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Sciatica

Sciatica (also called radicular pain) is commonly used to describe radiating leg pain. It is caused by inflammation or compression of the lumbosacral nerve roots (L4-S1) forming the sciatic nerve. Sciatica can cause severe discomfort and functional limitation.

People with sciatica usually describe aching and a sharp leg pain radiating below the knee and into the foot and toes. The pain can have a sudden or slow onset and varies in severity. Most people report coexisting low back pain. Disc herniations affecting the L5 or S1 nerve root are more common and cause pain at the back or side of the leg and into the foot and toes. If L4 root is affected, pain is localised to the front and lateral side of the thigh. Tingling or numbness and loss of muscle strength in the same leg are other symptoms that suggest nerve root involvement.

How common is sciatica?

In the UK about 60% of patients with back and leg pain were clinically diagnosed with sciatica.

How is sciatica diagnosed?

Sciatica is a clinical diagnosis based on the person’s symptoms and findings on examination. Symptoms and signs suggesting sciatica:

  • Unilateral leg pain more severe than low back pain;
  • Pain most commonly radiating posteriorly at the leg and below the knee;
  • Numbness and/or paraesthesia in the involved lower leg;
  • Neurological deficit associated with the involved nerve root (muscle weakness/absence of tendon reflexes/sensory deficit);
  • Positive neural tension test with provocation of pain in the affected leg (straight leg raise test/femoral nerve test/slump test).

Role of imaging

  • Routine imaging is not advised in people with non-specific low back pain with or without sciatica
  • Disc herniation is a common age related finding
  • Consider imaging if symptoms progress for more than 12 weeks, or if the person has progressive neurological deficits (signs of urinary retention or decreased anal sphincter tone ) or worsening pain

Conservative treatment

  • Encourage patients to remain active and avoid bed rest

What is the prognosis?

  • Most people experience an improvement in symptoms over time with either conservative treatment or surgery
  • For disabling symptoms lasting longer than 6 weeks with a lack of response to non-operative management, specialist referral (rheumatologist, rehabilitation physician, spinal surgeon) can also be considered
  • Laminectomy surgery for radiculopathy may shorten the duration of symptoms, but outcomes at 12 months are similar to non-operative treatment and surgery is associated with increased risk of further surgery
  • Decompression surgery for central lumbar canal stenosis may improve symptoms, but there is a lack of high -quality evidence for its superiority over non-operative management

 

References

  • Diagnosis and treatment of sciatica, bmj 2019
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Back Pain – Mythbuster

We are busting myths and reinforcing what the latest evidence says is best for your back.

Myth 1: Moving will make my back pain worse

Fact: Don’t fear twisting and bending, it’s essential to keep moving. Gradually increase how much you are doing, and stay on the go

Myth 2: I should avoid exercise, especially weight training

Fact: Back pain shouldn’t stop you enjoying exercise or regular activities. In fact, studies found that continuing with these can help you get better sooner, including using weights where appropriate.

Myth 3: A scan will show me exactly what is wrong

Fact: Sometimes it will, but most often it won’t. Also, even people without back pain have changes in their spine so scans can cause fear that influences behaviour, making the problem worse.

Myth 4: Pain equals damage

Fact: This was the established view but more recent research has changed our thinking. Modern physiotherapy takes a holistic approach that helps people understand why they are in pain.

We have to fight the fear and move more!!!

Problem is these myths create fear, which causes people to stop doing many of the activities they need to do to address the problem. So let’s bust those myths and reinforce what the latest evidence says is best for your back.

Physiotherapists are the experts in treating and preventing back pain.

Reference

http://www.csp.org.uk/mythbusters, 2016

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Knee arthroscopy. Does it work?

What is knee arthroscopy?

Arthroscopy is a minimally invasive surgical procedure in which a fiberoptic endoscope is inserted into the joint through a small incision. The surgeon makes a second incision through which to insert surgical instruments that can be used to debride or resect areas within the knee under visualization of the endoscope.

Knee arthroscopy is mostly performed to treat osteoarthritis (this process includes lavage of the joint with removal of loose bodies and/or chondroplasty of the articular surfaces)  and meniscal tear ( it is usually a partial meniscectomy, in which part of the torn meniscus is removed).

 

Does knee arthroscopy really work? Let’s have a look at the following articles…

 

Knee arthroscopy versus conservative management in patients with
degenerative knee disease: a systematic review (BMJ 2017)

Over the long term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function.

Patients and their healthcare providers must trade-off the marginal short-term benefits against the burden of the surgical procedure (pain, swelling, limited mobility, restriction of activities, over a period of 2 to 6 weeks).

Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial (BMJ 2017)

Arthroscopic partial meniscectomy (APM) is one of the most common orthopaedic operations, with an incidence that has increased steadily from 1990s until late 2010s. Most APMs are carried out in middle-aged and older patients with knee symptoms and degenerative knee disease. Several recent meta-analyses based on randomised controlled trials (RCTs) have failed to show a treatment-benefit of APM over conservative treatment or placebo surgery for these patients.

Conclusion:

In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after APM were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from APM.

 

Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline (BMJ 2017)

Approximately 25% of people older than 50 years experience knee pain from degenerative knee disease.

What is degenerative knee disease?

Knee disease is an inclusive term, which many consider synonymous with osteoarthritis. We use the term degenerative knee disease to explicitly include patients with knee pain, particularly if they are >35 years old, with or without:

  • Imaging evidence of osteoarthritis (OA)
  • Meniscus tears
  • Locking, clicking, or other mechanical symptoms except persistent objective locked knee
  • Acute or subacute onset of symptoms

Most people with degenerative arthritis have at least one of these characteristics. The term degenerative knee disease does not include patients having recent debut of their symptoms after a major knee trauma with acute onset of joint swelling (such as haemarthrosis).

Management options include weight loss if overweight, a variety of interventions led by physical therapists, exercise, oral or topical pain medications such as non-steroidal anti-inflammatory drugs, intraarticular corticosteroid and other injections, arthroscopic knee surgery, and knee replacement or osteotomy.

What you need to know

There is a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on systematic reviews. This recommendation applies to patients with or without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset.

Arthroscopic knee surgery for degenerative knee disease is the most common orthopaedic procedure in countries with available data and on a global scale is performed more than two million times each year. Arthroscopic procedures for degenerative knee disease cost more than $3bn per year in the US alone.

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Unilateral shoulder pain and bilateral MRI findings

Magnetic resonance imaging (MRI) is commonly used to diagnose structural abnormalities in the shoulder. However, clinical findings may not be the source of symptoms (article).

In this study was evaluated over 100 individuals who reported unilateral shoulder pain, with no signs of adhesive capsulitis, no substantial range-of-motion deficit, no history of upper-limb fractures, no repeated shoulder dislocations, and no neck-related pain. All partecipants had MRI (interpreted by an orthopedic shoulder surgeon and a musculoskeletal radiologist) of both symptomatic and asymptomatic shoulders.

Results: Abnormal MRI findings were observed in both shoulders.

Rotator cuff tendinopathy, partial-thickness tear, full-thickness tear, labrum alterations, acromial morphology (Type I, II, III), long head of biceps alterations, AC joint alterations, subacromial fluid, fatty infiltration, glenohumeral osteoarthritis.

Only the frequencies of full-thickness supraspinatus tendon tears and glonohumeral osteoarthritis (OA) were higher (about 10%) in the symptomatic shoulder according to the surgeon’s findings only.

Agreement between the musculoskeletal radiologist and shoulder surgeon ranged from slight to moderate.

Conclusion

Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders.

Consider additional factors to help explain patients pain (Todd Hargrove).

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Subacromial decompression. Does it work?

 

The shoulder

The shoulder is a ball (head of the humerus) and socket (glenoid cavity of the scapula) joint. There is a space between the acromion (which is part of the scapula) and the top surface of the humeral head, which is called the subacromial space (its height is 1-1.5 cm). This space is outlined by the acromion, coraco-acromial ligament and the coracoid process (which are parts of the scapula), which makes up the roof of the shoulder, and by the humeral head which makes up the floor of the shoulder. In this space are located tendons called the rotator cuff.

When the rotator cuff tendons, mainly the supraspinatus tendon, rubs against the roof of the shoulder repeatedly, at one point it will get inflamed and irritated, as a result it will cause pain. This is a common disorder of the shoulder, called Subacromial Impingement Syndrome (SAIS).

The SAIS can start suddenly or come on gradually. The symptoms are: pain in the top and outer side of your shoulder, which is worse when you lift your arm, especially when you lift it above your head; pain or aching at night, which can affect your sleep; weakness in your arm.

Normally people with the SAIS try first the conservative treatment (nonsteroidal antiinflammatory drugs, physiotherapy, steroid injections, etc…) and if it doesn’t work they go for surgery, Arthroscopic Subacromial Decompression (ASD). The operation aims to increase the size of the subacromial area and reduce the pressure on the tendons. It involves cutting the coraco-acromial ligament and shaving away the bone spur on the acromion bone. This allows the tendons to heal.

Does arthroscopic subacromial decompression (ASD) really work?

A study carried out in 2018 assessed the efficacy of arthroscopic subacromial decompression (ASD) by comparing it with diagnostic arthroscopy (a placebo surgical intervention), and with a non-operative alternative, exercise therapy.

122 patients with subacromial pain and unresponsive to conventional treatment; Age 35-65; Pain for 3 or more months.

59 patients ASD (arthroscopic subacromial decompression)

63 patients DA (diagnostic arthroscopy placebo)

Conclusions: Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months in terms of pain and functional outcomes.

It is important to know that with the advent of arthroscopy, the number of subacromial decompression procedures has increased many times between the 1980s and the 2010s. A study reported that the incidence of anterior acromioplasty increased over time with the crude rate of 3.3 per 100,000 in 1980 to 1985 to 19.0 per 100,000 in 2000 to 2005 in the US. The overall incidence was higher in men than women, with the highest incidence in patients age 41 to 64 years.

Another study compared ASD with conservative treatment (physical therapy, exercise programmes, NSAIDs, and steroid injections) in adults with atraumatic shoulder pain for more than 3 months diagnosed as subacromial pain syndrome (SAPS), also labelled as rotator cuff disease.

Results: Surgery did not provide important improvements in pain, function, or quality of life compared with placebo surgery or other options (after 1 year). Frozen shoulder may be more common with surgery.

Practical issues with surgery:

After surgery, 2 weeks off work are typically needed;

Avoid heavy lifting for one to three weeks, overhead activities for 3 months.

References

  • Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial –  BMJ 2018;
  • Arthroscopy and the dramatic increase in frequency of anterior acromioplasty from 1980 to 2005: an epidemiologic study – 2010;
  • Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline -BMJ 2019;

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Explaining Back Pain

Back pain is one of the most common reasons that people go to the doctor, and it is a leading cause of disability worldwide. Almost everyone has it at some point. Pain can be intense and is one of the top causes of missed work. Back pain often gets better on its own, but sometimes becomes chronic and it takes longer to go away.

It is important to understand the way your brain deals with pain especially when it is chronic, that way, you will be able to manage it and cope better with your situation.

For this reason I want to recommend a great book “Explain Pain” written by David S. Butler and G. Lorimer Moseley (2013) to all of those people who suffer with or have been suffering with back pain. It is an evidence based book designed for therapists, patients and students. As a Physiotherapist I deal with patients experiencing chronic pain on a regular basis, and reading this book helped me to develop a clinicians understanding of what the patient is going through, it also has good pictures and strategies to help with communication.

I have created a few mind maps about the book, where I have summarized the main concepts . I hope you will find them useful. For those who do not know, you have to read the mind map clockwise.

Explain pain

Explain pain 1

Explain pain 2

Explain pain 3

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Osteoporosis

What is osteoporosis?

Osteoporosis is a disease that is characterized by low bone mass, deterioration of bone tissue, and disruption of bone microarchitecture: it can lead to compromised bone strength and an increase in the risk of fractures. Osteoporosis is a risk factor for fracture just as hypertension is for stroke.

It was estimated that the number of patients worldwide with osteoporotic hip fractures is more than 200 million. According to recent statistics from the International Osteoporosis Foundation, worldwide, 1 in 3 women over the age of 50 years and 1 in 5 men will experience osteoporotic fractures in their lifetime.

Osteoporosis has no clinical manifestations until there is a fracture. Fractures cause important morbidity; in men, in particular, they can cause mortality (article).

Fortunately, a well designed exercise program can help to counterbalance the losses in bone density that occur with age and may even allow people to slightly increase their bone density.

What is the best exercise to get my bones stronger?

The best exercises to improve your bone density are weight training and weight-bearing exercises (eg. walking, jogging, etc.). We need to feed our bones with load. When a bone is loaded, this activates the production of bone building cells (osteoblast), which are responsible for the synthesis and mineralization of bone.

Exercise to promote bone and muscle strength (link):

 

 

 

 

 

 

Resistance exercise

  • Frequency: at least 2-3 times/week (non-consecutive days)
  • Duration: aim for 20-30 minutes on exercises that target legs, arms and spine
  • Intensity/Time: 1-3 sets of 8-12 repetitions of each exercise
  • Type: 1 exercise per body part

Weight bearing exercise with impact

The recommendations are:

  • For people with osteoporosis but without fractures: about 50 minutes moderate impacts on most days (jumps, skips, jogs, hops, etc.)
  • For people who have spinal fractures or are unable to do moderate impact: 20 minutes lower impact exercises on most days (walks, brisk walking, marching, stair climbing, etc.)

Balance exercise is also recommended, up to 20 minutes per day. Balance needs to be challenged in order for it to be effective and balance exercises must be maintained as balance can decrease quickly.

What about cycling and swimming?

These activities are not weight-bearing and don’t provide impact. They may strengthen muscles to some extent but because the weight of your body is held by the water or your bike, there isn’t much force going through to your bones. It is probably not enough to promote bone strength.

What about walking?

Walking is a form of exercise such as cycling and swimming, and it doesn’t provide enough of a loading stimulus to stimulate bone growth.

Conclusions

With an aging population and longer life span, osteoporosis is increasingly becoming a global epidemic. Therefore, increasing awareness among healthcare workers, which, in turn, facilitates increase awareness of the normal populace, will be effective in preventing this epidemic (link).

References

  • An overview and management of osteoporosis –  Tumay et al., European Journal of Rheumatology, 2016;
  • Royal Osteoporosis Society, http://www.theros.org.uk

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Physical activity throughout pregnancy

Regular physical activity is associated with health benefits, including improvements in physical and mental health, as well as decreased risk of chronic disease and mortality. Pregnancy is a unique period of a woman’s life, where lifestyle behaviours, including physical activity, can significantly affect her health, as well as that of her fetus. Although guidelines around the world recommend women without contraindication engage in prenatal physical activity, fewer than 15% of women will actually achieve the minimum recommendation of 150 min per week of moderate-intensity physical activity during their pregnancy.

Over the last three decades, the rates of pregnancy complications such as gestional diabetes mellitus, pre-eclampsia, gestational hypertension and newborn macrosomia have risen dramatically most likely as a consequence of rising rates of maternal obesity.

Who should be physically active during pregnancy?

All the women who do not have contraindications that would prevent them from engaging in physical activity. Women with absolute contraindications may continue the usual activities of daily living but should not participate in more strenuous exercise. Women with relative contraindications should discuss the advantages and disadvantages of moderate-to-vigorous intensity physical activity with their obstetric care provider.

Absolute contraindications Relative contraindications
Ruptured membranes, premature labour Recurrent pregnancy loss
Unexplained persistent vaginal bleeding History of spontaneous preterm birth
Placenta praevia after 28 weeks gestation Gestational hypertension
Pre-eclampsia Symptomatic anaemia
Incompetent cervix Malnutrition
Intrauterine growth restriction Eating disorder
High-order multiple pregnancy (eg, triplets) Twin pregnancy after the 28th week
Uncontrolled type I diabetes, uncontrolled hypertension or uncontrolled thyroid disease Mild/moderate cardiovascular or respiratory disease
Other serious cardiovascular, respiratory or systemic disorder Other significant medical conditions

Recommendations

  1. All women without contraindication should be physically active throughout pregnancy. Strong recommendation, moderate-quality evidence.
  2. Pregnant women should accumulate at least 150 min of moderate-intensity physical activity each week to achieve clinically meaningful health benefits and reductions in pregnancy complications. Strong recommendation, moderate-quality evidence.
  3. Physical activity should be accumulated over a minimum of 3 days per week; however, being active every day is encouraged. Strong recommendation, moderate-quality evidence.
  4. Pregnant women should incorporate a variety of aerobic and resistance training activities to achieve greater benefits. Adding yoga and/or gentle stretching may also be beneficial. Strong recommendation, moderate-quality evidence.
  5. Pelvic floor muscle training (PFMT) (eg, Kegel exercises) may be performed on a daily basis to reduce the risk of urinary incontinence. Instruction on the proper technique is recommended to obtain optimal benefits. Weak recommendation, low-quality evidence.
  6. Pregnant women who experience light-headedness, nausea or feel unwell when they exercise flat on their back should modify their exercise position to avoid the supine position. Weak recommendation, very-low quality evidence.

 

Safety precautions for prenatal physical activity

  • Avoid physical activity in excessive heat, especially with high humidity.
  • Avoid activities which involves physical contact or danger of falling.
  • Avoid scuba diving.
  • Avoid physical activity at high altitude (>2500 m).
  • Maintain adequate nutrition and hydration. Drink water before, during and after physical activity.

 

Reasons to stop physical activity and consult a healthcare provider

  • Persistent excessive shortness of breath that does not resolve on rest.
  • Severe chest pain.
  • Regular and painful uterine contractions.
  • Vaginal bleeding.
  • Persistent loos of fluid from the vagina indicating rupture of the membranes.
  • Persistent dizziness or faintness that does not resolve on rest.

Heart rate ranges for pregnant women

Maternal age Intensity Heart rate range (beats/min)
<29 Light 102-124
Moderate 125-146
Vigorous 147-169
30+ Light 101-120
Moderate 121-141
Vigorous 142-162

 

Conclusion

It is important that these Guidelines be implemented into clinical practice to achieve the significant and potentially lifelong health benefits for both the mother and the child.

 

References

Michelle F Mottola et al. 2019 Canadian guidelines for physical activity throughout pregnancy. Br J Sports Med 2018.

 

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Get better at push-ups

 

Why is important to do more push-ups?

It is important not only because you build upper body strength, but because you will reduce the risk of cardiovascular disease.

A study by JAMA (The Journal of the American Medical Association) in 2019, showed the association between Push-up exercise capacity and future cardiovascular events among active adult men.

Cardiovascular disease (CVD) remains the leading cause of mortality worldwide. Robust evidence indicates an association of increased physical fitness with a lower risk of CVD events and improved longevity.

Findings:

  • This study of 1104 occupationally active adult men (mean age 39) found a significant negative association between baseline push-up capacity and incident cardiovascular disease risk across 10 years of follow-up.
  • Participants able to complete more than 40 push-ups were associated with a significant reduction in incident cardiovascular disease event risk compared with those completing fewer than 10 push-ups.

Reference:

  • Association between push-up exercise capacity and future cardiovascular events among active adult men,  Justin Yang et al. 2019, JAMA.