🦀 Issue 48 - Flex, Text, Stab, and Walk

Welcome to the long, hot summer everyone! This email was originally supposed to send before the equinox, when it wasn't technically summer yet, but apparently my email system protested that prematurity and so you receive it as intended, just after the true summer begins. Here's your summer tip, especially for those in small and mid-size towns: check out minor league baseball! It's cheap (the Richmond Flying Squirrels are just $6/game and the beer's cheap too), outside so it's virus safe, and a good time. Check out your local team this week.

Let’s dive in!

Stabilization? Flexion? Either? Neither?

The Gist - In degenerative spondy, what works better, stabilization or flexion exercises? Well, according to this study from Mexico, either will do ya. The researchers took 92 patients over 50 who had degenerative spondy and randomized them to flexion or stabilization exercise groups. They met with a PT once per month for 6 months and were given exercises to do at home. To test outcomes, researchers used pain intensity and the Oswestry disability index. They also checked out flexibility and the Roland-Morris as secondaries. Overall, between group differences were not significant. Everyone got better, no one got better better. Stabilization and flexion exercises were samesies. Flexion exercises are simpler, so consider that in your prescription.

Tell Me More - The paper didn’t have too much detail on the exact exercises used, so we can’t dig deeper there. I will answer your burning question: one visit per month? Yea, I know. Idk too much about Mexico’s healthcare system, but these authors said they chose this because it replicates the PT availability of less well-off Mexican residents. All of their patients did improve, so that’s great news overall. They had follow-up for 84 of their 92 person cohort for 48 months and only 4 sought surgical intervention in that timeframe. This is great! Since apparently there’s not too much data about conservative interventions for degenerative spondy. This intervention worked well enough that the patient’s involved didn’t feel like they had to get more aggressive. How cool!

Paper it up. Ummmmm sure. Free for APTA members.

What does too much phone use hurt? (Other than our souls)

The Gist - In a research study that you’d expect to be more common, these researchers published the fourth systematic review of injuries due to mobile phone use and popped back some interesting results. Because of the low quality, heterogenous evidence they found, this paper doesn’t produce a lot of clinical insights, but it does give us some cues about what phones could be doing to our patients. The researchers stress that the MSK injuries are likely caused by the head and trunk flexion and unsupported arms common to phone use (and computer use, check your posture!). According to the 18 papers they looked at, people who use their phones a lot (an undefined statistic) experienced higher than typical rates of: neck pain, lower back pain, elbow pain, wrist pain, UE fatigue and stiffness, thoracic outlet syndrome, and fibromyalgia. I don’t think most PTs talk to their patients about phone use, so maybe consider adding that to your pt education when treating individuals who already have these problems. It seems like phone use could make them worse.

Tell Me More - Like I said, these researchers didn’t have high quality data to work with and it’s getting harder and harder to get it. Try doing an RCT where you take away half the people’s cell phones. Yea, not gonna happen. Almost every study they looked at also used non-standard questionnaires and didn’t do a great job of defining what significant mobile phone use was. Suffice to say, there are a lot of red flags here. I chose to include it in PT Crab mainly to get ya’ll thinking about how to education patients on mobile phone use. Phone posture is bad posture, we all know it. Lotsa phone use is going to make conditions worse and this paper argues that it could even cause some of these conditions. For a firm data point, the global prevalence of fibromyalgia is 2.7%, but these studies showed 10-25% of mobile phone superusers to have it. It’s sketchy data, I know, but it could be leading us toward some solid truths. Check out the whole paper for more.

I will do that. Cool, enjoy!

DN = Win-win for OA

The Gist - DN for hip OA, what? Yea, apparently so. This RCT from the Archives of PM&R showed that DN improved short-term (48hr) pain, hip strength, TUG, WOMAC, and the 40-meter walk-test more than control or sham DN. Noice! They went after trigger points in the rec fem, TFL, glute min, or iliopsoas over the course of 1 session per week for 3 weeks. Sham DN received the same amount of treatment, but with a blunt needle that didn’t penetrate the skin and control got nothin’. Before treatment, scores were similar across all three groups, but afterward the DN group improved more than MCID in pain, TUG, isometric strength, and 40-meter walking and more than standard error of measurement for the WOMAC. Why? Read on for what the researchers said about that.

Tell Me More - The researchers hypothesize that the dry needling reduced peripheral and central sensitization and increased endogenous opioid production in their patients, removing some central barriers to strength. They don’t argue that DN actually made these patients stronger. Instead, they say, it reduced their pain and reset their brain enough to allow them to work a bit harder across the tasks they were given. Because of this, they recommend that DN be paired with other therapies to take advantage of these temporary strength increases. These researchers didn’t combine DN therapy with any other interventions, so we don’t actually know that yet, but it’s a hopeful sign.

I wanna read this one! You should, it’s good and short (only 6 pages!)

Treadmill vs. The Ground Showdown in Stroke Rehab

The Gist - I did it again! It was an accident, I swear! I put three systematic reviews in one Crab. Ouch. This is nothing but value for you, but lotsa hard work for me. Fortunately, this one’s done and all these reviews were well-written anyway, making them pretty easy reading. What’s this last one about? Just the difference between overground walking and treadmill walking in stroke rehab. Traditionally, treadmill walking has been considered less effective than overground, but these researchers turn that on its head. From 16 trials with 713 participants, they were able to glean that treadmill walking is the same or a bit better than overground walking due to its ease of use. Participants who walked on treadmills tended to walk more often, for longer distances, helping put it a bit ahead of overground walking when it comes to rehabilitation effectiveness. Still, the gap is tiny (like tiny to the point of barely noticeable) so it’s not necessarily better and it’s almost certainly not worse.

Tell Me More - I say treadmill, but the authors allowed any type of mechanical gait trainer as long as it didn’t allow body-weight support. This allowed them to include two trials that used some sort of exoskeleton robot thing. The mean age of their participants ranged from 49 to 74 and they had three trials that assessed this in the acute phase, 12 that assessed in chronic, and one that did both. They had a lot of good data to work with (unlike most systematic reviews we see), so they were able to produce a robust result. There was little disagreement between the trials even though there was some heterogeneity. See the paper for details on that. Overall, a perusal of the forest plots puts every outcome measure (walking speed, walking distance, and participation) slightly onto the treadmill side with the confidence interval crossing over to favor overground walking too. I leave you with this eye-opening quote from the authors themselves: “the results suggest that it is not the treadmill that is important, but the amount of practice because when compared with same amount of overground walking, no real difference was found.”

There ya have it folks.

Can I read the whole thing?Sure thing. Another well written paper here. And open access.

That’s our week! Hope ya’ll enjoyed it. Hey, if you’re at a clinical right now (and I know some of you are) maybe tell your CI about PT Crab? Cuz I’d really appreciate it and I bet they’d think it was awesome that you’re reading so much research. Either talk to them about it or just forward this to them. Thanks!