The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature

Robert Cooperstein, Makani Lew

Abstract: Objective: Although it is common to find assertions relating functional leg length inequality (LLI) to pelvic torsion and other states of subluxation, comments and/or data concerning anatomical LLI in this same context are uncommon. This review of the literature synthesizes the evidence on pelvic torsion in relation to anatomical LLI.

Methods: The literature was searched using the PubMed; Manual, Alternative, and Natural Therapy Index System; Allied and Complementary Medicine Database; Cumulative Index to Nursing and Allied Health Literature; and Index to Chiropractic Literature databases for primary studies that related LLI, either artificially created or naturally occurring, to pelvic torsion. Extracted data included natural vs artificial LLI, method of creating or detecting LLI, subject selection, methodology for measuring pelvic torsion, and results.

Results: Nine English-language studies were retrieved published 1936-2004. Seven determined the impact of artificial, transient LLI on pelvic torsion, whereas 2 studied the effect of naturally occurring LLI.

Conclusion: Across varying methodologies for measuring LLI and pelvic torsion, a consistent, dose-related pattern was identified in which the innominate rotates anteriorly on the side of a shorter leg and posteriorly on the side of the longer leg. This finding was contrary to the common assertion that the ilium rotates posteriorly on the side of a short leg and vice versa. Practitioners of manual medicine who derive vectors for intervention based on leg checking procedures should consider the possibility that the direction of pelvic torsion may be variable depending on whether the LLI is of anatomical or functional origin.

Journal of Chiropractic Medicine, Vol 8, Issue 3, Pages 107-118 (September 2009) – abstract

Filed under: Assessment, Hip, Physical examination, Topic review , Leg length inequality, Sacroiliac joint, Torsion, Mechanical, Posture, Ilium

Massage for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Back Review Group

Furlan, AD; Imamura, M; Dryden, T; Irvin, E

Abstract

Study Design. Systematic Review.

Objectives. To assess the effects of massage therapy for nonspecific low back pain.

Summary of Background Data. Low back pain is one of the most common and costly musculoskeletal problems in modern society. Proponents of massage therapy claim it can minimize pain and disability, and speed return to normal function.

Methods. We searched MEDLINE, EMBASE, CINAHL from their beginning to May 2008. We also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 3), HealthSTAR and Dissertation abstracts up to 2006. There were no language restrictions. References in the included studies and in reviews of the literature were screened. The studies had to be randomized or quasi-randomized trials investigating the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific low back pain. Two review authors selected the studies, assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group, and extracted the data using standardized forms. Both qualitative and meta-analyses were performed.

Results. Thirteen randomized trials were included. Eight had a high risk and 5 had a low risk of bias. One study was published in German and the rest in English. Massage was compared to an inert therapy (sham treatment) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups. In 8 studies, massage was compared to other active treatments. They showed that massage was similar to exercises, and massage was superior to joint mobilization, relaxation therapy, physical therapy, acupuncture, and self-care education. One study showed that reflexology on the feet had no effect on pain and functioning. The beneficial effects of massage in patients with chronic low back pain lasted at least 1 year after the end of the treatment. Two studies compared 2 different techniques of massage. One concluded that acupuncture massage produces better results than classic (Swedish) massage and another concluded that Thai massage produces similar results to classic (Swedish) massage.

Conclusion. Massage might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this need confirmation. More studies are needed to confirm these conclusions, to assess the impact of massage on return-to-work, and to determine cost-effectiveness of massage as an intervention for low back pain.

Spine: 15 July 2009 – Volume 34 – Issue 16 – pp 1669-1684 - abstract

doi: 10.1097/BRS.0b013e3181ad7bd6

Full text available in  through MTABC member only website (link) under the research tab and then library.

Filed under: Exercise therapy, Lumbar spine, Massage, Patient education, Topic review , Low back, Lumbar spine, massage therapy, nonspecific low back pain, pain, Systematic review

Special physical examination tests for superior labrum anterior posterior shoulder tears are clinically limited and invalid: a diagnostic systematic review

Calvert, Chambers, Regan et al

Objective

The diagnosis of a superior labrum anterior posterior (SLAP) lesion through physical examination has been widely reported in the literature. Most of these studies report high sensitivities and specificities, and claim to be accurate, valid, and reliable. The purpose of this study was to critically evaluate these studies to determine if there was sufficient evidence to support the use of the SLAP physical examination tests as valid and reliable diagnostic test procedures.

Study Design and Setting

Strict epidemiologic methodology was used to obtain and collate all relevant articles. Sackett’s guidelines were applied to all articles. Confidence intervals and likelihood ratios were determined.

Results

Fifteen of 29 relevant studies met the criteria for inclusion. Only one article met all of Sackett’s critical appraisal criteria. Confidence intervals for both the positive and negative likelihood ratios contained the value 1.

Conclusion

The current literature being used as a resource for teaching in medical schools and continuing education lacks the validity necessary to be useful. There are no good physical examination tests that exist for effectively diagnosing a SLAP lesion.

Journal of Clinical Epidemiology, Volume 62, Issue 5, May 2009, Pages 558-563 – abstract

doi:10.1016/j.jclinepi.2008.04.010

Filed under: Physical examination, Shoulder, Topic review , Diagnostic accuracy, Physical examination, Sensitivity, Shoulder, Superior labrum anterior posterior (SLAP) lesion, Systematic review

Insoles for prevention and treatment of back pain

Tali Sahar, Matan J Cohen, Vered Ne’eman et al

Background

There is lack of theoretical and clinical knowledge of the use of insoles for prevention or treatment of back pain. The high incidence of back pain and the popularity of shoe insoles call for a systematic review of this practice.

Objectives

To determine the effectiveness of shoe insoles in the prevention and treatment of non-specific back pain compared to placebo, no intervention, or other interventions.

Search strategy

We searched the following databases: The Cochrane Back Group Trials Register and The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL to October 2008; reviewed reference lists in review articles, guidelines and in the included trials; conducted citation tracking; contacted individuals with expertise in this domain.

Selection criteria

We included randomised controlled trials that examined the use of customized or non-customized insoles, for the prevention or treatment of back pain, compared to placebo, no intervention or other interventions. Study outcomes had to include at least one of the following: self-reported incidence or physician diagnosis of back pain; pain intensity; duration of back pain; absenteeism; functional status. Studies of insoles designed to treat limb length inequality were excluded.

Data collection and analysis

One review author conducted the searches and blinded the retrieved references for authors, institution and journal. Two review authors independently selected the relevant articles. Two different review authors independently assessed the methodological quality and clinical relevance and extracted the data from each trial using a standardized form.

Main results

Six randomised controlled trials met inclusion criteria: Three examined prevention of back pain (2061 participants) and three examined mixed populations (256 participants) without being clear whether they were aimed at primary or secondary prevention or treatment. No treatment trials were found. There is strong evidence that the use of insoles does not prevent back pain. There is limited evidence that insoles alleviate back pain or adversely shift the pain to the lower extremities.

Limitations
This review largely reflects limitations of the literature, including low quality studies with heterogeneous interventions and outcome measures, poor blinding and poor reporting.

Authors’ conclusions

There is strong evidence that insoles are not effective for the prevention of back pain. The current evidence on insoles as treatment for low-back pain does not allow any conclusions.

High quality trials are required for stronger conclusions.

Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005275.- full text

DOI: 10.1002/14651858.CD005275.pub2.

Filed under: Lumbar spine, Spine, Topic review

Nonsurgical interventional therapies for low back pain: a review of the evidence for an american pain society clinical practice guideline

Chou R, Atlas SJ, Stanos SP, et al

STUDY DESIGN: Systematic review.
OBJECTIVE: To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain.

SUMMARY OF BACKGROUND DATA: Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy.

METHODS: Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.

RESULTS: For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies.

CONCLUSION: Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.

Spine. 2009 May 1;34(10):1078-93  – abstract

Full text available in  through MTABC member only website (link) under the research tab and then library.

Filed under: Lumbar spine, Topic review, therapies , interventional, Low back, nonsurgical, radicular pain, therapies

The History of Inflammation

Few concepts in medical theory have been so enduring as this one. The word, from the Latin iflammatio, to ignite or set fire, was probably introduced by the Roman Aulus Cornelius Celsus in the 1st century AD. Galenic medicine adopted the term, defining it according to four symptoms: redness, swelling, excessive heat, and pain. Traditionally, inflammation was explained as resulting from an excessive flow of blood to an injured or diseased organ. But by the 18th century, it was attributed to non-specific external irritants as well as psychic trauma. Inflammation was thus considered the local irritation of tissues brought about by the corresponding nerves.

Read more here – Inflammation : The Lancet.

Filed under: Topic review , Inflammation, The Lancet

Management of Symptomatic Lumbar Degenerative Disk Disease

L Madigan, AR Vaccaro, LR Spector, R Alden Milam

Symptomatic lumbar degenerative disk disease, or discogenic back pain, is difficult to treat. Patients often report transverse low back pain that radiates into the sacroiliac joints. Radicularor claudicatory symptoms are generally absent unless there is concomitant nerve compression. Physical examination findings are often unremarkable. Radiographic examination may revealdisk space narrowing, end-plate sclerosis, or vacuum phenomenon in the disk; magnetic resonance imaging is useful for revealing hydration of the disk, annular bulging, or lumbar spine end-plate (Modic) changes in the adjacent vertebral bodies. The use of diskography as a confirmatory study remains controversial. Recent prospective, randomized trials and meta-analyses of the literature have helped expand what is known about degenerative disk disease. In most patients with low back pain, symptoms resolve without surgical intervention; physical therapy and nonsteroidal anti-inflammatory drugs are the cornerstones of nonsurgical treatment. Intradiskal electrothermal treatment has not been shown to be effective, and arthrodesis remains controversial for the treatment of discogenic back pain. Nucleus replacement and motion-sparing technology are too new to have demonstrated long-term data regarding their efficacy.

Approximately 70% to 85% of adults will be affected by low back pain (LBP) at some point during their lifetimes.1,2 Numerous anatomic sites can be responsible for the pain, and accurate diagnosis is often difficult. Degenerative disk disease (DDD), internal disk disruption, lumbar disk herniation, and facet joint arthritis, as well as intra-abdominal pathology, are allpotential causes of LBP. Patients with DDD or discogenic back pain can present with aconstellation of symptoms that range from benign LBP to excruciating back pain with lower extremity symptoms. Risk factors for LBP, such as jobs requiring heavy lifting, use of a jackhammer or machine tools, or the operation of motor vehicles, have been identified in the literature.3 Continued degeneration of the affected disk can lead to secondary problems such as degenerative spondylolisthesis, lumbar stenosis, and facet arthrosis.

Journal of the American Academy of Orthopaedic Surgeons, 2009;17:102-111 – abstract

Filed under: Conservative therapies, Lumbar spine, Surgery, Topic review

RMT Options for Treating Osteoarthritis (OA)

“Therapy for arthritic knees often as effective as surgery” (CBC news)

Researchers at the University of Western of Ontario recently published a landmark study “A Randomized Trial of Arthroscopic Surgery for Osteoarthritis (OA) of the Knee” in The New England Journal of Medicine.

How does this new research affect your practice and patients?

Lets first start by looking at why is OA of the knee important to RMT’s?
In the EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis, we find out that osteoarthritis (OA) is the most common form of arthritis in Western populations. It is characterized pathologically by both focal loss of articular cartilage and marginal and central new bone formation. Knee OA is likely to become the fourth most important global cause of disability in women and the eighth most important in men. The annual costs attributable to knee OA are immense. There is therefore a burden on health from both morbidity and cost. Knee OA is associated with symptoms of pain and functional disability. Physical disability arising from pain and loss of functional capacity reduces quality of life and increases the risk of further morbidity and mortality.

What did the study “A Randomized Trial of Arthroscopic Surgery for Osteoarthritis (OA) of the Knee” tell us about OA management?
This study dealt only with arthroscopic surgery and physical therapy/medical management of knee OA. The main conclusion tells us that the long-term effects of arthroscopic surgery is the same as for patients that only have conservative therapy consisting of exercises and patient education. This study confirms the conclusions of an earlier 2002 study by Moseley et al called A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.
It is most imperative that manual therapists are made aware of this trial given its implications on patient management within medical and orthopedic practices. If accepted as part of evidence-based practice, this study will likely result in an influx of patients to conservative therapy clinics seeking treatment for OA of the knee. In addition, it is important for clinicians to demonstrate leadership and educate each other on trials such as this.

What other therapy options are there?

The EULAR report has 10 recommendations on knee OA management.

OARSI published guidelines on management of knee and OA that recommend directing treatments towards:
_ Reducing joint pain and stiffness
_ Maintaining and improving joint mobility
_ Reducing physical disability and handicap
_ Improving health-related quality of life
_ Limiting the progression of joint damage
_ Educating patients about the nature of the      disorder and its management.
OARSI lists 25 recommendations for the treatment of hip and knee OA. These are summarized in Table I together with the level of evidence (LoE) supporting them.
(OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines)

Exercises and Manual therapy for knee OA

In their study “Massage therapy for osteoarthritis of the knee: A randomized controlled trial” Perlman AI et al. provide preliminary evidence that a course of Swedish (classical) massage can have a positive influence on symptoms and functional deficits associated with osteoarthritis of the knee. These benefits seem to last, at least for the additional 8 week follow-up period used in this study.
There is a reat potential for massage as an adjunct treatment for OA. Pharmaceutical treatments for OA (the COX-2 inhibitors specifically) have recently been correlated with higher adverse event rates than previously thought.

In the randomized, controlled trial “Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee”
Deyle et al report that manual therapy, applied to the knee as well as to the lumbar spine, hip, and ankle as required, and performed a standardized knee exercise program in the clinic and at home yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.

In their second study “Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee: A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus a Home Exercise Program” Deyle et al conclude that the results indicate that a home exercise program for patients with OA of the knee provides important benefit. Adding a small number of additional clinical visits for the application of manual therapy and supervised exercise adds greater symptomatic relief.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis reports on 26 randomized controlled trials and controlled clinical trials. This review of the literature recommends the use of therapeutic exercises alone, or combined with manual therapy, for managing patients with OA

Investigation of Clinical Effects of High- and Low-Resistance Training for Patients With Knee Osteoarthritis:
A Randomized Controlled Trial, Mei-Hwa Jan et all
This study compared the effects of high- and low-resistance strength training in elderly subjects with knee OA. Both high- and low-resistance strength training significantly improved clinical effects in this study. The effects of high-resistance strength training appear to be larger than those of low-resistance strength training for people with mild to moderate knee OA, although the differences between the HR and LR groups were not statistically significant.

————————————–

Further resources

Cochrane Systematic reviews on knee and OA
(in the OVID databases select: EBM Reviews – Cochrane Database of Systematic Reviews)

•    Braces and orthoses for treating osteoarthritis of the knee
•    Aquatic exercise for the treatment of knee and hip osteoarthritis
•    Exercise for osteoarthritis of the hip or knee
•    Thermotherapy for treatment of osteoarthritis
•    Low level laser therapy (Classes III) for treating osteoarthritis
•    Intensity of exercise for the treatment of osteoarthritis.
•    Balneotherapy for osteoarthritis

Massage Therapists Asociation of British Columbia – OA literature review

• An evidence-informed educational material on the Assessment and Management of Osteoarthritis for Registered Massage Therapists

Filed under: Topic review