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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.
Only a few more days to sign up for the early-bird rate (expires 1st Feb) – this is a conference committed specifically to football medicine and takes place in London on the 21st-22nd April 2012. It has a massive line-up of presenters which read like a who’s who of football medicine. For more info checkout the conference website/programme at this link >. If it appears in Italian, don’t worry, just click the Union Jack flag in the top right hand corner for a UK version. You can sign up for one or both days and there are also student discounts available. The conference organisers are expecting around 700 delegates so it’s going to be a biggie!
Recent abstracts
These four recent abstracts were highlighted recently by the Soft Tissue Therapists’ group in Australia – click the links for more info. Each study is in a markedly different field but all have positive ramifications for our profession, in both physiological importance and job growth areas.
This type of study adds weight to the necessity of regular soft tissue work within the hospital arena – around the world. The amount of research that now provides evidence for not only health benefits and disease control but for monetary savings is substantial. It is now up to us, our associations, to collate this material and present it to the authorities in that format – health benefits and cost effectiveness/savings.
Childhood diabetes is in epidemic proportions around the westernised world. This study urges parents and the medical authorities to consider if not implement such strategies into mainstream child diabetes care. Minmise drug use in the child population.
The autonomic nervous system is implicated in many psychological conditions as well as musculoskeletal injuries (especially chronic pain). Here is some hard and fast evidence as to why STT and heat is of great benefit. Take this abstract and show your GPs. This is the type of evidence we need to reduce drug taking (pharmaceuticals won’t like us very much…) and get people back to drug free living.
This study is one of the most ground breaking we have seen. For the first time we have a measured analysis of how trigger points can mess not only with pain perception but antagonist, agonist relationships and reciprocal inhibition. This has huge implications to the sporting world that demands ideal physiology when competing. All you sports therapists out there, take this paper and show the coaches (maybe in a language they will understand!) to demonstrate the necessity not only for remedial work but for preventative work. Strength and Conditioning coaches and skill aquisition coaches will find this very interesting.
sportEX medicine contains the following articles:
- Medial tibial stress syndrome – a case study
- Medial tibial stress syndrome – rehab advice leaflet for patients
- Clinical reasoning and it’s role in rehabilitation
- Muscle injury and rehabilitation – an update on the evidence-base (inc. animations)
- The Spine: injury diagnosis and rehab refresher – last in series (inc. animations/videos and patient rehabilitation leaflet)
- Journal watch – round up of this quarter’s research
sportEX dynamics contains:
- High Intensity Training – when less is more
- Active release therapy for tissue adaptation following injury – case study
- Posterior calf pain – stop the clot (inc. printable poster)
- Massage practitioners: who are we?
- Achilles tendonitis: patient information and rehabilitation leaflet
- Journal watch – a round up of this quarter’s research
Remember if you don’t have a subscription and you haven’t received a recent sample issue, why not request one. Just click here – it’s totally free and no payment information is required – there’s no obligation to subscribe – nothing – we just want you to see how good the journals are in the flesh!
Order a free sample issue of sportEX medicine or dynamics.
We’d love it if you’d share this with your colleagues and friends too through Facebook and Twitter or via email – the more people who see the journals the better!
This is predominantly an online ebook/emagazine but we printed some physical versions and there are still a couple available to anyone purchasing the online product.
For more info click here or to purchase click here.
As medical professionals who treat painful conditions, one of our goals is figure out why our patients are in pain. In the United States, one of the ways in which we attempt to find the root cause is Magnetic Resonance imaging (MRI). This month’s edition of the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) has several articles which analyze the current recommendations for the use of imaging, the positive and negative effects of imaging and what the images tell us in relation to our patient’s complaints.
MRIs have been utilized for the past 35 years to provide clinicians with images, in all anatomical planes, of a variety of tissue characteristics, blood flow and metabolic functions. These images have led to an improved ability to confirm a diagnosis as well as identify serious pathology such as infection, fracture or tumor.1 The rate in which lumbar MRI’s are ordered in the United States is growing at an enormous rate. A recent study in the Journal of the American College of Radiology found that 26% of diagnostic images ordered were unnecessary.2 Flynn and colleagues believe that the overutilization of lumbar MRIs have led to a 2- to 3- fold increase in spinal surgical rates in the past ten years.3
The American College of Physicians and the American Pain Society have published the following guidelines in ordering diagnostic imaging in the management of low back pain(LBP):4
- Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific LBP.
- Clinicians should perform diagnostic imaging and testing for patients with LBP when severe or progressive neurological deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination.
- Clinicians should evaluate patients with persistent LBP and signs or symptoms of radiculopathy or spinal stenosis with MRI or computed tomography, only if they are potential candidates for surgery or epidural steroid injection.
Flynn further believes that the inappropriate use of lumbar spine imaging can lead to several harmful effects. He states that an MRI may facilitate the “medicalization” of low back pain (LBP).3 He sites a study which analyzed the lumbar MRI images of asymptomatic individuals 60 and older. This study found that 36% had a herniated disc, 21% had spinal stenosis and over 90% had a degenerated or bulging disc.5 Again, these results were found in individuals with NO PAIN. Other harmful effects noted include the increased risk associated with unnecessary surgeries as well as the nocebo effects related to labeling an imaging abnormality. This likely correlates with the patient focusing on the abnormality as the “source” of the pain when in reality, the two may not be related and may not improve despite provided interventions.
Information and education about low back pain is vital in improving the general public’s perception of why it exists. As stated in one of my earlier pieces, pain is an output from the brain and tissue damage is not necessary for pain; if the brain perceives there is a threat to the low back, it will send an output of pain to protect it. This is likely why the article cited by Flynn showed that individuals had abnormalities on MRI but experienced no pain. Their brain simply did not perceive a threat, despite the abnormalities present.
This months edition of JOSPT provides more studies which state that should not blame a disc herniation, stenosis, or arthritis as the cause of the back pain . Our patients may have had these issues for a while prior to the onset of their current symptoms. We should instead try to figure out why their brain perceives a threat and what we can do to modify it. Our increased usage of diagnostic imaging may actually be limiting our ability to effectively treat our patient’s pain and leading to unnecessary medical interventions. It may be leading us to blame the wrong things as the cause of their condition!
1. Strudwick MW, Anderson SE, Dimmick S, et al. Pearls and pitfalls of magnetic resonance imaging of the upper extremity. J Orthop Sports Phys Ther 2011; 41: 861-872.
2. Lehnert BE, Bree BL. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic center: how critical is the need for improved decision support? J Am Coll Radiol 2010;7:192-197.
3. Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: A reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther 2011; 41: 838-846.
4. Chou R, Qaseem A, Owens DK, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147:478-491.
5. Boden SD, Davis DO, Dina TS, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990; 72: 403-408.
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