Sample Issue - PT Beats Glucocorticoids, Why You Should Be Checking BP, Dry Needling vs. Ischemic Compression, and KT for Back Pain

Luke Hollomon -

We open with a short paper about PT vs. Glucocorticoids for Knee OA where PT wins in the long term, move onto a wonderful piece about why you should be checking BP in PT clinics (and how to do it properly), feature a tight contest between dry needling and ischemic compression in treatment of cervicogenic headache and trigger points, and finish with a promising systematic review about the use of KT for chronic, non-specific low back pain. This edition is a cracker.

Let’s dive in!

PT Outperforms Glucocorticoid Injections for Knee OA

The Gist - This isn’t information that you can easily put to work in the clinic, but it’s great knowledge to have and share with your patients and physician contacts. An RCT conducted in the U.S. Military Health System split 156 patients with pain from knee OA into a glucocorticoid injection group and a PT group, then checked their pain and WOMAC scores at baseline, 4wk, 8wk, 6mo, and 1yr. The PT group improved their scores more at every measurement point, but the largest difference was at 1 year, where the between group difference was 18. The WOMAC’s MCID is 12-15 points, so that’s well within the noticeable range.

Tell Me More - The trial compared patients with radiographic evidence of OA and knee pain from it, and followed them for a full year, making this one of the most complete analyses of these two methods of treatment. It’d have to be too, this one comes at us from the NEJM itself. It’s also one of the more readable papers you’ll come across so, if you’re interested, it’s a good read through the link below.

Now into the stats. The main point of this study was to compare these interventions at a year, where PT showed the greatest improvement, both absolutely and relative to the injection. Interestingly, the PT group’s rate of improvement was increasing at that time juncture while the injection group’s was leveling off. The study did not continue after a year, but there may have been more results to be seen at 18 and 24mo. Of the 78 in the PT group, 8 (10%) did not reach the WOMAC MCID improvement of at least 12 points even at a year, while 20 (26%) from the injection group did not reach this milestone. Lastly, even though it wasn’t a formal comparison, researchers observed that healthcare costs in the 1 year period were similar between the groups, making PT more cost effective too.

Paper please.You should read it for more, cuz it’s great. Just sayin’. But also it’s not open access, so ☹️

Please Check Your Patient’s BPs. Here’s Why and How.

The Gist -This exhortative article comes from PTJ and begs you to take a BP screening if you’re an outpatient therapist. The authors go through a ton of detail and arguments about why this is important and how to do it accurately and cost-effectively, so here are some notes in brief.

  • BP measurement should be in a routine exam of all patients
  • Only 10 - 15% of PTs measure BP, even in cases of direct access, where they may be the only healthcare provider the patient is seeing
  • BP screening is an effective strategy for early detection of HTN
  • HTN screening is an ethical duty of care due to HTN’s morbidity, disability, and mortality
  • HTN screening is fast and easy to do in outpatient clinics as part of a routine exam

I could go on (and they do and you should read it) but just start screening your patients, okay?

Tell Me More - I already made the major point, so here’s what you need to do it. 1 stethoscope per therapist, 1 standard BP cuff per 2 therapists, 1 small and 1 large cuff per clinic, and 1 thigh cuff just in case. Keep your equipment calibrated by checking it every 6 months (22% of PT’s gauges are inaccurate 😲) and follow a standard protocol when taking BP: seating, rested position for 5 minutes, feet flat on the floor and uncrossed with back supported. None of that legs off the plinth nonsense, it can throw you off by 8mmHg. Tell that patient to shut their mouth too, talking can mess things up by 15mmHg. Wow.

The paper also goes into some great discussion of why PTs should be measuring BP response to exercise. Mainly, PT is the only place that most patients will even have the opportunity to exercise near a healthcare provider (and the only place where many will exercise at all) so it’s a perfect time for screening that’s easier than a real stress test but can still show pathologies. The Crab has previously covered hypotension and why that’s a big problem, but obviously, hypertension is bad too. So take BP people! The paper has more details on when, how, and why. Give it a quick read, it’s worth your time.

Here’s that paper - It’s open access too. Yay!

Headache and Trigger Points? Ischemic Compression and Dry Needling Have Your Back

The Gist - Cervicogenic headache is an oft-covered topic on PT Crab, and there are a lot of ways to treat it, but this particular study compares ischemic compression to dry needling in myofascial trigger points of the sternocleidomastoid. Interestingly, it adds one more element too, using ultrasound and an experienced visualizer to actually see what the two techniques are doing. If you want to see what a myofascial trigger point actually looks like, pop open that paper. It’s pretty cool.

As far as the research goes, it was quite straightforward. They split 29 women with a neurologist’s diagnosis of cervicogenic headache due to SCM trigger points into three groups, one which received ischemic compression, the other which got dry needling in the area, and the third which got nada. They got 4 session in 8 days and the outcome measures used were a headache questionnaire and myofascial trigger point pressure sensitivity. They also looked at what happened to the trigger points afterward. Both groups improved significantly relative to control with no significant between group differences.

Tell Me More - I’m going to focus on the ultrasound because I just think it’s really cool. After treatment, the visualized myofascial trigger points shrunk, though they did no disappear completely. Their elastic modulus (found by doing some fancy math based on the ultrasound) also decreased and this decrease was correlated with headache intensity. Both dry needling and ischemic compression caused the shrinkage, and again, there was no significant difference between them.

Lastly, the discussion section is a treasure trove of the physiology and speculative mechanisms of ischemic compression and dry needling. Give it and its references a look to learn a lot more about both modalities.

Dat paper?- It’s not open access, but I requested one through ResearchGate and will let you know when it pops through. In the meantime, here it is on the journal’s page.

KT for Non-Specific LBP? Yea, It Seems to Work

The Gist - A group of writers from PTJ got together to dig through the trials on kinesiotaping for chronic nonspecific low back pain and they found something pretty good. They had a small, heterogenous set of trials to work from, but most trials showed a positive, interesting result. They took 11 RCTs with 785 patients and were able to demonstrate that KT lowers pain intensity and improves disability when compared to control, sham taping, and KT with no tension. Multiple methods were used in the studies, but the most common was two strips, placed bilaterally over the erector spine muscles. Compared with the placebos, pain was reduced an average of 0.73 on a 0-10 scale and disability by 0.51 on ODI. Pretty good results for a simple intervention.

Tell Me More - The gold here lies in the subgroup analysis, since the studies are so heterogenous and some are pretty small. For example, the bilateral strips over the erector spinae showed pain reduction of 0.5 over all controls, KT vs. sham tape was a 0.84 difference in pain reduction, and KT vs. no tape was 0.74 different. I could dig deeper into the subgroups, but that’s poor reading for those who don’t want it all, so dive into the paper for more. Because of the risk for bias when pooling everything together, the authors gave KT interventions low-quality evidence for improvement in pain and disability in chronic non-specific low back pain. Good results so far and there may be more data on this in the future. I’ll be sure to report it when there is.

Can I read the whole thing? Yes! If you have access to PTJ. Here’s the PubMed link.