Sample Issue - Back Manips, An App for Carpal Tunnel, Cupping for Neck Pain, and a Barefoot Case Study

It's a big week at PT CRAB as we push out our longest issue yet. Don't worry though, it's still less than a 10 minute read and will take you through three studies and one case study before you know it. They're wide-ranging this week, from the feet to the neck with a couple in between, so hopefully I've hit on things can are useful to all. Here it is without further ado.

Let's dive in!

Just Push Anywhere - Generic Vertebral Manips are Equal to Directed Manips in Chronic LBP

The Gist - This study from the Journal of Physiotherapy assessed two different styles of vertebral manips, directed and generic. Building on previous research that showed that generic manips were equal to directed ones in one treatment, the researchers checked out how a long term treatment program with only generic manips would work. What’s a direct vs generic manipulation? A PT applied P-A vertebral pressure at each spinal level, and the patient told them where it was most symptomatic. In the direct manipulation group, that level was then selected for manipulation. In the generic manip group, they went through the same pain ID process, then had manips done in the mid-thoracic (T5 or T6). Patients had a total of ten treatments over the course of four weeks, then were assessed at weeks 4, 12, and 26.

Pain intensity was the primary measure, and they used a disability scale as well. Total, there were 148 patients in the study and the pain differences at weeks 4, 12, and 26 were all within 0.1 points, not clinically significant. Almost exactly the same! So manips at the most painful level or in the mid-thoracic caused the same pain reduction for LBP.

Tell Me More - The big question you’re probably asking is “why does this matter?” The study authors assess that as well. Since there are no clinically important differences in pain, disability (according to the Roland Morris Disability Questionnaire) or Global Perceived Effect between the two techniques, it allows the PT to choose where to manip without sacrificing treatment efficacy. According to the study authors:

Based on the results of this trial, the therapist may choose his/her preferred therapy: non-specific or specific manipulation. In the case of patients with severe low back pain, for example, the therapist’s decision would be to manipulate a site away from the painful segment. Also, the therapist’s ability with either technique may be considered. Therapists may choose to manipulate the patient specifically at the most affected level or not, according to the technique in which he/she is most skilled and has the most experience.

They go a bit deeper on this analysis in the whole paper as well, so check that out if you’re looking for more reasons why it matters.

The big remaining questions are: 1) Why these techniques are the same? and 2) What are the study's weaknesses? The big answers are: 1) We don’t really know but we think that it’s because the lumbar and thoracic regions are interdependent, so this is like treating the thoracic spine to help with neck pain and 2) the therapist wasn’t blinded to the technique used (because, how?). Overall, really interesting study that opens up new avenues in treating complex patients.

Alright, where’s that paper? Right here!

There’s An App for Carpal Tunnel Rehab. Because, Of Course. But Also, It Works.

The Gist - Apparently, rehab following carpal tunnel surgery is controversial, but one thing we do seem to know is that face-to-face rehab is about as good as home exercise programs targeted for the condition. In that environment, this paper attempts to establish a bit more high quality evidence about what exactly to assign. In pursuit of that, they gave 50 people one of two interventions after surgery. Half got the standard handout of home exercise programs and the other 25 were assigned exercises from a tablet app, ReHand. Within 10 days of surgery, they received instructions to do the program (digital or paper) five times per week for four weeks and then were given the QuickDASH, measurements of grip strength and pain intensity, and the Nine-Hole Peg Test.

The app-enabled folks scored 21 points better on the QuickDASH than the non-app people. Since the minimally clinically important difference is just 10 points, this is a significant difference. They didn’t beat the paper group in strength or dexterity (the peg test), just outshining them in function.

Tell Me More - Sure! The study did a great job of avoiding bias, much better than many I cover. The authors also did a fantastic self-commentary in the Discussion portion of the article, so let’s parse it a bit. The downside of using an app is its availability and the lack of affect on the secondary outcome measures. QuickDASH scores are very important, and there was a big difference, but the authors have difficulty understanding why that difference didn’t carry over to the other outcome measures. Pain, specifically, was only 0.1 points different on the standard 0-10 scale. Just not much. Function though, is essential in PT and there’s an inarguable functional difference here.

This brings us to the biggest drawback of the study. Keeping in mind that the protocol was strict, the results were clearly significant, and the study was peer-reviewed into a very high profile physical therapy journal, we can’t look past the competing interest statement at the end of the paper. The article hails from Andalusia, Spain, where the Andalusian Health Service has an agreement with ReHand (the app used) whereby they make money if ReHand does well. Two of the authors involved in ReHand’s development. This doesn’t mean that the results aren’t valid (they probably still are quite good) but this is the jsyk you get for reading the Tell Me More section. Now you know all.

Paper? Yupp.

Dry Cupping Makes Your Hemos More Dynamic and Can Help With Neck Pain. Briefly at Least.

The Gist - A group of ATCs from Illinois published this one in the Journal of Athletic Training last month, writing about for Dry Cupping could help with nonspecific neck pain and change SubQ hemodynamics. They split 32 folks with nonspecific neck pain into three groups: actual cupping, sham cupping, and control. Then they found the most painful part of their necks (measured via the Visual Analog Scale) by poking them gently and presumably waiting until they said “Ouch!”. After that, an ATC placed either a real dry cupping cup or a sham cup over the spot, gave it three pumps, and left it for 8 minutes. Immediately before and after the intervention and 24 hours later, they took pain, pain-pressure threshold, and lots of blood flow measurements, then synthesized the results. The control group got the same measurements done, but laid restfully in a face pillow for the 8 minute treatment times. No cups went near them.

The results were strongest immediately post-intervention, as pain went down 20 on the VAS (equivalent to about 2 on a normal 0-10 scale) for the cupped group, down 3 for the sham group, and down 7 for the control. Pain-pressure threshold didn’t change significantly, but hemodynamics definitely did (more on the blood in the Tell Me More section below). After 24 hours, the pain difference held, with cupping down 13 points, sham up 5, and control down 5. Pain-pressure threshold was down significantly too. Hemodynamics weren’t significantly different at 24 hr. This study adds clout to theories about what cupping does and why it works, and shows that it could certainly be a good intervention for nonspecific neck pain.

Tell Me More - Cupping needs a lot more research, but more and more keeps coming up positive. I definitely have a half-full viewpoint on the therapy overall. The hemodynamic measurements in this study are the most interesting, as the researchers used NIRS to take many measurements that showed some big immediate differences. Specifically, the 8 minute cupping intervention increased superficial and deep oxygenated hemoglobin in the area and increased the tissue saturation index 5 times over. This fits with one major theory behind cupping’s efficacy, that it supplies the treated tissues with fresh blood, helping promote healing and reduce pain. While it’s nice that cupping directly reduced pain in this study, the more important data is the hemodynamic information. It shows that cupping could have real legs in the rehab marketplace.

The study does have limitations related to blinding of investigator and participant, as that may have thrown off the sham cupping’s effect. Patients who knew what real cupping feels like may have been tipped off that the sham wasn’t indeed real. The homogenous participant group is also a concern in reviewing the study. Lastly, how do you make a sham cupping cup? I was confused about this one as well. The researchers used a previously validated method of poking a small hole in the cup, then placing tape around its edge. The small hole would let the cup come up to pressure, simulating the feel of cupping, but then it would slowly allow the suction to leak away and the tape would hold the cup in place. Cool, right?

I’d like to read the whole paper. I thought you might.

A Brief on Being Barefoot

The Gist - This last one is the first case study featured at the CRAB and comes with its share of pitfalls. It’s from a poster published by a PT Student at the University of New England earlier in the year. This isn’t presented as any type of gold-standard, just a good idea we came across in research for this week’s edition. The student was treating a 39 year-old male complaining of pain along his left medial longitudinal arch and a flexible flatfoot deformity. He wanted to return to running but could not due to the pain. The student diagnosed him with Stage II posterior tibialis tendon dysfunction and put together a barefoot based plan of care to return to sport. The focus was on intrinsic foot muscle and post tib strengthening along with some stretching and moves over the course of a few weeks. Afterward the patient was able to return to running and increased their LEFS score from 49 to 71, so it looked to be effective in this patient.

Why Should I Care? I know, I know. It’s just a case study. By a student. I get it. But hear me out. Barefoot training strengthens foot intrinsics and helps stabilize the “foot core”. The second article is a huge one that I may break down in the CRAB someday, but too big for this edition. This is just here to share a moderately interesting case that brings attention to an ill-understood part of the body: intrinsic foot musculature. It’s a light end to a big edition this week.

Fine, I’ll Check Out the Poster Cool! It’s here. With a link to its accompanying paper as well.