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In my last post, I discussed how using a cluster of signs and symptoms can significantly improve our diagnostic accuracy for differentiating issues in the neck and upper extremity. Moving down the kinetic chain, there are other regions of the body in which cluster diagnoses have been identified. In this month’s post, I want to highlight how a cluster of tests can help us differentiate pain at the sacroiliac (SI) joint as well as identify if arthritis is occurring within the knee.
In 2005, Laslett et al. wrote an article which redefined a way which many of us examine the SI joint. His article examined the validity of movement and provocation testing and demonstrated that the best way in which we can differentiate pain in this joint, from other surrounding joints, is through a cluster of tests which provoke pain. Provocation tests, which have been around for a couple of decades, appear to be our best way of discriminating an issue occurring in this region. Palpatory tests (such as iliac crest height, standing and seated flexion, and long sitting) suffer from very low agreement in terms of validity and inter-rater reliability and clinical use, according to the literature, is questionable.
Proposed provocation tests that appear to hold clinical value include the distraction, compression, thigh thrust, Gaenslen’s (right and left) and sacral thrust test. Alone, these tests tell us little but 2 out of 4 positive provocation tests (distraction, compression, thigh thrust or sacral thrust) demonstrate a sensitivity of .88 , specificity of .78, positive likelihood ratio (LR) of 4.00 and negative LR of .16 for SI joint pathology. 3 out of all 6 provocation tests have a sensitivity of .94, specificity of .78, positive LR of 4.29 and negative LR of .80 for SI joint pathology ( the reference standard for determining if there is truly dysfunction at this joint is pain relief after an intra-articular injection). Other authors have reexamined Laslett’s results and a systematic review in 2009 confirmed that a cluster of provocation tests has discriminative power. Before using this cluster of tests, it is expert opinion that one clears the lumbar spine and hip for other contributing pathology.
Review:
Distraction Test: The patient is supine the examiner applies pressure to “spread” the ASISs.
Compression Test: The patient is in sidelying. The tester is behind the patient with both hands applying a downward pressure through the anterior portion of the ilum, spreading the SIJ.
Thigh Thrust Test: The patient is supine and the hip is flexed to 90 degrees with the knee bent. The tester then applies a posterior shearing force to the SIJ through the femur. Avoid excessively adducting during this exam.
Gaenslen’s Test: The patient is lying supine near the side of table. The examiner stands on the side of the patient and places the patient’s leg closest to them off the edge of the table. The examiner then instructs the patients to actively flex the opposite leg to their chest and hold. The examiner then applies pressure to the leg hanging off of the edge of table, forcing it into extension.
Sacral Thrust: The patient is prone and the examiner applies an anterior pressure through the sacrum.
In addition to the cluster testing for SI joint dysfunction, a 2010 article in the Annals of Rheumatic Disorders attempted to develop evidence-based recommendations for the clinical diagnosis of knee osteoarthritis. It has been stated that 25% of individuals over the age of 55 suffer from knee pain. Out of these individuals, about half have been shown to have OA changes on radiograph and a fourth are disabled because of it. Because of this prevalence, these examiners wanted to determine a quick algorithm to use to diagnose knee OA.
The examiners of this study used a Delphi consensus approach and analyzed recommendations given by experts in 12 European countries as compared to a systematic review of available literature. They then calculated the diagnostic accuracy for the answers given by the experts to formulate a mathematical probability for someone having knee OA. They found that when three specific signs and three specific symptoms were present, the probability of someone over the age of 45 having OA was 99%. The three signs include: crepitus, restricted movement, bony enlargement and three symptoms include: persistant knee pain, limited morning stiffness and reduced function. It is proposed that clinical assessment alone, looking at these six variables, can provide a confident rule-in diagnosis.
Overall, literature is indicting that a multitude of tests used together, is the best method in forming a clinical diagnosis. In next months blog, I plan on highlighting a topic I discussed early this year: pain.
In the US, physical therapists are gaining increased autonomy by becoming direct access providers for medical care (by diagnosing and treating musculoskeletal conditions without a medical referral). A recently published large, retrospective study assessed the effectiveness of this system and found that early access to a Physical Therapist led to fewer needed visits (86% of physician referred) and lower overall cost of treatment (87 cents for every America dollar). Despite the positive outcomes found in this study, it is vital that we continue to assess, critique and understand our diagnostic strengths as well as limitations. One way in which I believe we can improve outcomes is by looking for cluster diagnoses, or a combination of signs and symptoms which lead to a high likelihood for an individual having a disorder. These improve our mathematical accuracy for making a diagnosis which ultimately leads to more effective treatment and resolution of symptoms.
When considering cluster diagnoses I would like to begin with the shoulder. It is estimated that six million people a year seek medical attention due to shoulder pain (in the US). Two of the most common conditions in this region, that we must differentiate, include subacromial impingement syndrome and rotator cuff tears. Both conditions often evoke similar positive signs but did you know that a cluster of tests exist for diagnosing rotator cuff pathology with high accuracy? A 2005 article in the Journal of Bone and Joint Surgery found that a combination of a positive Hawkins Kennedy test, infraspinatus strength test and painful arc of motion lead to a positive likelihood ratio of 10.56 for an individual having any degree of subacromial impingement. The authors further found that a combination of a positive drop arm test, infraspinatus strength test and painful arc of motion have a positive likelihood ratio of 15.57 for having a full thickness RTC tear. These clusters of three positive tests demonstrate our ability to detect two pathological conditions, and a positive Hawkins Kennedy vs. drop arm test is the only necessary differentiator between someone having impingement versus a full thickness rotator cuff tear. For review:
Hawkins Kennedy: Passively flex the patients arm to 90 degrees within the plane of the scapula, stabilize the elbow which is bent to 90 degrees and internally rotate the shoulder. Sensitivity: 71.5%, Specificity: 66%
Painful Arc: The patient elevates their arm in the scapular plane actively and complains of pain between 60 and 120 degrees. Sensitivity: 73.5%, Specificity: 81% Infraspinatus muscle strength test: The patients elbow is flexed to 90 degrees and the arm is adducted to neutral. Manual pressure is applied into internal rotation and the patient resists into external rotation. A positive test is giving way. Sensitivity: 41.6%, Specificity: 90.1%
Drop arm test: The patient is asked to elevate (or examiner passively elevates) arm fully and then is asked to hold and then slowly lower that arm. A positive test is if the arm drops suddenly or if the patient has severe pain holding it.
Sensitivity: 26.9%
Specificity: 88.4%
When assessing for shoulder pathology, it is always pertinent to rule out the neck as the origin of symptoms. One condition that can refer pain to the shoulder from the neck is cervical radiculopathy. Wainner et al demonstrated that there is an accurate cluster diagnosis for this condition, and it consists of four positive tests. These include a positive upper limb tension test (ULTT) of the median nerve, cervical rotation < 60deg, a positive distraction test, and a positive Spurlings test. When these are present, the patient has a positive likelihood ratio of 30.3 and specificity of 99% for having cervical radiculopathy(it doesn’t get more accurate than that)! For review:
Upper Limb Tension Test: Patient is supine and clinician depresses the shoulder girdle, abducts the humerus to 110 degrees, supinates the forearm and extends the elbow, wrist and fingers. The cervical spine is then sidebent away from the tested UE. A + test is reproduction of symptoms.
Sensitivity: 97%
Specificity: 22%
Distraction Test: Patient is supine and examiner applies a traction force to the cervical spine. A + test is resolution of symptoms. Sensitivity:44% Specificity:90%
Spurlings Test: The patient is seated and lateral flexes + extends the cervical spine. The practitioner applies axial pressure through the top of the head. A + test is reproduction of radicular pain or numbness down the UE. Sensitivity: 30%, Specificity: 93% As you can see above, the tests by themselves have variable clinical accuracy but when in combination with others, they can make us great diagnosticians.
In the next installment, I anticipate assessing additional cluster diagnoses as well as clinical prediction rules which can help improve our diagnostic skills!
Pendergast, J., Kliethermes, S. A., Freburger, J. K. and Duffy, P. A. (2011), A Comparison of Health Care Use for Physician-Referred and Self-Referred Episodes of Outpatient Physical Therapy. Health Services Research. doi: 10.1111/j.1475-6773.2011.01324.x
Park HB, Yokoto A, Gill HS, Rassi GE, McFarland EG. Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome. Journal of Bone and Joint Surgery. 2005: 87; 1446-1455.
Tong H, Haig AJ, Yamakawa K. The Spurling Test and Cervical Radiculopathy. Spine 2002: 27; 156-59.
Wainner RS, Irrgang JJ, Delitto A. Reliability and Diagnostic Accuracy of the Clinical Examination and Patients Self-Report Measures for Cervical Radiculopathy. Spine 2003: 28; 52-62.
To read more from Joseph, check out his new blog www.forwardthinkingpt.com
Articles in this issue:
Don’t forget the iPad/iPhone app is now out – just search the Apple app store for sportEX:
- Autosomal Dominant Type 2 Accessory Navicular: A Key Component in the Differential Diagnosis of Medial Foot Pain by Sarah Morton – An accessory navicular (AN), often referred to as os naviculare, is prevalent in adolescent females and is a recognised cause of medial foot pain. There are many differential causes of medial foot pain in adolescent female athletes, and a painful AN should be considered as part of the differential diagnosis. This article presents a case report to investigate medial foot pain as a result of an AN. The article notes the similarities with Crisp–Padhiar syndrome where there is presence of a Type 2 AN, tibialis posterior dysfunction, tibialis posterior tendinopathy, anomalous tibialis posterior tendon attachment, acquired flat foot and synchondrosis. One difference is also noted; there is no acute trauma. The presenting symptoms of AN and its genetic pedigree are also outlined, along with the suggested management, both conservative and surgical (includes video).
- Assessing Patellofemoral Pain Dysfunction: A Kinematic Paradigm by associate professor and athletic trainer, Darrin Smith – Traditional assessment and rehabilitation of patellofemoral pain (PFPS) tends to focus on isolation of specific knee structures. Evaluation of upright function requires the basic understanding of both internal and external movement influences. Accessory and physiological movement components work in conjunction with ground reaction force, gravity and momentum in order to effectively produce, reduce and dynamically stabilise movement in the lower extremity during functional activity. Breaking pathological movements down into phases allows the clinician to identify the point at which the PFPS pathology occurs. Once identified, the clinician can address movement requirements necessary for phase completion of the function associated with the patient’s complaint of pain. Assessment and rehabilitation strategies performed in a non-weight-bearing environment do not replicate internal and external influences that drive the knee during upright function. Therefore, assessment and rehabilitation procedures should address these influences in order to successfully treat patients diagnosed with PFPS (includes videos).
- Athletic Shoulder Rehabilitation by physiotherapists Ben Ashworth and Ian Horsley – The relevance of the role of proprioception in the athletic shoulder is explained with a brief summary of theoretical background and recent research on the effect of the rugby tackle on joint position sense. Applied assessment and rehabilitation of proprioception in the shoulder is discussed. Key methods of assessment are identified and a framework for rehabilitation progression is given with examples of a wide range of rehabilitation concepts and ideas.
- The (Re-)evolution of Barefoot Running: Does it Reduce Injury? by physiotherapists Paul Remy Jones, Christian Barton and Dylan Morrissey – It could be argued that distance running in advanced industrial society is no longer required for survival, in that hunting has been replaced by shopping and predators tend not to arrive at speed from behind a tree or boulder. However, the health benefits of running are well documented, and it is clearly a potent way to add life to years as well as years to life. Perhaps running is more essential to survival in Western society than first thoughts would indicate? And yet there are risks – as any sports medicine professional and thousands of patients know all too well – of both trauma and, particularly, of repetitive use injury. Footwear has become a multi-billion pound industry and, recently, a contentious issue. For the past 50 years, industry has been attempting to enhance and optimise the running shoe for both performance and injury prevention. However, a question has arisen recently as to whether we should run minimally shod, or even barefoot, with many arguing that the typical running shoe is part of the injury problem. Is this an industry-driven fashion or a back-to-nature scientific advance in our understanding? This article considers what we now know and what we would like to know about the issue of ‘barefoot’ running and injury risk, in order to best guide our practice and our patients.
- Quarterly Journal Watch - our popular (and unique) roundup of this quarter’s sports medicine research from the research journals.
If you have never seen a copy of sportEX medicine you can sign up to a 3 month subscription, completely free, you don’t need to enter any payment details. Just click here and order the journal or journals you wish to receive.
Articles in this issue:
Don’t forget the iPad/iPhone app is now out – just search the Apple app store for sportEX:
- Kinesiology Tape: The Low Down by physiotherapist Paul Coker – Kinesiology taping, first invented in the 1970s, has seen a dramatic, recent increase in popularity. With the Olympics looming could this be the edge our athletes need to heal faster and perform better? But it’s not just a treatment for the elite: from postural problems to swollen ankles, a simple roll of kinesiology tape could help almost every patient you treat. The author presents in this article a few simple but powerful techniques (inc. videos), and discusses what kinesiology taping is and how it’s thought to work.
- Overpronation: Does it actually exist? by sports podiatrist, Ian Griffiths – This article examines the commonly used term “overpronation” and puts forward the case that it should be abandoned from the vocabulary of every sports injury professional who deals with lower limb pathology. Despite being one of the most frequently used terms associated with foot mechanics, the basis upon which it is used is nothing more than conventional habit, with next to no evidence supporting it as a medical concept. A review of the literature regarding foot level pronation is presented, and the historical assumptions of ‘normal’ (upon which most biomechanical evaluations and treatment plans are based) are challenged (including videos).
- The Manipulation of Load in the Management of Tendinopathy: A multidisciplinary approach by EIS soft tissue therapist Paula Clayton – Although the pathophysiology is ambiguous when looking at tendinopathy, the main theory among several (1) is the mechanical theory; therefore, the knowledge of risk factors is essential for developing preventative measures (2). This article stresses the importance of a multidisciplinary approach when dealing with injury, without the inclusion of multiple disciplines how can we be certain we are not missing a vital piece of the puzzle?
- What’s in a Name? by soft tissue therapist Paula Clayton – Each month we ask a soft tissue practitioner and a physical therapist to contribute to our sportEX blog and the intros to these blog posts appear in our monthly email newsletter with a link to the full post. However, unsurprisingly because of the jobs you do, we know that many of you don’t sit in front of a computer all day and therefore miss out on these posts, so we like to publish the ones that generate some discussion, in the journal itself. Paula Clayton wrote the blog post and a number of you shared your views so we’ve published the whole blog post below in the hope that more of you will get involved in the discussion. Tell us what you think by visiting the following link and adding your thoughts to the comments area (you can do this anonymously if you’re the shy type but feel free to speak out – you never know you might become part of an industry change! To comment click here http://spxj.nl/yNIvoq or to read some of our other blog posts post go to www.sportex.net/blog.
- Book and DVD Reviews by various authors – we review Muscle Energy Techniques by John Gibbons, Advances in Functional Training by Michael Boyle, Postural Assessment by Jane Johnson and Kinesiology Taping Fundamentals DVD.
- Quarterly Journal Watch – our popular and unique take on the key soft tissue research that has been published in the previous few months.
Many may already be aware of the 21st edition of the International Conference on Sports Rehabilitation and Traumatology: ‘Football Medicine Strategies for Knee Injuries’ (which will be hosted by the Isokinetic FIFA Medical Centre of Excellence at Stamford Bridge Stadium between April 21st-22nd).
The event is shaping up to be the largest Football Medicine conference in the world with over 800 delegates from more than 50 countries already signed up to attend. However the organisers have recently announced that they’re also planning to offer a live, high quality stream of the main conference events, which will be available over the internet, for those who face geographical or financial barriers to attending the event in person.
The main presentations will be streamed and viewers will also have the ability to send questions directly to the conference chairmen via Twitter, who will aim to present the best questions to the speakers at the end of their sessions.
There are two streaming packages available, one for Universities, Colleges and Associations which can act as satellite centres in a dedicated meeting room or lecture theatre, and one for individuals who can watch from their office or home. So if you’re interested in one of these options (or want more info about attending the meeting in person) the best thing is to visit the conference website at the following link at www.isokinetic.com (click the Union Jack flag in the top right hand corner if the site doesn’t show in English!).
sportEX are hoping to attend the event in person – follow me on Twitter (@sportEXjournals) and I’ll tweet a meeting point that fits around the schedule should anyone want to come and say hi!
What’s in a name?
In the UK as soft tissue therapists we have a confusing array of ‘titles’ attempting to explain who we are and what we do. We have been going through a similar identity crisis to our counterparts over in Australia who have written a number of articles on this very subject (see sportEX dynamics Jan 2012 issue).
Why do I call myself a soft tissue therapist? For the same reason a doctor, osteopath, chiropractor or physiotherapist, is not identified by one of their many interventions, i.e. pill prescriber, manipulator or ultrasounder. This is not only incorrect but also pretty insulting considering the degree of training we all undertake. Why would it be then that some of our profession chose to describe themselves as a technique? I am not suggesting for a second that to do so is incorrect; I would also never suggest that people should change if they are happy with their current title. I am simply attempting to explain why there may ‘alternative’ titles have emerged.
Within elite sport (I can only speak for myself here) the traditional idea/notion of ‘massage/sports massage’ is such a minute part of my arsenal that I can go days without actually opening any lotion let alone applying it to a large surface area. So, for me, being described by this technique is actually a misnomer. This is why I worked hard to change the name of the practitioners working within the EIS and within UKA as ‘soft tissue therapist’ – after all, that’s who we are and what we do and leaves the question open, ‘what is a soft tissue therapist?’ At least with this question we can go on an explain in our own words, exactly what we do. It eliminates the preconceived notions of whale music and candles for all professions with the word ‘massage’ in. I would like to add here, that I love whale music and candles when I’m getting my regular relaxation massage by my very qualified and very talented therapist. However, she would be the first to agree that what we do is worlds apart. She even suggested that she was the ‘off licence’ and I was the Somelier.
why is it that we seem to always be surrounded by the negativity of … ‘research suggests … doesn’t improve …’. We are part of a profession that bases our outcomes on what we feel and what we see. Our assessment process is critical to our clinical reasoning and therefore our decision-making when it comes to our selection of performance impacting soft tissue techniques. So, being skilled in assessment is of paramount importance. How, without this critical ingredient can we possibly determine whether we have actually made a difference, and therefore justify charging for our service?
I would go on to suggest that it is a much easier process to justify to the critics of soft tissue work that the research out there when it comes certain techniques is unquestionable. What we need to move away from is the dogged determination to prove that ‘circulation is increased’ or ‘lactate is removed’ or ‘eliminates DOMS’.
Being a qualitative girl who struggles to find the relevance in research which tries to quantify ‘how many of certain fibers are in a frogs leg’ , when it comes to our profession it’s results that count. Have we improved range/reduced pain/improved ADL/etc…? whilst I know this is seen as subjective or empirical, it is what we do.
When asking one of our sports doctors many years ago where I could find the research to negate a claim by one of my managers that “what you do isn’t really a job is it?” (Yes, I agree, outrageous) his reply remains with me. “Paula, there is no research out there that states that anything in sports medicine (including physiotherapy) actually works as most of what we do is empirical.”
This leads me wonderfully onto an amazing ‘eye opening’ April Fool’s research article called ‘Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials‘ (Smith & Pell, 2003). Sometimes, we can’t prove that what we do works, it just does.
So, what’s your title, is it a true reflection of what you do? Maybe we should be pushing our professional associations to acknowledge the versatility factor is missing in the current titles. Are we in need of adding ‘& Soft Tissue Therapy Association’.
See you later this month …
One of the most common reasons individuals seek outpatient Physical Therapy services is due to low back pain (LBP). Literature indicates the LBP affects 60-90% of the population with reoccurrence rates documented as high as 90%. The condition is often difficult to manage due to the inability to identify the causative agent for the pain. In the research community, the Holy Grail for approaching the treatment of low back pain is finding a successful way to intervene, before it even begins.
Preventative interventions for LBP continue to remain limited. Studies indicate that exercise is more effective than no activity but there haven’t been enough higher quality trials to indicate what type of exercise should be performed. Psychological education for LBP has also been supported with limited research, but to date, no studies have compared which intervention is more effective. Last month, several US researchers published a cluster randomized trial in BMC Medicine searching for that Holy Grail. And the authors may be traveling down the right path…
Steven George et al joined forces with the military to conduct a very large randomized clinical trail to compare four variables for the prevention of low back pain: traditional lumbar exercise, traditional lumbar exercise with psychosocial education, core stabilization exercise, and core stabilization with psychosocial education. The educational session occurred during one session and the exercise programs were performed daily for 5 minutes for 12 weeks.
- Traditional lumbar exercise: consisted of exercises targeting the rectus abdominus and oblique abdominal muscles. These consisted of: sit-ups, sit-ups with trunk rotation and abdominal crunches.
- Core stabilization exercise: Targeted deeper trunk muscles such as the transversus abdominus, multifidus and erector spinae. These consisted of: abdominal drawing-in maneuver crunch, horizontal side supports, hip flexor squats, supine shoulder bridge, quadruped alternate arm and leg.
- Psychosocial education: Consisted of a lecture with a visual presentation followed by a question and answer session. The information was designed to reduce threat and fear of LBP, with coping strategies. Each soldier was also issued a back book for personal use.
After determining eligibility, 4,235 soldiers enrolled in this study. 71% were male with a mean age of 22 years old and no prior history of low back pain. The program took place after completion of basic training. The subjects were not individually randomized, but instead their company was assigned to one of the four intervention groups.
The results of this study were measured by those who sought healthcare due to LBP. Statistical analysis indicated that there was no benefit to performing core stabilization activities versus traditional lumbar exercises to prevent the seeking of medical service for LBP. In contrast, the addition of psychosocial education to either of the exercise groups resulted in a statistically significant lower two-year incidence rate in the seeking of healthcare for LBP. These results are promising because education is cheap, easy to administer and could result in much lower healthcare costs, due to the burden of money spent treating LBP.
One of the major flaws in this study was the authors’ decision to change how they would measure the long-term outcomes, mid-way through the study. They made this decision due to the low participation in long- term follow-ups (likely due to deployment to war which limited the participant’s ability to complete a web-based follow-up report). The investigators had to make the decision to track all of the soldiers that sought healthcare for LBP versus the occurance of LBP. This change in measurement allows us to only know that there was a reduction in those who sought care. It does not tell us there was a reduction in overall pain. But that stated, this study is one of the largest out there and indicates there is promising research being conducting to find ways to combat LBP.
George SZ, Childs JD, et al. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial. BMC Medicine 2011, 9:128 doi:10.1186/1741-7015-9-128.
Has your back, neck or knee ever “told” you that the weather was going to change? Chances are, yes. Or at least so you thought. For thousands of years, there has been a widespread and strongly held belief that pain and weather are related. Modern research is finally giving us some insight into why this phenomenon is thought to occur. And the relationship between the two may not be as strong as you may think.
The association between weather and pain is thought to have originated as early as 400 B.C. In his book, Air, Water, and Places , Hippocrates recognized an association between chronic disease and rain/wind. He believed that weather could affect someone’s health. This belief has continued up through current times, where many individuals have become convinced that weather holds the properties to modulate disease and pain. I am sure as a kid, you were told to “zip up your coat or you’ll get sick” or heard from a parent, “my knee hurts because it’s going to rain”. So this stated, why do we continue to focus on associating seemingly unrelated experiences to explain pain? Wouldn’t it make as much sense to relate pain to a bad meal. Or maybe a really boring conversation? Are rain and pain associated because they rhyme?
An article published in 1996, by Redelmeier et al. examined how we psychologically relate pain and weather. In this paper, he stated that individuals with arthritis tend to look for changes in the weather when they hurt more, and neglect it when they don’t hurt. Quite simply, they look for a cause of their pain and many blame weather. In fact, weather has been found to be the second most commonly perceived cause of disease activity flair-ups in individuals with rheumatoid arthritis (RA). But despite this strongly held belief, there is only weak, empirical evidence for an association between RA and pain. A 2011 systematic review of all of the existing literature on weather and pain indicated that the current research has not shown any consistent group effect of weather conditions on people living with RA.
A population-based epidemiological study (in North West England) published in 2010 assessed if weather variables had an influence over pain in a subgroup of individuals living in a specific region. The authors monitored hourly information on sunshine, precipitation, air temperature and pressure and ran an analysis of relationships to see if any of these variables caused pain. While the authors found that a strong relationship existed between lack of sunshine, cool temperature and pain, they were unable to demonstrate that pain was a true consequence of weather.
Another study, more closely examined if a relationship exists between pain and barometric pressure. Two-hundred individuals diagnosed with knee osteoarthritis reported their pain for three-months. During this time, daily values for temperature, barometric pressure, dew point, precipitation and relative humidity were also obtained from a local weather source. The researchers analyzed the results and discovered that barometric pressure and ambient temperature had an influence over the reported severity of knee pain. Eureka! Finally, a study discovered the two are related! Weather causes pain. But not too fast. There were several significant flaws which any novice scientist would point out regarding this research. The most significant is that this study failed to look at two key components which have been highly correlated with pain: activity levels and psychological variables. Over the past decade, a significant amount of literature has demonstrated that decreased activity levels are associated with pain. So, if rain/snow/sleet/wind/etc. limit someone from going outside and being active, the pain could likely be more related to inactivity vs. weather. And rainy, gloomy days are also related to depressive moods which are associated with pain. So it could be speculated that someone’s depressive mood could be modulating the pain versus the weather alone.
Overall, the research between weather and pain shows a loose association at best. There does not appear to be a causative relationship between the two. So the next time it is raining and you or your patients hurt, try to search for a cause other than weather, because rain does not cause pain.
Redelmeier DA and Tversky A. On the belief that arthritis pain is related to weather. Proc. Natl. Acad. Sci. US 1996 : 93; 2895-2896.
McAlindon T, Formica M, et al. Changes in barometric pressure and ambient temperature influence osteoarthritis pain. The American Journal of Medicine 2007: 120; 429-434.
Affleck B, Pfeiffer C, et al. Attributional processes in rheumatoid arthritis patients. Arthritis Rheum 1987:30; 927-931.Macfarlane T, McBeth J, Jones G, et al. Whether the weather influences pain. Results from the EpiFunD study in North West England. Rheumatology 2010: 49; 1513-1520.
Smedslund G, Hagen K. Does rain really cause pain? A systematic review of the associations between weather factors and severity of pain in people with rheumatoid arthritis. European Journal of Pain 2011: 15; 5-10.
There’s so much going on in the journals these days I thought it might be a good idea to highlight a few of the interactive features that can be found online for those of you who tend to favour the paper versions and might miss these extra elements of your subscription.
Interactive/online features in the Jan 2012 issues of sportEX medicine and sportEX dynamics:
- Video showing over-pronation as a possible medial tibial stress syndrome cause (sportEX medicine)
- Printable exercise leaflet for patients with MTSS (sportEX medicine)
- Sliding filament animation which accompanies the muscle healing article (sportEX medicine)
- MCQ quiz which again goes with the muscle healing article and can be found under the eLearning section of the website (successful outcome results in a printable/downloadable certificate) (sportEX medicine)
- Four animations showing the movement at various vertebrae levels in the spine (sportEX medicine)
- Printable exercise rehab leaflet for patients with sacroiliac pain (sportEX medicine)
- 2 x videos demonstrating high intensity training on a bike and in uphill running (sportEX dynamics)
- Video with Tom Myers explaining the rules of anatomy trains (sportEX dynamics)
- Animation showing myofascial lines of the body (sportEX dynamics)
- Animation showing the how a DVT occurs (sportEX dynamics)
- MCQ quiz on posterior leg pain and DVT (successful outcome results in a printable/downloadable certificate) (sportEX dynamics)
- Printable leaflet for patients with Achilles tendinosis (sportEX dynamics)
If you have a current, up to date subscription you can access these interactive extras by logging into our website using the details on this email. For help logging in click here.
We’ve been asked to find reviewers for about 10 newly published books and DVDs. If you’re interested in reviewing them, the application form is on our Facebook page. You’ll need to be a fan to see it (well we don’t want any old riff raff applying  ). Visit www.facebook.com/sportEX.net and if you’re a fan you’ll see the link “Apply to review” in the menu on the left.
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