New Research and other Random Thoughts

I recently read two articles that caught my eye in the January 2009 issue of the Journal of Orthopaedic and Sports Physical Therapy. I'll give you a quick rundown on each.

Differences in Hip Kinematics, Muscle Strength, and Muscle Activation between Subjects with and without Patellofemoral Pain (Souza RB and Powers CM) (1)

The objective was to determine if subjects with patellofemoral pain would demonstrate increased hip adduction and internal rotation range of motion during running, step downs, and a drop jump test. The investigators also hypothesized that subjects with pain would demonstrate decreased strength in the hip abductors and external rotators, specifically the glute medius and maximus respectively.

The results of the study did show that hip internal rotation range was greater during all tasks in those subjects with patellofemoral pain (running> step downs> drop jumps). Hip adduction range was greater in the pain group but it was not statistically significant. Glute medius strength was decreased by 15% in the PFP group, and glute max strength was decreased by 16%. Something of interest the authors noted was that the glute medius strength difference did not translate into greater hip adduction during the tasks in the PFP group. They hypothesized that subjects could have compensated by using a lateral trunk lean. I would agree with that thought as I see if all the time.

Thoracic Spine Manipulation for the Management of Patients with Neck Pain: A Randomized Clinical Trial (Gonzalez-Iglesias J, Fernandez-De-Las-Penas C, Cleland JA, and Gutierrez-Vega MDR) (2)

The objective of this study was to determine if patients with mechanical neck pain receiving thoracic spine thrust manipulation would experience superior outcomes compared to a group not receiving the manipulation. Other treatment methods included use of an infrared lamp and TENS.

Individuals in the manipulation group demonstrated greater cervical ROM, reported less pain, and also reported less disability.

That's it in a nut shell.

I was glad to see this research appearing in JOSPT but I would bet that many of us could have predicted the results of each study with a good degree of confidence. Not that I think I know it all, but that is the way I've been approaching patellofemoral and cervical pain for quite some time now, as well as many others in the rehab and training community. Look no further than Mike Boyle's article: A Joint by Joint Approach to Training, to know that establishing stability at the hip will spare the knee. Gaining mobility through the thoracic spine will spare the cervical spine and reduce pain. It's the argument for regional interdependence as the basis of the Selective Functional Movement Assessment. Focusing on the knee will not always solve knee pain. You must also look above and below for effective long-term solutions. This goes for any joint in the body, over use syndrome, etc. So this brings me to my point for writing this article. A.k.a. my 'random thoughts'.

Clinical experience tells me something works, and I prove it over and over again with my patients and the athletes I train. Evidence based research is important in that it proves that my clinical experience and observations are correct, or incorrect. The problem is that the research only comes about because someone has already been doing something for quite some time. The Functional Movement Screen is 10 years old and only in the past few years have the first bits of research been coming out. I've talked to therapists who work with world renown surgeons who have heard of the FMS but won't consider it until more research is done on it. It blew my mind to hear that. Intuitively I know it works for me and again, I have proved it time and time again with my clinical outcomes.

When I first asked for advice on this site from my former professors, they literally couldn't understand the idea of a site with articles, videos, interviews, etc. based on clinical experiences. I explained that the research would be referenced, and that these were not 'far out' ideas. The response was not glowing. They would only be interested in the site if I were posting solid research, discussing evidence-based treatments, etc. My response was that if I were to wait on the research to validate everything I want to do, I would be at least 5 years behind the times. This was part of the reason I felt ill-prepared for orthopedics and sports medicine coming out of school.

Not only that, but even with well done research there are always more questions to be answered. The lab is an ideal situation. People are excluded because of prior injuries. I don't get to exclude them from my clinic. The intervention was performed using a specific technique in a certain ideal position. Well, my patient can't get into that position so I had to modify the technique. You can see what I am getting at.

I don't want anyone to think I'm downplaying the importance of research. I realize that to be viewed as professionals with some level of autonomy, and to be paid like it, we need to prove that our treatments work. But to me, what makes our professions great, is the ability to use our problem solving skills and draw upon our experiences when the situation calls for it. My patients and athletes subjective reports and objective measures are my proof.

The prime example goes back to the first article. The idea of emphasizing VMO strengthening to treat patellofemoral pain. That is what I learned in college. It didn't take long before I discarded that thought and started searching for a better way. I read how therapists, trainers, and strength coaches were focusing more on the hips and ankle to control knee position. It made more sense to me than the VMO so I started playing around with it and with good success. Powers, et al came out with their landmark study in 2003 demonstrating through the use of MRI that lateral patellar tilt and lateral patellar displacement during a weight bearing squat was the result of hip internal rotation as opposed to movement of the patella (3). There was my proof and best of all I was way ahead of everyone still chasing the VMO.

And if the research is so important to academia, then why are students still graduating with this notion that the VMO will solve patellofemoral pain? Why do we get referrals from docs who are disgusted with their patient's treatment at other clinics. I had a patient the other day come in 2 months status post lumbar fusion. Their original PT was stretching the hell out of their low back with knees to chest and rotational exercises. Don't they know the lumbar spine craves stability over mobility? And with an instrumented fusion on top of that. No wonder the patient continued to have significant pain.

So as I said earlier, research is important. Let's apply it where needed especially in education, but let's not get bogged down with it as we have in the past. I want to be on the cutting edge and improve the quality of life of my patients as quickly as possible. I'm constantly tweaking things to find the best possible solution and that is what makes my job enjoyable as a PT and a coach. Not being in the academic arena I feel that my ability to share my clinic experiences with my co-workers and members, and vice versa, is just as valuable as the research.

References:

1. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009; 39:12-19.

2. Gonzalez-Iglesias J, Fernandez-De-Las-Penas C, Cleland JA, and Gutierrez-Vega MDR. Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2009; 39:20-27.

3. Powers CM, Ward SR, Fredericson M, Guillet M, Shellock FG. Patellofemoral kinematics during weight bearing and non-weight bearing knee extension in persons with lateral subluxation of the patella: a preliminary study. J Orthop Sports Phys Ther. 2003; 33:677-685.