Physiotherapy vs ankle sprains

 

Physiotherapy is increasingly moving towards an evidence-based model of practice, where research evidence is combined with clinical experience and patient expectations and goals to create a treatment plan. One limitation of that approach is that the research is often low quality and incomplete. Large clinical trials are expensive and therefore few and far apart. But when a large-scale, well performed clinical trial is published it should absolutely be given full consideration and should affect decision-making.

One such large, high-quality clinical trial was recently published in the BMJ (1) and tested the efficacy of 7 sessions supervised evidence-based intervention with full clinical evaluation by the physiotherapist against a 1-page self-care guide.

Without going into too much detail, the physiotherapy intervention did not perform better than providing a 1-page self-care guide. This is not that unsurprising, an ankle sprain is an acute injury and as such a large part of the process is simply allowing time to pass for the tissues to heal. Daily activities may provide adequate rehabilitation for most people if braces or crutches aren’t used.

Studies like this provide good evidence of what the average outcome is, and if a decision will „pay off“ or not. On average, therefore, patients who come in with simple ankle sprains should be given an educational self-care guide. There can still be cases that can benefit from more personal guidance. It’s reasonable that people with learning disabilities will not benefit as much from the self-care guide and should, therefore, be followed up more closely. High-level athletes with a small room for error, where a difference in 2-3 days of returning to sports may be important can choose to have more supervision with their program as well to ensure optimal recovery (2).

Personally, I’d have loved to see this study support that physios should book simple ankle sprains for 7 sessions, it’s good for job security and as these treatments will most often be successful, patient satisfaction will tend to be high. However, reality does not always match expectations. I hope physios will take this to the clinic and discharge the majority of simple ankle sprains with a self-care guide, but as always some physios will continue to do whatever they have been doing anyway.

The Evidence Behind: Motion Palpation

What is motion palpation:

It’s common for therapists to believe they can palpate the amount and quality of movement between individual spinal segments and in the sacroiliac joint. The movements being palpated are minute, usually just a few degrees. Numerous factors could affect the sensitivity of the tester, including the facts that these movements are evaluated through rather thick skin and being resisted by muscle forces. These methods are taught worldwide, and the knowledge and skill the student possesses on these techniques is examined and graded. This is done without any objective criteria to evaluate if the teacher has a superior skill or sensitivity (this is merely assumed), or if these techniques have merit at all.

Studies (0) have examined how well a bunch of people are able to agree with a „palpation guru“, or just the ability of a group of people to have a reasonable degree of agreement (it’s known as inter rater reliability), or even if a person can just simply agree with themselves (intra rater reliability).

The whole gig is akin to an inition ceremony, like two blind men discussing the color of the emperors new clothes. To graduate, you must of course guess the same color as the teacher. It sounds far fetched, but the idea is attractive and has some face value. It’s also the source of many a legend in the physical therapy profession – everyone has heard of these therapists with fingers that are like eyes that can see into the body and feel every knot, twist, limitation, microscar, and blood flow restriction under the sun. Painscience has a nice article on how easily human senses can be tricked by beliefs and expectations.

However, at the end of the day what matters is if the method is valid. Validity is assessed by how well a method or test performs against some objective standard. I’d prefer to only look at studies where the judgement of a palpating therapist is tested against an objective criteria, such as ultrasound, x-ray imaging, MRI or compatible techniques – but there aren’t too many of these, so when lacking direct evidence I’ll discuss some indirect evidence instead.

Sacro-iliac joints

It’s difficult to accurately palpate the location of bony landmarks around the sacro-iliac joint, the precision is about 20 mm (1), and that’s without trying to track movement as well. To put that number in context, the movement of the sacro-iliac joint is between 1,2° and 4.5°, with a high degree of variability between individuals (2) – less than 10 mm of motion, and so way outside the accuracy of palpating bony landmarks. Somewhat similar to hearing a whisper from another room where music is being played. Also indicated by (2) the difference between problematic and non-problematic sacro-iliac joints is more likely in the pattern, not amount, of movement.

Given this, it’s hardly surprising that clinical palpation and motion testing of the position of the sacro-iliac joint is positive before and negative after a manipulation – even though no changes occur in the sacro-iliac joints themselves (3). This is why researchers should blind examiners – for a motion palpation difference to be plausible, the motion increase of the sacro-iliac joint would have to be way outside the physiological range of motion. So a study to demonstrate this would have to be very robust.

Lumbar spine

Palpaters have difficulties locating the correct spinal segment, being successful in only 50% af attempts (4). That makes it unsurprising that the agreement between different raters of lumbar spine segmental mobility is not high, although each rater is fairly consistent (5). Similar findings for assessing the rotatory mobility of spinal segments (6).

There are unfortunately few studies that objectively evaluate motion palpation in the lumbar spine against an objective measurement. The only study close to it used ultrasound to evaluate lumbar segmental rotation based on the depth of the transverse process from the skin (7). The results demonstrated that the examination technique and the ultrasound examination agreed on a dysfunction of a spinal segment. Unfortunately, only the „dysfunctional“ spinal segment was evaluated, the change of depth from a treatment that was provided was around 0.5 mm, and everyone was rotated towards the left. As a result, it’s impossible to say if it’s the diagnostic technique that’s valid or that everyone is just rotated a little bit towards the left (maybe because they are all right-handed). The study design, unfortunately, just can’t answer that question*.

If one is looking for a reason to manipulate a spine, there’s no need to perform any of these palpatory techniques. Studies have looked at when a lumbar spinal manipulation is most useful; pain has been present less than 16 days, no symptoms below the knee, hip mobility is good, and the spinal gross range of motion is limited (8).

Cervical spine

Palpating the location of the uppermost cervical segment  is actually pretty accurate (9), so that’s already better than the rest of the spine. However, therapists apparently can’t identify segments with differing mobility, and even though mobility is increased acrosst he board by cervical spinal manipulations, there was no connection between mobility changes and the clinical outcome of treatments (10).

There is one way to increase the validity and accuracy of certical spine motion palpation and manipulation: slice away the skin and muscles first (11)! Good luck selling that to patients. Unlike the lumbar spine, there are no clinical indications to predict when manipulations are useful (12).

 

Closing remarks

Compared to how extensively used and taught these motion palpations are, the research on their validity is certainly lagging far behind. However, the research is fairly homogenous: motion palpation is inaccurate and lacks validity, and the results of such palpations are entirely unrelated to clinical outcomes. The motions being palpated are simply too small, and there is too much interference from other tissues for these tests to even be humanly possible.

But no reason to panic, even though motion palpation is outdated there’s plenty of other methods out there that are supported by the evidence.

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• For those interested in research designs, the study has various flaws. There was no way to confirm the clinical palpation was changed by the treatment, because everyone received manipulations and only one rater was used. There was no control group, and no blinding – the study was only a pilot study (although no follow-up is yet published), meaning it was meant to generate ideas for better research later. A small flawed pilot study that goes against the majority of other studies should not guide clinical practice.

Spinal Manipulative Therapies: Long-term Effectiveness

In part I of this series I talked about myths associated with methods used alongside spinal manipulation (and got fired because of it). In part 2 (not available in english) I discussed research on the short-term effects of spinal manipulations (tl;dr: pain relief, maybe some range of motion improvements). In this third installment I’ll discuss the long-term effectiveness of spinal manipulation treatments.

Most people seeking physiotherapy aren’t looking to receive a palliative therapy for the foreseeable future, they view it as curative – a part of really getting better.

Answering a question such as “do spinal manipulations work?” is a fairly complex endeavor. When doing a randomized trial one needs a large group of people to demonstrate a small treatment effect, but a small group will suffice to demonstrate a large treatment effect. It’s fairly easy to establish a very large treatment effect on an otherwise stable condition (like thyroid hormone therapy where there is no placebo effect on serum hormone levels). So the fact that this question is still even being asked  today already implies that spinal manipulations likely have a small or non-existing treatment effect. Basically, if they worked really well for a significant number of people (i.e. they worked as well as spinal manipulative therapists will tell you), one would only need a couple of medium or small sized studies to settle the issue.

Further, if one follows two groups of people who have a condition that is unstable – people frequently improve on their own, or get worse on their own – it’s fairly likely that the groups will be unequal at the end, regardless of interventions. Large powerful intervention studies are expensive, and so only a few of them are performed. Small studies with conflicting results give little or no information individually, but allow cherry-picking the data. So those small studies need to be combined into a meta-analysis, and it’s one of these that I will center this discussion around, a study published in 2014, authored by Menke.

A meta-analysis like this pools the treatment effects from multiple clinical trials and uses statistics to compare interventions. The strength of the Menke analysis is in how inclusive of studies it is (more difficult to cherry-pick), and the fact that he does a comparative analysis of different treatment groups from spinal manipulation trials. His analysis is highly informative and extremely interesting, even if the paper is in many ways unorthodox. The main conclusion to be drawn from the paper, sorry for the spoiler, is that spinal manipulative therapies provide no overall benefits long-term.

I will present here some key points from his analysis, that help to answer the question of how well spinal manipulations work clinically in the long-term. I say clinically, because there is a great paradox of why these therapies remain popular despite the evidence of their ineffectiveness and their weak theoretical foundation. Some parts of his analysis reveal components of the “formula for success” of how and why spinal manipulative therapists thrust cash in their pockets.  The interested reader is of course advised to read the original meta-analysis.

#1 – A waiting list is significantly worse than doing nothing.

Most treatment groups had comparable results if they were manipulations or electrotherapy or what have you. But treatments that required any human contact outperformed those without human contact. People put on a waiting list (a waiting list control) were the only group that worsened in the short term. So it’s better to purposely do nothing than to wait for a therapy. It’s reasonable to assume from this that going from a waiting list to any intervention at all will always result in an improvement, so a waiting list is a good strategy to improve patient satisfaction without improving treatment effects.

#2 – The effect size of spinal manipulations remains unchanged since the first trials

Menke converts the results of individual studies into effect sizes  which may be compared between studies – think of effect sizes as a unit of comparison – this is similar to converting pounds and stones into kilograms to compare people’s weights. What this reveals is that the effect sizes of spinal manipulation have remained the same from when trials on them started. Improved study quality, better health care, MRI etc. have not lead to a bigger effect of the spinal manipulations. As spinal manipulation outcomes are unchanged despite better research and healthcare, it’s reasonable to assume that they will be unchanged in the foreseeable future as well.

#3 – The prognosis is actually good, with or without interventions

One of the difficulties in researching back pain treatments is that the condition is unstable. This means that spontaneous improvements are common, and the pain and disability vary greatly due to natural fluctuations throughout the year. Most people seek treatments (and register into clinical trials) at their worst, and will then improve regardless of the intervention. So for this reason, most interventions that cause little or no direct harm will have good clinical results.

#4 – Spinal manipulation success has the same statistical chance as a throw of the dice

If treatment wings within trials were classified according to whether or not they outperformed sham treatments, the chance of spinal manipulations being the best treatment was equal to a throw of dice where the sides on the dice equal the treatment arms. Two treatment arms – 50% chance. Three treatment arms – 33% chance, etc.

When two treatments are compared on an unstable condition with small groups, it would be expected that the groups were unequal at the end of the study despite treatments. Any treatment under study needs to outperform this natural variability to show any meaningful results. Spinal manipulations fail to do this.

#5 – It makes no difference who performs the manipulation, or how, or why

In 30+ years of spinal manipulation research, no group of therapists has proven more effective than another. They’ve tried chiros, physios, bonesetters, you name it. It also makes no difference if the specific technique is chosen by the therapist based on an examination or by a researcher based on nothing.

#6 – Out of all the comparison groups, only one intervention stands out

You guessed it. Exercise. Something which actually has a demonstrable long-term effect on how the body functions is the only intervention that works better than sham therapies, including manipulations. It may not matter much which type of exercise or training system is chosen, but it’s important to get the patient moving. This is in-line with most clinical guidelines for treatment of back pain (1), so it’s hardly surprising.

Discussion

Strength:

While being far from conclusive for all patients, under all circumstances at all times the Menke article has many strengths to it. The biggest in my mind is that it answers one very important clinical question that is worth emphasizing:

If a person with low back pain decides on his/her own to see a therapist that does spinal manipulations, the results will be in line with Menke’s review.

Recent research in spinal manipulative therapy has come up with clinical prediction guidelines to predict which patients respond most favorably to spinal manipulations (1). Applying these guidelines must be done clinically, preferably by the first contact doctor or physio. If the person sees a spinal manipulative therapist first, the benefit will be non-existent.

Limitation:

It would not be fair of me to only discuss the strengths of the review without any of the limitations. The review does not discriminate between patient groups. It’s possible that future studies will identify means to effectively apply spinal manipulations, perhaps due to clinical prediction rules or sophisticated use of emerging technology such as ultrasound imaging. However, the key point remains that currently the lack of long-term effectiveness of spinal manipulative therapies are largely known for the broad strokes of clinical populations.

Getting Fired – Legality and Social Media Policies

One question posted in the aftermath of blogging about getting fired for blogging (so meta!) was from Naomi McVey:

„can I ask if/how employment law & social media guidance/polices differ in Iceland?“

I understand the question as asking if there is a difference between what is allowed according to employment laws, and what is allowed according to social media policies. That is, is it legal according to employment laws to fire someone for social media conduct, or violating the social media policy?

I’m no expert on employment laws or social media policies. When thinking about this, I googled around for some examples of policies to look at and found the Mayo Clinic social media policies. Reading over those, I don’t think I would have violated them had identical policies been in place. The blog post contained no personally identifiable information, was factual, and did not confront or attack any person. I even had a disclaimer on my website declaring the content my personal opinion and not that of my employer.

But, there was no social media policy in place. I don’t know what kind of social media policy would allow my other posts, but not that one. I think what it comes down to, is not where or how, but what I said. The subject was taboo to blog about, obviously. Should clinics make a list of taboo subjects its employees are allowed to discuss openly or publicly? Such policies sound more medieval than modern.

Then it comes to employment laws. I know even less about employment laws then I do social media policies (thanks google). I do think that the reason I was fired was allowed for in the contract I signed. However, the resignation notice (two weeks) is illegal (3 months minimum for employment, 6 months for renting of business housing – unsure which one should apply in this case).

I’m not planning to file any charges (but I do reserve the right to). Getting the decision to fire me overthrown would have made no difference, since they would just find another reason.

Personally, I don’t care that much about the legality, practicality, or fairness of the decision to fire me. I do care about the implications – about how dinosaur physiotherapists remain unreasonable and actively do not allow for open discussions of evidence, because it’s financially unfavorable to them. I also do think it’s an important topic for the physiotherapy community to discuss, and this is why I shared it.

 

The Consequences of Blogging About Getting Fired

I’ve had numerous questions and comments on Twitter and my blog about the topic of getting fired. I’ve decided to do a series of mini-posts to answer some of them more fully than Twitter-length.

The first one I’ll address was posted by @physiowizz on Twitter. His comment/s was along the lines of my post being the wrong tone, and the whole shebang hurting my job prospects.

I think one assumption that led to this comment must have been that the post was written hastily and emotionally, which is not true. It was six months from getting fired until I posted the article, and in that time emotions had cooled enough so I could make rational decisions about both the content, direction, and purpose of the post. I also contemplated the consequences of posting it. Certainly the worst case scenario was that my work opportunities were ruined, and I’d find myself something else to do or somewhere else to do it. I accepted this possibility.

I’m passionate about physiotherapy, but I’m often disappointed with the current state of the profession. I’d rather try and change things, even if it involves risks, than blend in with the crowd.

The best-case scenario is pretty much what has happened so far. My post has sparked discussions and the internet reaction has been largely positive and supportive.

PhysioWizz also mentioned that future employers look for professionalism in unfair situations. I think the fairness or unfairness of the situation is irrelevant. My personal situation was hardly the point, but rather highlighting the fact that professional disagreement can get you fired in the current climate of physical therapy. It’s one thing to deny the evidence, and brush it off with weak arguments. However, actually firing someone for discussing a topic is something else.

Finally, numerous people wished me the best in finding new opportunities. Personally, things turned out for the better as I was hired at another clinic a few weeks after getting laid off. I told the management about the blog and being fired, and it did not put them off. If anything, it improved my standing. (And no, I didn’t get fired again).

The blog post that got me fired

If posted under different circumstances, the title of this post would be: „Spinal manipulation – is it a precise science?“. Within a day of posting this, I was given two weeks notice. I’ve done my best to keep the tone and presentation as close to the Icelandic version as I can, even if the English suffers a bit. I’m not dressing this up any fancier, just because of the circumstances under which I post.

When I originally wrote this, I was very much political about it. I made a special effort to identify areas where manipulations may be useful, and make a point of not directly recommending that patients don’t receive them. The main purpose was to first point out some limitations to the methodology behind them in this article and follow through with the mechanisms of action, and ultimately their effectiveness as an only therapy in future articles.

I’ve made comments [in brackets] that are intended as a supplement or explanation to the english reader, and those were not included in the original article.

So without further ado:

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Spinal manipulation – is it a precise science?

A memorable story I once heard involved a practitioner of some sort performing some sort of motion palpation when his wrist cracked. This prompted his client to say „ahhh… just what I needed!“. I don’t know if this story is true or not, but spinal manipulations are certainly very sought after treatments in Iceland – and unfortunately many confuse popularity for effectiveness.

Professionally I’ve met many individuals who have had a poor experience with spinal manipulations, be it from chiropractors, physios, bonesetters, or osteopaths. Many of them have booked countless treatment sessions and spent considerable money without getting any real improvements. Some are unsure if the treatment has been effective or not, others are certain that it was useful.

Still, the fact of the matter is, there are many myths around about the techniques associated with spinal manipulations. I’m going to take a look at some of the research that’s been done on spinal manipulation methods: how precise they are, if they can alter the position of joints in the spine, and if choosing the right manipulation technique is important.

Spinal manipulations aren’t precise

Many believe it’s possible to influence to a large degree which spinal joints to manipulate, for example to manipulate adjacent segments to a disc herniation. Studies have been performed to test this theory using sensitive vibration sensors placed on various segments to locate the source of the „pop“ sound. The results of these suggest that for the lumbar spine, only about half the manipulations hit the targeted joint, despite most of them manipulating more than 1 segment (1). If the target may be defined as either the upper or lower lumbar spine, accuracy improves up to 70% (2), and one is pretty certain to hit the correct half (left or right) most of the time. So, if one wishes to *not* manipulate a certain segment, the safest would be to at least have a 3 segment safety margin.

Spinal manipulations don’t alter joint position

Sometimes x-rays are used to support decision making for spinal manipulations where the therapist is looking for a misaligned segment to correct with a manipulation. It actually kind of amuses me that it’s no problem to take a diagnostic x-ray, but the second x-ray to verify the changed alignment is usually too much radiation…

Thankfully, not everyone has a problem with that second x-ray to confirm that at least sacroiliac joint manipulations don’t change sacroiliac joint alignments (3). The study used manual positional testing / motion palpation that diagnosed abnormal position of the joint before manipulation, and a correct alignment after the manipulation – but with no change in the actual position of the joints on x-rays. It remains an open question [this line included a link to another blog post I wrote about motion palpation, not translated at this time] what these motion palpation tests are actually testing.

I’m not aware of compatible studies on lumbar joint positions. The closest I could find was this study that used MRI’s to assess the height of the facet joint space before and after manipulations. The MRI was taken immediately after the manipulation, before the patient could get up from the therapy bench – so the significance of the change they found is uncertain. (4)

The giant’s bite [directly translated for amusement], when there’s a sudden onset of back pain with a restricted range of motion is very painful and can be quite scary. No one has yet confirmed the mechanism behind such sudden range of motion loss, although numerous theories exist. Further, there are no studies directly on the effects of manipulations of joints in this state or if they reverse whatever is causing the loss of range of motion. I don’t see any obstacles to trying out manipulations on this patient group.

You don’t need a detailed examination to select the proper manipulation technique

A meta analysis (5) examined if there was a difference in outcomes between studies where the practitioner can select the manipulation technique used, or when the technique is chosen beforehand by the researchers and found there was no difference at all. The results suggest that the method chosen, or the methods used to select the proper technique probably matter very little if at all. A study on cervical spines did not find a correlation between cervical range of motion as measured, and as palpated to be hypomobile by a therapist (6) [the link #6 in the Icelandic version links to a different article by mistake, I’m here linking the correct one] – so using such techniques to select joints to manipulate is likely meaningless anyway. I’ve previously discussed [link to Icelandic blog post] if motion palpation can be useful, and the short answer is no – long answer in link.

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These three myths are a source of a number of theories about trying to find the right technique for the right person. There is no data to back any of that up, only hundreds of years of tradition and guesswork. Only recently has it been possible to adequately study these methods with sensitive measures like imaging, but the results so far all point in the same direction: if you are going to manipulate a spine, just go ahead and manipulate a spine. No real need for a complex examination scheme beforehand.

A second installment of this article series will discuss the effects of spinal manipulations on the body, and if there’s a reason to use those effects as part of treatments. A third article will discuss the long-term clinical effectiveness of spinal manipulations on low back pain. [I include this last paragraph about planned future articles only for completeness, the second one is already published and the third one nearly complete, but they are in Icelandic]

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So that was it. I’m sure (or perhaps I hope?) that readers will find this less inflammatory than they had anticipated (or hoped?). It certainly could have been more direct in it’s message, and I think it would have made a better article that way as well since the parts about possible benefits of manipulations stray away from the direct topic at hand. But while I wrote this, I was very much mindful of those reading it.

How blogging about physiotherapy research can get you fired

Recently, a blog post I wrote about limitations of spinal manipulation got me fired!

Somehow that doesn’t surprise me, maybe that’s just what happens when you rattle some dinosaur cages. A dinosaur in physiotherapy is someone who is stuck in the past, and refuses to update his/her views with new evidence unless it feeds their confirmation bias (1). It’s obviously not a technical term, but a valid description that I am by no means the first one to blog about (2). It’s also not a blanket description of everyone that graduated before me. It’s not the age that defines the dinosaur, but rather the attitude. There’s plenty of physios with many years of experience that still remain open to new ideas and evolve their practice to reflect these ideas.

Dinosaurs and their followers are very prevalent today, even among the young folk who work with and are influenced by the older ones. It’s only in recent years that evidence based physiotherapy is flourishing, facilitated by the explosion of research (3) coupled with social media that allows the open discussion, criticism, and dissemination of information by physiotherapists (4).

And, naturally, the dinosaurs are pissed. Not only has almost every therapy they have been providing failed the test, but the whole paradigm of why these treatments should work has failed. Dinosaurs are too deeply committed to these outdated ways of thinking to objectively evaluate the science, too married to old ideas to divorce them. To them, decades of consistent research can be brushed off with “you can feel it working”, or “It’s been working for years!”, or even the abysmally short-sighted “I have a waiting list so I must be doing something right”. They are in an endless loop of using temporary analgesic effects to justify unnecessary or even harmful treatments, confusing immediate patient satisfaction with good clinical outcomes and consciously forcing patients in dependency instead of promoting self-efficacy.

So when I challenged the dinosaur viewpoint by pointing out that there are important limitations to spinal manipulation, I got fired.

Icelandic physiotherapy is undergoing a silent crisis, and in my opinion dinosaurs are causing it. The average out-patient physio in Iceland sees ~5,5 patients per day (5), which is less than a full time job. Some of the more popular ones see 18+ patients per day, which means that at the lower end are physios who hardly see any patients at all.

Seeing 18 individual patients per day can’t be considered ethical practice. That means working 9 hours straight, without a break, every day. Making decisions and staying focused becomes difficult (6). It gets more and more tempting to just do the easiest thing, and that often includes providing passive analgesic therapies. Using active treatments and engaging the patients in a therapeutic union takes presence of mind and concentration. I would sure not like being patient number 18.

Discussing treatment options and prognoses – real prognoses, not a unicorn story – may end up with a patient deciding not to attempt an intervention. And that’s ok, people have a right to accept or decline any medical treatment plan. It is our job as physiotherapists to provide patients with the best possible information regarding their condition and work with them to tailor a treatment plan. This may include various therapies if indicated and the patient chooses to use them after discussing it with the physio. But sometimes, this includes one of the hardest decisions a physio makes: recommending no intervention at all.

Other times this may include something unpopular, such as recommending that a patient skips a competition or a planned trip. In that situation, it’s our job to provide the patient with information regarding possible risks associated with participation, but the patient usually makes the final decisions, after all it’s their risk. If the therapist is greed-driven, working from a business model of more sessions per patient = better, these are surely worthless strategies. In that case, it’s much better to tell the patient „we’ll do everything in our power to make that trip!“ and proceed to throw every therapy under the sun at the patient and hope for the best.

Dinosaurs have indeed become good at milking as many treatment sessions as possible out of every single patient that walks through their door. They take their money by spending countless sessions fixing imaginary blocked sacroiliac joints, softening up tight muscles, and telling stories about remarkable single-session quick fixes.

The same udder-squeezing skill-set results in increasing numbers of patients who realize they spent considerable time and money for little benefit. This in turn creates people who are skeptical about physiotherapy, and will just stop booking sessions. It’s a vicious cycle of over-treating causing decreasing numbers of sessions, resulting in increased over-treating.

Evidence based physiotherapy is – compared to the bloated dinosaur therapy – streamlined, resource-efficient and requires much fewer treatment sessions on average. It’s a scalpel next to a chainsaw. It’s a breath of fresh air next to a garbage dump. Even the popular dinosaurs can smell the change coming, and they are stressed enough over it to fire people like me for making the patient better informed.

Even patients that receive a fake therapy, literally a machine that is turned off, will still improve with treatments (7). This means that every physio will get apparently decent outcomes by simply being equal to the passage of time and a machined turned off. The goal is to provide the patient with information about their condition and the efficacy of possible treatments. Every intervention attempted should have a good chance of performing better than time, and to that end it’s so important to use the research evidence to weed out the useless therapies and set reasonable treatment goals. If no treatment is indicated – the patient will receive information regarding his condition, but no voodoo tricks.

The trend is to increasingly emphasize evidence-based physiotherapy in physiotherapy education. It’s also increasingly emphasized that the knowledge gap between science and the public should be bridged by communicating findings to the public. I got fired for just that, discussing information and evidence – evidence the dinosaurs obviously want to sweep under the rug so they can remain complacent and their clients blissfully ignorant. I believe more physios need to openly support evidence-based physiotherapy and speak up against these outdated methods and together we just might be the meteor that saves physiotherapy.

Hnykkingar #2 – Skammtíma áhrif

Í fyrsta hluta þessarar seríu  fjallaði ég um hve lítið nákvæmar og stýranlegar hnykkingar eru, og að þær ólíklega hafi áhrif á hryggskekkjur eða stöðu hryggjarliða. Í þessum hluta fer ég yfir hvaða áhrif hnykkingar hafa á bakverki og líðan.

Algengt er að fólk telji að skekkjur á hrygg, smávægilegir snúningar stakra hryggjarliða, eða önnur smávægileg atriði hafi dramatísk áhrif á starfsemi líkamans. Ef áhrifin væri slík þyrfti ekki flóknar eða viðamiklar rannsóknir til að sjá það, hægt væri að einfaldlega mæla skekkjurnar og bera saman við starfsemi og verki og fá sterka fylgni. Í kjölfarið væri gerð framsýn rannsókn þar sem hópur fólks án verkja er mældur með reglulegu millibili, og borið saman hvenær verkir byrja og hvernig skekkjurnar í hryggnum eru þá.

Svo er ekki. Auðvelt er að sjá stór áhrif í rannsóknum, þó einungis lítill hluti þátttakenda þeirra sýni mikla jákvæða svörun við meðferðum. Að þessi spurning skuli enn vera opin eftir allar þessar rannsóknir bendir til að áhrifin, séu þau einhver, séu lítil og tímabundin.

Rannsóknir á lífeðlisfræði hnykkinga hafa varpað ljósi á virkni þeirra. Stærstu áhrif hnykkingar eru að lækka verkjaþröskuld, og ekki bara sértækt á hrygg heldur einnig í útlimum sem bendir til að um miðlæg áhrif sé að ræða en ekki staðbundin áhrif á hrygg. Væntingar viðskiptavinarins til hnykkingarinnar skipta hinsvegar meira máli. Áhrif væntinga til hnykkingar á verkjaupplifun heilbrigðra einstaklinga hefur verið skoðuð í rannsókn. Verkjaþröskuldur var metinn í útlim og í baki en rannsakendur höfðu áhrif á væntingar fólks til áhrifa á hrygginn. Þeir sem voru látnir eiga von á auknum verkjum fengu aukna verki en með jákvæða væntingu minnkaða verki – án væntinga minnkuðu verkir einnig (1).

Einhverjar vísbendingar eru til um að hnykkingar bæti lítillega hreyfigetu og sparkhraða í innanfótarsparki (2), en óljóst er hvort þau áhrif séu vegna, eða sambærileg við, upphitun frekar en bein áhrif hnykkinga.

Það eru því vísbendingar um að áhrif hnykkinga séu ekki ósvipaðar og af verkjalyfjum og upphitun. Þær geta vissulega verið varasamar (3) en ef engar frábendingar eru við notkun þeirra er ekkert til fyrirstöðu að beita þeim.

Lyftinganámskeið – Takmarkað pláss!

Fjögurra vikna námskeið í lyftingum byrja reglulega.  Auktu möguleika þína á árangri með aðstoð þjálfara (1). Auktu styrk, snerpu, liðleika og lærðu lyftingar hjá sjúkraþjálfara með meistaragráðu í íþróttasjúkraþjálfun og þjálfararéttindi í lyftingum frá evrópska lyftingasambandinu.

Æfingar eru 3x í viku, á mánudögum og miðvikudögum og föstudögum kl. 17–18:30 í topp æfingaaðstöðu Ármanns undir Laugardalslaug. Einungis 10 pláss í hvert námskeið tryggja að hver iðkandi hefur góðann aðgang að þjálfara, sem tryggir fyrsta flokks þjálfun.

Fyrir hvern er námskeiðið

Lyftingar byggja upp styrk, auka liðleika, og auka snerpu. Að læra lyftingar og að stunda styrkþjálfun er gagnlegt fyrir alla, hvort sem það er íþróttafólk sem vill auka árangur sinn eða venjulegt fólk sem vill stunda lyftingar sem hluta af heilbrigðum lífstíl. Allir þurfa að byrja á grunninum, læra að þekkja líkama sinn, og að beita honum rétt.

Hvað eru lyftingar

Lyftingar sem íþróttagrein felst í tveimur greinum, snörun (e. snatch) og jafnhendingu (e. clean & jerk). Aðrar styrktaræfingar eins og t.d. hnébeygjur og pressur eru mikilvægur hluti af lyftingaþjálfun.

Lyftingar henta öllum! Ef þér finnst ekki spennandi að hangsa á hlaupabretti og glápa á sjónvarpið, þá gætu lyftingar kannski verið eitthvað fyrir þig!

Hvað færð þú út úr þessu námskeiði

• Einstaklingsmiðaða lyftingakennslu frá vel menntuðum þjálfara
• Tekið tillit til veikleika og styrkleika hvers og eins
• Lærðu á þínum hraða! Þú þarft ekki að fylgja næsta manni, hver og einn lærir á sínum hraða
• Fámennir hópar tryggja að þjálfari nær að sinna öllum iðkendum
• Aðgangur að sundlaugum Reykjavíkur fram að sumri!
• Aðgangur að æfingaaðstöðu út önnina!

Margt sem þú lærir á námskeiðinu er tengt því hvernig þú hreyfir líkamann þinn og hvaða sérþarfir hann hefur í þjálfun og gagnast því út lífið!

Þjálfarar

Haraldur B. Sigurðsson er menntaður sjúkraþjálfari með MSc (meistaragráðu) í íþróttasjúkraþjálfun og þjálfararéttindi frá Evrópska Lyftingasambandinu. Hann hefur stundað lyftingar í fjöldamörg ár og kennt byrjendum réttu tökin samhliða því. Haraldur hefur sterkan grunn í einstaklingsmiðaðri þjálfun, þekkingu á greiningu hreyfinga, og reynslu í að finna og leiðrétta veikleika í hreyfikerfinu. Allt þetta skiptir gríðarlega miklu máli þegar kemur að þjálfun byrjenda í lyftingum.

Sigmundur Davíðsson er með þjálfararéttindi frá Evrópska Lyftingasambandinu og alþjóða dómararéttindi. Hann hefur dæmt á erlendum mótum ásamt mótum innanlands, setið í stjórn Lyftingasambands Íslands og  æft lyftingar lengi.

Verð

Námskeiðið kostar einungis 20.000 kr fyrir fjögurra vikna námskeið með möguleika á að klára önnina með áframhaldandi aðstoð þjálfara fyrir 20.000 kr. Iðkendur hafa aðgang að lyftingasalnum og sundlaugum Reykjavíkur án aukakostnaðar út þá önn sem námskeiðið er tekið. 

Takmarkað pláss er á námskeiðin – ekki bíða – hafðu samband strax á halli.physio@gmail.com

Hnykkingar – Eru hnykkingar nákvæmnisvinna?

Mér er minnistæð ein saga af fagaðila sem var að meta hreyfanleika hryggjarliða með þrýstingi þegar small í úlnlið fagaðilans. Við smellinn heyrðist í viðskiptavininum “ahhh…akkúrat það sem mig vantaði”. Hvort sem sagan er sönn eða ekki, þá eru hnykkingar gríðarlega vinsælt meðferðarform á Íslandi og því miður margir sem rugla saman vinsældum og gagnsemi.

Í mínu starfi hef ég hitt marga einstaklinga sem hafa misgóðar reynslur af hnykkmeðferðum, hvort sem það er frá kírópraktorum, sjúkraþjálfurum, eða hefðbundnum asískum meðferðaraðilum. Margir þeirra hafa farið ótalmörgum sinnum til hnykkjara og eytt í það gríðarmiklum peningum án þess að fá út úr því neinn bata. Sumir eru óvissir um hvort meðferðin hafi skilað sér, en aðrir eru fullvissir um að meðferðin hafi verið gagnleg.

Eðli málsins vegna eru fjölmargar mýtur til um hvað hægt sé að gera með hnykkingum. Ég ætla að fara hér yfir rannsóknir á eðli hnykkinga, hve nákvæmar þær eru, hvort þær geti breytt stöðu hryggjarliða, og hvort máli skipti að velja rétta hnykkingu.

Hnykkingar eru ekki nákvæmar

Margir telja að hægt sé að hafa mikil áhrif á staðsetningu hnykkingarinnar með ýmsum leiðum. T.d. eru dæmi um að hnykkja eigi “framhjá” brjósklosum með því að staðsetja meðferðina rétt. Ýmsar rannsóknir hafa verið gerðar sem meta að hve miklu leiti hægt er að stýra hnykkingum, má þar helst nefna rannsóknir þar sem víbringsnemar mæla hljóðið sem kemur af hnykkingunni og staðsetja með þeim hætti hvaðan það kemur. Niðurstöður slíkra rannsókna eru að í mjóbaki lenda eingöngu um helmingurinn af hnykkingunum á réttum hryggjarlið þrátt fyrir að flestar hnykkingar hnykki fleirum en einum hryggjarlið. Í brjóstbaki var betri nákvæmni og var rétt yfir helmingurinn á réttum stað (1). Ef skilgreina má þrjá hryggjarliði sem “skotmarkið”, batnar nákvæmni hnykkinga upp í um 70% (2), og nokkuð víst að hægt sé að stýra hnykkingunni amk á rétta líkamshlið (hægri / vinstri). Þrír hryggjarliðir eru þá eingöngu helmingurinn af mjóbakinu, svo það er hægt með um 70% vissu að vita hvort maður sé að hnykkja efra eða neðra mjóbaki, en eingöngu um 50% líkur vilji maður hnykkja ákveðnum hryggjarlið. Vilji maður *ekki* hnykkja ákveðnum hryggjarlið (t.d. vegna brjóskloss) er engin leið að vita hvort það takist öðruvísi en að hnykkja engum lið í a.m.k. 3 hryggjarliði í hvora átt.

Hnykkingar breyta ekki stöðu liða

Stundum eru röntgenmyndir notaðar til að stýra hnykkmeðferð. Er þá verið að leitast eftir “skekkjum” á stöðu hryggjarins til að leiðrétta með hnykkingu. Mér finnst alltaf sniðugt að meðferðaraðilar sjái ekkert að því að taka röntgen mynd til greiningar, en þegar kemur að því að taka aðra mynd og sjá breytingu eftir hnykkinguna er allt í einu röntgenmyndin orðin of mikil geislun….

En ekki allir  kippa sér upp við að taka tvær röntgen myndir til að sjá að spjaldliðshnykkingar breyta ekki stöðu spjaldliðs. Stöðupróf voru notuð og sýndu afbrigðilega stöðu fyrir meðferð en eðlilega stöðu eftir meðferð án þess að staða spjaldliðanna sé breytt. Það er því opin spurning hvað þessi stöðupróf séu raunverulega að meta (3).

Ekki eru til sambærilegar rannsóknir á breytingum á stöðu mjóhryggs. Það næsta sem kemst því er rannsókn sem notaði segulómskoðun (MRI) til að meta stærð liðbils smáliða í hrygg fyrir og eftir hnykkingu. Rannsóknin tók segulómmyndina strax eftir hnykkinguna, án þess að manneskjan væri einusinni búin að standa upp af bekknum áður, og því óljóst hvort sú breyting sem þeir fundu hefði einhverja þýðingu (4).

Þursabit, þar sem skyndilegt tak kemur í mjóbak og kemur í veg fyrir ákveðnar hreyfingar, er mjög sársaukafullt ástand. Engin skýring er fundin á því hver ástæðan fyrir skerðingu á hreyfigetu er í þursabiti þó einhverjar kenningar séu á lofti og þar af leiðandi eru heldur engar rannsóknir á því hvort hnykkingar breyti einhverju í stöðu hryggjarins undir kringumstæðunum. Það er því ekkert til fyrirstöðu að prufa hnykkingar gegn þursabitum.

Það þarf ekki að velja rétta hnykkingu með nákvæmri skoðun

Yfirlitsgrein (5) sem skoðaði muninn á þegar meðferðaraðilar velja hnykkingu eða þegar hnykking er valin fyrirfram af rannsakanda fann engann mun á milli meðferða. Niðurstaðan bendir til að aðferð hnykkingarinnar skipti ekki máli. Hálsrannsókn fann ekki samræmi milli mældrar hreyfigetu milli hálsliða og hvaða hálsliða meðferðaraðila þótti stífur, svo að skoðun sem byggir á að finna slíkann mun er trúlega ekki áreiðanleg hvort eð er (6). Ég hef áður fjallað um hvort hægt sé að þreifa mis-stífa hryggjarliði út með höndunum eða öðrum aðferðum, stutta svarið er nei en langa svarið er hér. Ljóst er að slíkar aðferðir geta ólíklega stýrt vali á hnykkingarmeðferð.

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Þessar þrjár ranghugmyndir eru uppspretta slatta af kenningum í hnykklækningum sem miða að því að finna réttu hnykkinguna fyrir réttu manneskjuna. Það er þó ekkert sem styður við þetta annað en árhundruðir af hefðum og pælingum. Einungis nýlega hefur verið mögulegt að rannsaka þessar aðferðir með fullnægjandi hætti, en allar niðurstöður benda til hins sama: ætli maður sér að hnykkja þá getur maður bara hnykkt án þess að til þess komi skoðun eða greining.

Í næstu grein ætla ég að skoða áhrif hnykkinga á starfsemi líkamans, og hvort ástæða sé til að nota þær við meðferð. Í þriðja hluta mun ég fjalla um rannsóknir á áhrifum hnykkinga á bakverki.