpretation of pain signals by the brain. It is more likely to be nerve root irritation or possibly compression. With root irritation they are much more irritable and you are more likely to see swelling, redness, and acute irritable pain. Sympathetic nerves flow with the nerve bundles exiting the lumbar spine and go for a ride to the same area as the sensory and motor nerves that they serve. I have seen more nerve root irritation as a cause of achilles tendinitis and as someone stated earlier, the reports of night pain are a certain giveaway that the pain could be neurologically derived. Another diagnositic technique would be to test the S1 dermatome for sensory changes. I have also found that many people with shin splints have L5 radiculopathy/nerve root irritation. You will be able to assess this by testing great toe extensor strength which will be much weaker than the opposite side (generally a whole MMT grade or more less). Performing mobs, manipulations, neural gliding will often give immediate pain relief as Ginger states and you will often see a significant increase in the MMT of the originally weakened muscles. Nerve root irritation is often due to instability on the affected side and you will sometimes see nerve root compression on the opposite side. That may be why Ginger does not get good results from high force gapping techniques on the affected side. I get good results from and would highly recommend gapping and rotation techniques on the contralateral L5/S1 area. They can also be taught to perform joint blocking/positional traction techniques to stretch the contralateral side. I would challenge you to assess the neural tissues through dermatomal and sensory testing as able (gastroc testing in L5/S1 situations with achilles tendon pain will give you the same results regardless but you can check hip abduction in supine and will often notice weakness in the ipsilateral side with L5 or S1 involvement, but you have to give SIGNIFICANT resistance sometimes to notice the difference in the hips) and also to ask all of your achilles or shin splint patients about LBP history. Most of my achilles tendinitis and rupture patients have a history of LBP and many of them have had procedures performed at L5/S1. Coincidence??? You will ultimately be the judge.
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Re: ACHILLES INFLAMMATION AND PAIN - May 25, 2006 8:19:00 PM
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ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
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PTDirector , your words are fresh air to my harried senses, write more please.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: ACHILLES INFLAMMATION AND PAIN - May 25, 2006 9:49:00 PM
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nari
Posts: 1568
Joined: November 14, 2003
From: Australia
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PTDirector,
Ditto!! what ginger said. Especially the neural stuff - essential to my way of thinking.
Nari
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