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

Luke Hollomon -

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 how a full bladder affects your gait (especially if you’re incontinent), what dynamic varus means for IT band syndrome (it’s not good, unsurprisingly), 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).

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.

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.

Drink some water, change your gait.

The Gist - We already know that women with stress urinary incontinence use different hip biomechanics that women without, but now we know that they don’t adjust their gaits to a full bladder the same way that women without do. Before we go deeper, you should know that “half of recreationally active women report episodes of stress urinary incontinence,” so this is a big deal. The goal of this study was to check compensatory gait strategies used by women with and without stress urinary incontinence with a full bladder.

They included 42 women, 19 with stress urinary incontinence and 21 without, then put them through gait analysis, water drinking, strength testing, and a bit more. Then, one hour after drinking, they checked their bladder volumes and did gait analysis again. From this, they got a lot of data and you should read the whole thing if this is your thing (the tables are so pretty, seriously), but this is the gist, so I’ll highlight. The groups differed in gait before and after drinking water, more on that later. What’s most important here is that women with stress urinary incontinence didn’t adapt their motor patterns as much as those without. The researchers say that this “suggests an aberrant neuromuscular strategy used by women with SUI.” They presume that this could be due to greater “co-contraction of ER and IR muscles for stability” due to poor pelvic floor strategy, but we don’t know for sure.

Tell Me More - I know we’re already getting a bit in the weeds on gait analysis so I’ll do my best to keep it clinical but I can’t be perfect.

Women in the non-incontinence group had greater hip flexion and adduction angles with full bladders than did those who had stress urinary incontinence and they had more variance between their empty and full bladder gaits. The researchers pop into a lot of speculation here about what’s going on since they weren’t doing EMG analysis and I thought it better to pop their thoughts in here than try to rehash them

Perhaps, the PFM benefits from the lesser hip ER positions when the bladder becomes full because the OI (ie, hip external rotator) can generate an isometric contraction, thus providing a more stable attachment site for the levator ani muscle to maximize its stiffness and effectiveness in supporting the bladder. Alternatively, less hip ER motion could occur by using greater cocontraction of the hip stabilizers, particularly the hip internal rotators such as the anterior fibers of the gluteus medius and minimus and adductor longus and brevis.

Hashing this out wasn’t the point of the paper, but it’s an interesting dive into clinical relevance as they try to make this useful to you outside the research department. And now, I think I’ve jabbered on quite enough, so check out the paper if you do this kinda thing (and if you don’t, cuz I’ll bet you treat women with SUI whether you know it or not).

Paper? Yay, read it!

Here’s what happens when you can’t go to IPR.

The Gist - Okay, so that title oversells it, as usual. This is a case report of a 27 year old man with a severe TBI (GCS: 5 at the scene, remember, even a toaster gets a 3 so 5 is real bad) who never got cleared for inpatient rehab by his insurance company. Instead, they left him in the acute care hospital for 35 “additional days” after he was recommended for discharge. Over that time, he got 79% less PT than he probably would have in IPR but still progressed from performing less than 25% of functional tasks to 100% with supervision or CGA, including stairs! Through his time in the hospital, he saw PT, OT, and Speech a lot, but Imma focus on PT cuz that’s what kind of crab it is.

Tell Me More - It wasn’t all great news. On discharge, at day 54, the patient was prescribed 24 hour supervision and had problems with safety awareness, attention, following commands, dynamic balance, and more. But on the positive side, they went from GCS-5 and an inability to do just about anything to GCS-15 and an ability to do (technically) everything that was in their goals, all with only 21% of the expected PT treatment for such recovery.

So why does this case report exist? Well, it tells a pretty nice story, and also

this case report is presented to examine the effect of dosage of rehabilitation for an individual after TBI. While the neurorehabilitation literature encourages high-dose, intensive rehabilitation early in recovery, this patient showed significant functional improvement with a lower dosage of therapy than the projected amount if he were at an IRF.”

It’s just a case report, so it doesn’t hint at any real possible changes to our protocols, nor should it, but it’s evidence that it is technically possibly to get back with a much lower dose of PT than expected.

Paper? Indeedy-doody

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