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Re: Patellofemoral pain
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Re: Patellofemoral pain - June 6, 2006 3:29:00 AM
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PTupdate.com
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Joined: October 8, 2001
From: Pittsburgh, PA USA
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"Wake up America. You are the victims of a system, that crushes the freedoms you so admire" That makes no sense whatsoever ginger. This country has done a fine job of leading the world with medical and technical/scientific knowledge for generations. We pride ourselves on this, and we are always open to new ideas, even ones that seem bizarre early on. All we ask is for proof.
Please note that there is already a trend in this country with regards to central problems compounding distal complaints. JOSPT has published an article detailing more rapid improvement in treatment of lateral epicondylosis with concomitant manual therapy of the cervical spine. More treatments for "trochanteric bursitis" are being aimed at the lumbar spine.
In this country, chiros are taking a beating because they claim many different maladies are due to central and spinal problems. Long, drawn out treatment sessions and no scientific backing or proof lead to insurance denials and reduced claims/reduced benefits.
You say "I do not have , at this stage , a solid framework of RCT's, scientific comparison studies or other papers at this time to offer you" How convenient! Isn't that strange, that I work a good 50 hours per week, manage a website, take care of a house and two kids, and I can get all kinds of information to back what I do?
You suggest "why you all seem so utterly stuck in the medico-legal framework that tolerates no tactic, no matter how safe , easy to learn or effective that differs from what your doctor/surgeon/insurance Co may require you to do" Not true. All PT's I know treat via methods that work and/or can be backed. I have no problem suggesting to MD's that I treat the neck in tennis elbow patients, as I can provide proof of its efficacy. Those debating you here have their names and credentials plastered up for all to see. How do I know that "ginger" is not some bored auto mechanic that takes it upon himself to treat people? Who are you and why should I implement a treatment based on what you say?
"For those of you not sincere in the business of learning, maybe stick to another forum" PLEASE, can I STAY???
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Patellofemoral pain - June 6, 2006 4:12:00 AM
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PHSPT
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From: Oklahoma
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Nari,
My question to you is if in fact the root of the problem is d/t a dysfunction in the spine. Then given that "FACT" why is it then that (regardless whether it takes longer)that Sx's can be resolved by addressing the issuse at a local level?? Tx the knee vs. spine? Shouldnt you still have pain at the knee? You still have a "dysfunction in your spine"!!!
First of all your rationale is a good one. Except for all you are doing is modulating the pain pathway as it travels through the spinal cord. All you are doing is tricking the brain that the pain is not there, by stimulating/producing a secondary stimulus which detracts the brain from the source of pain.
Which is great if your concern is pain and only pain.
You still have not fixed the problem Nari!
You are simply sweeping the dirt under the carpet!
As clinicians we need to get our pnts well not just quickly but effectively.
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Re: Patellofemoral pain - June 6, 2006 11:11:00 AM
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nari
Posts: 1568
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From: Australia
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PHSPT,
All I can say at this point is that we agree to disagree, nicely. You understand, in all fairness, that local treatment works, by mechanical means.
I'm not saying that is not true; just that we are coming from different premises. One is a traditional premise of exercise and stretches; the other is resolution by treating the origin of the pain. We both get results, and both can be equally effective. Your statement that management of pain centrally simply "distracts" the brain is not correct according to the wealth of evidence which I have mentioned above in those PTs and biologists who are investigating how the body works.
However, it has been an interesting conversation.
Maybe the different premises which we both work with will become clearer in years to come. In the meantime, each of us will do what we understand (not 'believe')is the quickest and most effective method to resolve dysfunction on a permanent basis.
Cheers
Nari
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Re: Patellofemoral pain - June 6, 2006 1:32:00 PM
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Lieutenant_Dan
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From: Camp Pendleton
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Ginger,
I think a good deal of the resistance you are meeting here is due to the fact that, whether you are willing to admit it or not, PFS is a complicated issue. There are lots and lots of treatment methods that have been taught, utilized, sold, hell even patented and most have limited applicability to the entire population of PFS sufferers, despite research supporting some of these methods. Now you come along and essentially guarantee a significant improvement in all patients with PFS with L3 facet mobs, but state that you don't have any empirical evidence, just experience. To not be skeptical of that kind of statement would be reckless on the part of anybody reading it.
Now, having said all of that, I seek your counsel. I have a patient with whom I am willing, as is he, to "Give it a go". Chronic L knee pain for no discernable reason. We have tried most all the other traditional approaches without significant benefit. I had come to a point where I told him, "sorry, that's about the best I can do for you until we return to homeport, and at that time I'll refer you to orthopedics to consider a potential medical discharge." Well then I stumbled onto this thread and now I'll give this a shot, it could be his last hope and he's at the 17 year mark in his career, would be a shame for it to go down the drain.
At any rate, upon physical exam today I actually noted that he seemed more hypomobile on the contralateral side versus ipsilateral. Given that several studies have shown the reliability of that type of exam to be fairly poor, I decided to go ahead and mobilize the ipsilateral side, since that is what you preach. I lasted about 6 or 7 minutes before my thumbs fell off, still having some difficulty typing this message as a result. At what frequency do you treat these patients and how quickly should he expect positive results? Are you mobilizing the L3-4 facet joint or the L2-3 joint?
I still remain a skeptic, but I'm willing to try it when all else has failed. Will post my results once he is either healed, my thumbs lock up or we just give up altogether.
Thank you all for the intriguing reading.
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Re: Patellofemoral pain - June 6, 2006 4:35:00 PM
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ginger
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From: Melbourne Victoria
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Good morning all , thanks Dan, Nari and PHS for an entertaining thread .
Dan, your fellow with knee pain, you didn't mention wether or not he had patellofemoral pain , no matter. If he has referred pain and altered patterns of recruitment then this will be amply demonstrated by the effect of mobs.
Patient prone, pillow under pelvis. Ipsilateral unilateral mobs done for sufficient time for there to be a reduction in both resistance ( intrinsic muscle tone) and pain will have reduced the protective response at the joint mobilised. I call the joints , numbered from L5S1 up, L5, L4, L3 etc. So your efforts will need to directed at L3, and L4 . As you haven't mentioned where his pain is, I must assume that there will be a contribution from both these levels.
Usually ten minutes is enough to get even the most chronic and stubborn facet joint to respond to mobs. If your thumb is buggered, use the other. Put one over the other. Keep practicing and they will toughen up .
It is not the amount of mobilising FORCE that is the key to success, but the degree to which your efforts are able to localise both pain and resistance and work slowly and steadily at them. Force at the joint is minimal. Effects are usually observable as above after 30 seconds. Any test you would ordinarly do for his knee to recognise pain/dysfunction can be used as the pre and post RX test. I usually ask patients to do something that hurts before I commence, keep it simple. A squat or half squat is usually enough. Palpable tenderness associated with referred pain is also a good guide. This will reduce immediately along with observed change at the relevant facet joint.
Don't believe anything untill you give it a go and put your best efforts to work. I'm not asking you to have faith in me or anything I say , just be willing to put your hands to the test and acknowledge the reality yourself.
Keen to hear of your results.
Cheers
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patellofemoral pain - June 6, 2006 4:39:00 PM
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ginger
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From: Melbourne Victoria
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Oh and John, sometimes I just like to kick the bucket to hear the tin rattle, no offense, but your rattle was fun.
OHMMMMMM
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patellofemoral pain - June 6, 2006 5:19:00 PM
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rwillcott
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From: Canada
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I have to agree with Duffy and PHSPT on this one. There are so many other factors to consider when treating a patient with PFS. Before we go ahead and mobilize the lumbar spine I think we have to be sure we have exhausted other avenues. I think any PT who jumps to the lumbar spine as the root of all peripheral problems without conducting a thourough evaluation of the patient is treating unethically.
If you perform a detailed lower quadrant scan including neurodynamic testing without any findings then you have to begin to look peripherally for the cause of the problem.
As a PT, how on earth could you not look at the hip, knee or ankle in a PFS patient? That's ridiculous!
For instance , you have a patient who is obese with a tight ITB and Iliopsoas. They don't exercise and work in an office 8 hours a day and then spend the night on the couch. You mean to tell me that you are going to simply mobilize their lumbar spine and their pain will resolve? Give me a break. Say by some miracle that patient does notice reduction of symptoms due to the spinal gate theory ( i.e I don't feel my knee pain due to the odd pressures that were performed on my back), what is the home exercise program for this patient? Continue to stay inactive and sit on your couch? Push their thumbs into their back when their pain returns?
What if their pain does return? They have not been educated on any type of activity to perform in order to manage and prevent their symptoms. What you have then created is a patient who has become dependant on their therapist who presses on their back in order to fix their knee. They have no knowledge on how to help themselves. That is not what we as Physiotherapists are meant to do. We have falied as PT's if that patient has not been taught the cause of their PFS and how they can manage their symptoms on their own independently.
It seems to much like Chiropractic to me to simply moblize a patients back without addressing other probable causes of that patients knee pain. This leads me to my next question. Ginger, are you a Chiropractor?
Rob
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Re: Patellofemoral pain - June 6, 2006 5:52:00 PM
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ginger
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From: Melbourne Victoria
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Rob , I'm a physiotherapist.
"You mean to tell me that you are going to simply mobilize their lumbar spine and their pain will resolve?"
Yes.
"What if their pain does return?"
This would only happen if there was a failure for some reason to fully resolve the spinal hypomobility/neural/inflammatory issue.
"what is the home exercise program for this patient?"
One which encourages self management/mobility/strength in a general sense.With the necessary care taken to ensure that
a. it is not overly complex
b. it will stand a better than average hope of actually being done.
"There are so many other factors to consider when treating a patient with PFS"
If you say so Rob ,going to the source of the problem is the best and quickest way to the ultimate result , wouldn't you say?
Cheers
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patellofemoral pain - June 6, 2006 7:01:00 PM
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PTdirector
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I treat many patients with an ecclectic approach to their symptoms including spine work and neural flossing techniques as needed to go along with my biomechanical treatments. If you are looking for scientific reasons why the spine can play a role in someone with known articular or tracking issues at the knee then go no further than your basic myotomal training in school. I am sure that you realize the L3 feeds the quad with not only strength, but total motor control including timing, proprioception, etc.. I am not sure that I would go so far as to say that all knee pain is "referred" because referal of pain refers to mixed signals to the brain regarding the source of a pain such as a facet pain and while that could occur I am more sceptical. However, dermatomal pain from L3 or L4 could arise from neural irritation due to a hypermobility. In fact, the statement by Dan regarding his findings of hypermobility on the affected side are something that I often find to be true. The affected side will often but not always have hypermobility that causes nerve root irritation with associated pain in the dermatomal distribution. The contralateral side will often be hypomobile and will be the side that I direct my joint mobilization techniques which is sometimes difficult to explain to patients. However, by alleviating the neural irritation you can not only affect the pain from the nerve root but positively affect any other motor control issues that have developed in the L3 myotomal distribution as well (how many times have we heard that tracking issues may arise from poor timing of the quad contraction). It is basic neurophysiology folks and is often neglected in our treatment patterns. I have only recently begun using more central treatment techniques to assist in the recovery of my patients (about 2 years). But I can tell you it has made a huge difference in my outcomes and in my business. I can also tell you right now that I am thrashing my competitors that are practicing with a narrow focus on the joint at hand because my outcomes are superior and the physicians, patients, and most importantly case managers realize this. I continue to treat the affected joint as well because the spinal mobilizations or taping (strapping) that I perform do not take up much of the treatment sessions and self mobs or stretches can be given as part of the HEP. Also, if the problem has gone on for very long the improved recruitment in the motor nerves is not enough to compensate for hypertrophied muscle tissue and re-education and retraining issues are still necessary. Someone else also asked why traditional treatments give relief if there is neural/central involvement and I would say to you that straight leg raises might also provide spinal stabilization or gentle neural flossing, hamstring stretches provide neural flossing, many closed chain exercises (especially in single limb stance positions) provide spinal stabilization/strengthening, etc... I used to be very rigid in my thought processes and did not keep an open mind but it is a dangerous road to follow. In my opinion, it is never a good idea to allow the patients diagnosis, their subjective complaints, other therapists, or preconceived notions to guide your evaluation, your finding, or your practice. How many of us have heard a patient describe shoulder pain at night and after testing the shoulder could not come up with a plausible diagnosis because strength was full, ROM was normal, and special tests were all negative. It is easy to assume you missed something and treat on a whim. But you may want to assess myotomes and dermatomes, perform cervical clearing exams next time and you may be amazed at what you find!
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Re: Patellofemoral pain - June 7, 2006 11:16:00 AM
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nari
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From: Australia
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Junction,
Global influences on any sort of painful joint area are indeed present; and consideration of the effects of pain on patients' function is essential. But one has to consider the brain in all this and not just look at a string of segments around the limb. I am not saying you do this, but global influence is not just a physical, mechanical series of facts.
If the pain is reduced or resolved by whatever means (Ginger's or other neural-focused ways) then the joint/muscle can largely fix itself. Many need some extra work such as some taping or an exercise or two, but the brain is remarkably efficient at fixing up its own organism...once the nociceptive elements have been reduced.
Nari
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Re: Patellofemoral pain - June 8, 2006 9:42:00 AM
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Alex Brenner PT MPT OCS
Posts: 1057
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From: Kentucky
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I have recently been doing a lit review for manipulation and muscle inhibition and thought that this citation was interesting. It could possibly help explain why Ginger is getting results at the knee by treating the lumbar spine. Her treatment approach may not be too far off. I don't necessarily agree that it should be applied to every knee that comes in the door but there may be a certain subgroup that could respond to this intervention.
Conservative lower back treatment reduces inhibition in knee-extensor muscles: a randomized controlled trial.
Suter E, McMorland G, Herzog W, Bray R.
J Manipulative Physiol Ther. 2000 Feb;23(2):76-80.
Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee pain.
Suter E, McMorland G, Herzog W, Bray R.
J Manipulative Physiol Ther. 1999 Mar-Apr;22(3):149-53.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Patellofemoral pain - June 8, 2006 12:53:00 PM
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nari
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The chiropractic approach seems to match the traditional PT approach - except they cover all bases. Can't see much difference. Both seem to take quite a long time, during which some natural recovery would occur as well, particularly if running and jumping were ceased.
Nari
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Re: Patellofemoral pain - June 8, 2006 3:42:00 PM
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rwillcott
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From: Canada
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I think this is a case where everyone is right. PFS is a complex condition and there are many factors to consider including both biomechanical and neural.
I think that there are times when a neural component is the main contributing factor and times when it is mainly a biomechanical factor that needs to be addressed.
I would find it helpful if there were clinical prediction rules that we could all agree upon in order to determine which sub-group of PFS patients would benefit from spinal mobilizations and flossing techniques.
I know that the SLR test can bias branches of the femoral nerve that can cause knee pain. Nari, do you mind explaining how you perform this test? Also, maybe a positive Slump along with other tests such as PA mobs (hypomobile versus hypermobile).
I think that if a patient were to meet certain criteria then I would feel more comfortable treating their lumbar spine for knee pain. I would also know that I did not just decide to treat their back because I thoguht it might work without checking many other factors.
It's the same as the clinical prediction rules for the back. Rather than just grouping everyone as Mechanical Low back Pain we have know learned the importance of sub-grouping theses patients (stability, mobilization, fear avoidance etc.) and treating accordingly. We are already seeing the amazing outcomes of this approach. There is no reason we can't do the same for the knee.
I'm sure all of the experienced clinicians on this site could agree on some great tests to perform.
Just a thought since it's clear to me that we are all on the right track; we just need to try and piece this together rather than arguing about who's right and who's wrong.
Rob
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Re: Patellofemoral pain - June 8, 2006 4:56:00 PM
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nari
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From: Australia
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Rob,
Sub-grouping patients can be useful but it does run the risk of overlooking something in the face of so many variables.
I am not sure what you mean by the SLR test biasing the femoral. Can you explain? If I want to look at what the femoral nerve is doing, I would use PKB with and without some stabilising of the thoraco-lumbar area, both sides. Often it will reproduce knee pain in the area of complaint.
You are right - nobody's right or wrong, all Rx is done on clinical reasoning from a known physiological basis.
Nari
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Re: Patellofemoral pain - June 9, 2006 1:09:00 AM
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Alex Brenner PT MPT OCS
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Rob,
Students and faculty from the the Army-Baylor Program conducted a study "Clinical prediction Rule for those with PFPS who respond to lumbar manipulation" or something close to that. It is currently in revision and should be published soon according to one of the authors that I spoke with last month. The abstract was presented at CSM last year and is published in the January issue of JOSPT.
[QUOTE]I would find it helpful if there were clinical prediction rules that we could all agree upon in order to determine which sub-group of PFS patients would benefit from spinal mobilizations and flossing techniques.[/QUOTE]I am not sure exactly what you mean from the above quote but it doesn't quite work like that. We really don't get to agree on the prediction rules. The statistics are fairly complicated and unfortunately I probably am not the best one to explain; maybe Jason Silvernail will chime in. Essentially potential prediction variables from the authors physical exam and interventions were entered into a stepwise logistic regression equation to determine the most parsimonious set of predictors for success using a multivariate model. The statistics and regression model "picks" the variables for us.
I can't remember which predictors fell out for the PFPS/Manip study but I remember that one of them was hip internal rotation which is very interesting because as you probably know it is also one of the predictors for success for those with low back pain who respond to manipulation.
Myself and a couple other therapists have a case series that is almost ready to be submitted for publication that looks at the effect of manipulation on hip range of motion. We found some very interesting things happening at the hip after we maniped the lumbar spine. The findings suggest some sort of regional interdependence between the hip and lumbar spine. We are submitting our abstract for CSM in Boston and will hopefully be sending the manuscrip to a journal in the next month or so.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Patellofemoral pain - June 9, 2006 1:17:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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I can't remember my APTA member number to log onto JOSPT's website and my card is packed with my stuff coming from Italy.
Could someone log onto JOSPT, search the January issue 2006 and cut and paste the abstract that I mentioned above? It is published in the CSM Orhtopaedic Abstracts section in the back.
Thanks!
Alex
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Patellofemoral pain - June 9, 2006 4:18:00 AM
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PHSPT
Posts: 119
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From: Oklahoma
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You cant paste it b/c its an adobe file.
sorry alex
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Re: Patellofemoral pain - June 9, 2006 4:27:00 AM
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Synergy
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From: Texas
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You can copy and paste text from Adobe files if you use the 'text select' tool. Anyways, I think this is the one you're referring to Alex.
DEVELOPMENT OF A CLINICAL PREDICTION RULE FOR
CLASSIFYING PATIENTS WITH PATELLOFEMORAL PAIN
WHO RESPOND SUCCESSFULLY TO LUMBOPELVIC MANIPULATION
Iverson CA, Sutlive TG, Crowell M, Morrell R, Perkins M, Garber MP,
Moore JH, Wainner RS
Physical Therapy, US Army-Baylor University, San Antonio, TX; Physical
Therapy, Brooke Army Medical Center, San Antonio, TX
Purpose/Hypothesis: To develop a clinical prediction rule (CPR)
consisting of clinical examination items predictive of an immediate
positive response to lumbopelvic manipulation in patients with
patellofemoral pain syndrome (PFPS).
Number of Subjects: Twenty-six men and 23 women (mean age
24.5 ± 6.8 years).
Materials/Methods: Forty-nine participants (26 males, 23 females
with a mean age of 24.5 ± 6.8 years) underwent a standardized
clinical examination. Subjects performed 3 functional activities and
rated their knee pain during each activity on a numeric pain rating
scale. All subjects then received identical treatment with a
lumbopelvic manipulation technique and repeated the functional
activities and pain ratings. Treatment success was defined as an
immediate 50% reduction in pain or a score of at least 3 on a
global rating of change questionnaire. Likelihood ratios (LRs) were
calculated to determine which examination items were most
predictive of treatment outcome, and logistic regression analysis
identified an optimum number of items for predicting treatment
success.
Results: The best predictor of treatment success was the examination
finding of a side-to-side difference in hip IR>14° and resulted
in a +LR = 4.9 (95% CI = 1.2, 20.8). The CPR consisted of the
combination of the hip IR variable and any 3 of the following
examination items: squatting as the most painful activity, no
stiffness with sitting>20 minutes, navicular drop>3 mm, ankle dorsiflexion>16°. The CPR resulted in a +LR = 10.0 (95% CI =
0.6, 17.9) and increased the probability of treatment success from
45% to 89%.
Conclusions: The CPR developed in this study to predict a
successful response to lumbopelvic manipulation consisted of hip
IR asymmetry and any 3 of the remaining predictors, resulting in a
positive likelihood ratio of 10.0.
Clinical Relevance: The CPR may help clinicians identify patients
with PFPS who respond successfully to lumbopelvic manipulation.
_____________________________
Chris Adams, PT, MPT
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Re: Patellofemoral pain - June 9, 2006 12:56:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Thats the one. Thanks Chris.
PHSPT, if you click on the text tool in adobe you can then highlight, cut and paste out of the adobe file. I just learned that myself about a year ago.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Patellofemoral pain - June 9, 2006 6:41:00 PM
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Synergy
Posts: 592
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From: Texas
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No problem! :)
_____________________________
Chris Adams, PT, MPT
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