🦀 PT Crab Issue 76 - Make it hurt Doc

I’m writing this in 2021 and you’re reading in 2022 so this is like time travel, right? Assuming we made it to 2022. I just hope we all agreed this year not to malign 2021 and say that 2022 can only be better. We learned our lesson with 2019/2020, right? Right? You’d better have learned it.

With that subtle threat out of the way, let’s talk treatment. Specifically, how people with PFP pain respond when you make that pain even worse (or better), early improvement in LBP treatment, and more. More at least for King Crab supporters. They get twice as many articles every week, as I’m sure you know. If PT Crab helps your practice and life, please do become a supporter here. I have ads but they don’t cover costs, the supporters are what keep PT Crab alive.

Those supporters got two more articles, one on how to do better when working with hospitalized adults with intellectual and developmental disabilities and a second on what orthoses do for PFP pain.

Also this week, I’ve recently fallen in love with an awesome storytelling game called Dread. It’s the best possible use for a Jenga set, an allegory for your slow descent into pain, madness, and death (in the game). Basically, someone tells a story, your character makes choices, hard choices require a pull from the Jenga tower and the fall of the Jenga tower means death for your character. If you like to tell stories or have a friend who does, it’s a quick game to learn and really fun to play.

With that (finally), let’s dive in!

Help early, help more

The Gist - This retrospective paper lays out the case for more rapidly assessing the effects of your LBP treatments and being open to changing them early if they’re not working. They looked at Intake Function, Discharge Function, Progress Report Function, and more to show that 70% of functional change occurs in the first 45% of PT care in their sample of 11,945 patients. Interesting.

To make these determinations, they compared results on the Low Back FS patient-reported outcome measure, a 25 item outcome measure that’s sort of a combination of the Back Pain Functional Scale and the SF-36. It scores from 0 (low function) to 100. The data came from 122 outpatient clinics and no controls were applied about the treatment types or anything like that, it’s just strict medical chart observation.

So our top-line, 70% of total change in 45% of care is quite interesting, but there’s even more below the surface on this one.

Tell Me More - Unsurprising, but necessary to report is how much more quickly people with acute pain recovered. Patients with prior symptom durations of 0-7 days improved by about 21 points in the first four weeks of care while those with symptoms greater than 6 months improved by about 10 points. People with more acute pain also recovered more, with the 0-7s improving by 28 points on average and the 6 monthers improving by 14 points on average after a full course of care.

Another interesting bit is the loss to followup. All of these patients got to their first progress report, at an average of four weeks into PT, but only about half (6,559) made it to two progress reports which allows us to get more data on these folks than the 5,000-odd dropouts. I could go on, but ya’ll know where to find more details, in the paper. Instead I’ll just pop in a takeaway here:

The results of this study yield further support for the importance of rapid functional improvements during a PT plan of care. This study may help clinicians identify if they need to alter their plan of care secondary to lack of early functional improvements.

Or as I like to say, “Early to measure, early to apprise, keeps patients healing, good feeling, and wise.” Or something.

Enough shitty rhymes, paper? Sure, but you don’t have to be mean about it sniff, I was proud of that.

Make it hurt, doc

The Gist - This one is about what happens to running mechanics when we temporarily make PFP pain better or worse and it’s quite an interesting idea.

They used repeated single leg squats to make the pain worse and TENS over the knee to make it better, then did strength and gait testing to compare it to a baseline they took earlier. What did they find? Well.

They had 20 participants an average of 26 years old who were “physically active” men and women. In the pretest, mean pain was 3.1, after TENS it was 1.9, and after SLS it was 4.4, so those activities definitely seemed to make a difference. After all that, the pain reduction from TENS didn’t appreciably change strength, but the pain increase changed hip extension strength and both hip abduction and hip extension moments during running. Interesting indeed.

Tell Me More - So why did hip extension strength change? Researchers speculate that it’s due to quads inhibition and concurrent hamstring strength reduction. Why didn’t TENS make this better? We don’t know, but the researchers speculate that just 15 minutes of sensory level TENS isn’t enough to change the body that much and who am I to judge?

What we did learn overall is that kinematics do indeed change, as these folks adjusted their running gaits when they were in increased pain. So even though short-term pain reduction doesn’t appear to make a difference, short-term pain increases definitely can, especially at the hip. According to the authors, “Pain is often considered only a symptom of PFP. This study provides preliminary evidence that pain plays a much more complex role in the cause and progression of PFP.” Well hidey-ho then.

Paper? Yah mon.

Thanks for reading ya’ll, I really appreciate it. Shoot me an email if you want to hear about any particular topics you feel you need more details on, I’m all ears for recommendations. Cheers!

P.S. theWife and I always make pasta by hand using a chitarra (a traditional Abbruzese pasta cutting tool that uses guitar strings to slice the dough) over Christmas. We love how it’s a connection to her ancestry. Here’s what we made this year.

Bye!

Here’s this week’s bibliography:

• Bazett-Jones, D. M., Huddleston, W., Cobb, S., O’Connor, K., & Earl-Boehm, J. E. (2017). Acute Responses of Strength and Running Mechanics to Increasing and Decreasing Pain in Patients With Patellofemoral Pain. Journal of Athletic Training, 52(5), 411–421. https://doi.org/10.4085/1062-6050-53.3.04
• Walston, Z., & McLester, C. (2020). Importance of Early Improvement in the Treatment of Low Back Pain With Physical Therapy. Spine, 45(8), 534–540. https://doi.org/10.1097/BRS.0000000000003318