🦀 PT Crab Issue 74 - Advice? Yeah, nah.

This week in PT Crab we’re talking about how advice helps! But only a little bit in people with non-specific spinal pain. I’m sure you’re not giving advice-only treatment but if you are, maybe rethink your decisions? The paper’s got more than that, so read on for it all. We’re also talking about what dynamic varus means for IT band syndrome (it’s not good, unsurprisingly). My King Crab supporters (thank you so much y’all) got two more articles this week (as always), one on how a full bladder affects your gait (especially if you’re incontinent), and a case report on PT dosage in recovery from a TBI (AKA what happens when insurance doesn’t approve inpatient rehab but will let you spend 54 days in the hospital).

Become a supporter by clicking the link here:

And if the price is too steep for you students out there, lmk by replying to this email and we’ll work something out. Or just tell your professor about it and maybe they’ll subscribe and share it with you. Just an idea…

Also this week, Merry Christmas! It’s my holiday of choice in the winter and I hope that you have a nice December 25 no matter which holiday you choose to celebrate. Also also this week, did anyone like the geometry on the GRE? No, just me? Well, even if you didn’t, I’m still going to recommend an awesome twitter account from a math(s) teacher in the UK. She posts amazing puzzles all the time and I absolutely love them. Like this one: https://twitter.com/Cshearer41/status/1472947560784568328?s=20. Enjoy!

With that, let’s dive in!

Advice helps! A bit…

The Gist - This short and tidy systematic review and meta-analysis points out something that you probably already knew, advice / education about non-specific spinal pain is more helpful than placebo. Yay! But only a tiny bit. Boo! They analyzed 27 articles to reach this conclusion, all of which were of parallel, randomized design. Some were on chronic patients, some on acute, some both, and they varied with the exact method of intervention. Followup ranged from 0 weeks to 104 weeks.

With that out of the way, I can tell you that 18 trials with 2,241 participants showed advice having a small effect on pain the short term (mean difference of 8.2) and negligible at all secondary time points. 19 trials showed a small effect on disability in the short term and negligible at all secondary timepoints, and adverse events were minimal throughout (but only 2 trials published them, a problem previously highlighted here in the Crab).

Tell Me More - I know, I know. What’s the point? For one, this is an update in the research, which we need from time to time. The last study doing this kind of work was published in 2002 so it was time. Secondly, some guidelines currently in use (specifically in Australia but elsewhere as well) wholeheartedly recommend advice-only education and that’s obviously a problem. And thirdly, digging into the research this deeply starts to reveal items of interest, like how ergonomic advice did best while “contemporary guideline advice” (whatever that really means) did worst. Lastly (hey, I said this was short and tidy), remember, this was all relative to sham/placebo advice or now advice, not relative to exercise interventions and whatnot, so it may not change your practice but it is important work.

Paper? Right here ya’ll.

This week's PT Crab is brought to you by Morning Brew, a daily newsletter that catches you up with everything you need to know in five minutes or less. It's free, it's a great read, and I highly recommend it. With millions of subscribers, Morning Brew is bringing just what you need to know to your inbox, every day. Sign up for free to get it and support PT Crab in the process. It's an easy way that you can help us along. Thanks!

P.S. Don’t like ads? Become a PT Crab supporter here. You also get to suggest topic areas, twice as many articles every week, the full archive, and more.

Dynamic Varus (and Stiff Feet) Could Give You ITBS

The Gist - This piece from the Journal of Athletic Training split Air Force Academy incoming cadets into two groups based on how they went through some significant training, those who did not develop overuse injuries and had no history of them and those who did develop those injuries or had histories of them. The specific injury they were looking at was IT band syndrome. Of the 68 cadets who entered the trial, 20 developed overuse injuries, 22 had a history of them, and 26 did neither. The split into these groups let them identify gait differences that may have led to their injuries.

What they spotted were frontal plane problems, quite a few of them. Maximum knee varus angle, maximum varus velocity, and maximum knee adduction moment were all higher while maximum varus velocity occurred earlier during stance. Loading rates and ground reaction forces were the same, it was all ‘bout that varus thrust. The same varus thrust that leads to knee OA. Hmmmm…

Tell Me More - Based on their data and other recent studies the researchers speculate that increased lower extremity stiffness (especially in the arches of the feet) could lead to increased varus thrust and thus increased IT band syndrome and possibly knee OA. The theory, from this study, is that increased lower extremity stiffness leads to soft tissue overuse, leading to IT band syndrome. The varus thrust is due to the foot not absorbing enough shock, causing the hip to varus as a shock-absorptive measure. It’s pretty cool biomechanics work IMO and opens up the potential treatments for IT band syndrome.

But this whole thing comes with significant limitations. The group allocations were odd and retrospective, the people who developed ITBS during the study could have been having a flare-up from previous injuries, and all data observed was right-leg data, regardless of the side that presented the problem. But hey, it’s interesting information even if it’s not perfect and does make one think about the foot when assessing the IT Band, which I think is quite cool.

Paper? Of course, of course.

Thanks this week to PT Crab partner, NPTE Final Frontier. They provide awesome NPTE study materials, classes, practice exams and more. Check them out here: NPTEFF.com

And that’s our week! Once again, please share with friends and colleagues. And if you want to give a gift subscription to the Crab for a friend, lmk and we can totes arrange it. Luke@PTCrab.org for that.

Have a great rest of your (hopefully shortened) week!

To close things out, here’s this week’s bibliography.

• Hartigan, E., McAuley, J. A., & Lawrence, M. (2020). Women With and Without Self-reported Stress Urinary Incontinence Walk Differently Before and After 16-Ounce Water Consumption. Journal of Women’s Health Physical Therapy, 44(4), 182–192. https://doi.org/10.1097/JWH.0000000000000178
• Jones, C. M., Shaheed, C. A., Ferreira, G. E., Kharel, P., Christine Lin, C.-W., & Maher, C. G. (2021). Advice and education provide small short-term improvements in pain and disability in people with non-specific spinal pain: A systematic review. Journal of Physiotherapy, 67(4), 263–270. https://doi.org/10.1016/j.jphys.2021.08.014
• Stickley, C. D., Presuto, M. M., Radzak, K. N., Bourbeau, C. M., & Hetzler, R. K. (2018). Dynamic Varus and the Development of Iliotibial Band Syndrome. Journal of Athletic Training, 53(2), 128–134. https://doi.org/10.4085/1062-6050-122-16
• Tolland, J., Miccile, L. A., & Burke, K. (2020). Effect of Physical Therapy Dosage on Functional Recovery Following TBI. Journal of Acute Care Physical Therapy, 11(3), 139–150. https://doi.org/10.1097/JAT.0000000000000127

To close things out, here’s this week’s bibliography.

• Hartigan, E., McAuley, J. A., & Lawrence, M. (2020). Women With and Without Self-reported Stress Urinary Incontinence Walk Differently Before and After 16-Ounce Water Consumption. Journal of Women’s Health Physical Therapy, 44(4), 182–192. https://doi.org/10.1097/JWH.0000000000000178
• Jones, C. M., Shaheed, C. A., Ferreira, G. E., Kharel, P., Christine Lin, C.-W., & Maher, C. G. (2021). Advice and education provide small short-term improvements in pain and disability in people with non-specific spinal pain: A systematic review. Journal of Physiotherapy, 67(4), 263–270. https://doi.org/10.1016/j.jphys.2021.08.014
• Stickley, C. D., Presuto, M. M., Radzak, K. N., Bourbeau, C. M., & Hetzler, R. K. (2018). Dynamic Varus and the Development of Iliotibial Band Syndrome. Journal of Athletic Training, 53(2), 128–134. https://doi.org/10.4085/1062-6050-122-16
• Tolland, J., Miccile, L. A., & Burke, K. (2020). Effect of Physical Therapy Dosage on Functional Recovery Following TBI. Journal of Acute Care Physical Therapy, 11(3), 139–150. https://doi.org/10.1097/JAT.0000000000000127