12 junho, 2012

Early Imaging of Low Back Pain Unnecessary, Harmful

No Reino Unido, por ex, não existe o "hábito" de fazer exames de imagiologia ( rx, tac, rm) se não houverem fortes razões que o justifiquem. Por um lado, são exames potencialmente danosos para o paciente, por outro, o estado ( no caso do sector público) gasta muito dinheiro em fazer exames de diagnóstico e a informação adicional, que poderia direccionar ou ajudar na terapêutica escolhida, é muitas vezes, a maior parte, insuficiente ou sem dados novos. Por isso, fazem parte dos cuidados de saúde primários, os profissionais de Osteopatia, que são especialistas no aparelho músculo-esquelético e têm conhecimentos para fazer diagnósticos diferenciais. Se houverem sinais de alerta, o paciente é encaminhado para outro profissional de saúde ( regra geral o médico de especialidade ou de clínica geral) e pode-se optar por fazer exames de diagnóstico complementares. Lembrem-se: Fazer um rx ou tac, grande parte das vezes não muda em nada a estratégia do tratamento. Somos muito mais que imagens estáticas. Esses exames são essencialmente para diferenciar, afastar, patologias graves. Existem outros meios de diagnóstico primários, suficientes para o tratamento da maior parte das queixas neuro-músculo-esquléticas e que estão ao alcance, ou deveriam de estar, de qualquer cuidador de saúde ( primário), em particular os Osteopatas, que, como disse, são especialistas nesta matéria e somos bem mais eficazes que um rx e anti- inflamatório :).
Deixo-vos um artigo que corrobora a ineficácia de um exame imagiológico precoce nas lombalgias comuns.
'As part of its "Promoting Good Stewardship in Clinical Practice," the National Physicians Alliance recommended against imaging for low back pain within the first 6 weeks of onset unless red flags are present. Now, a new literature and financial analysis supports and explains that recommendation.
In one sense, the analysis by Shubha V. Srinivas, MD, MPH, from the Department of Medicine, University of Connecticut Health Center, Farmington, and colleagues covers well-traveled ground from the 30-year history of clinical guidelines indicating that most cases of lumbar back pain resolve themselves with minimal clinical intervention.
However, the findings of the analysis, published online June 4 in the Archives of Internal Medicine, as part of the "Less is More" series, also help maintain momentum for Choosing Wisely, a multi–medical society initiative designed to encourage physicians and their patients to make smart choices about the use of expensive medical technologies that do not deliver improved clinical outcomes in every situation.
The recommendation to avoid early imaging for low back pain was included in the National Physicians Alliance’s list of " 'Top 5' Health Care Activities for Which Less Is More" which was published in the August 8, 2011, issue of the Archives of Internal Medicine.
In the current literature review, Dr. Srinivas and colleagues report that imaging for lower back pain is extremely common. A 2011 study ( Spine J. 2011;11:622-632) indicated that 42% of patients with back pain undergo imaging (mainly plain radiography) within a year of the onset of pain. Of that total, 6 of 10 patients had imaging on the same day as their diagnosis. Eight of 10 underwent imaging within a month.
Dr. Srinivas and colleagues also note that another review concluded that lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes ( Lancet. 2009;373:463-472).
Furthermore, Dr. Srinivas and colleagues estimated that nearly $300 million could be saved annually by restricting imaging during the first 6 weeks of lumbar back pain to specific severe indications, including severe or progressive neurological deficits or when serious underlying conditions, such as osteomyelitis, are suspected.
They surmised that the only benefit of authorizing early low back imaging would be to cater to the patient's demands and emotional need for clinical action. With that issue at hand, they cited an article titled, "Getting to 'No': Strategies Primary Care Physicians Use to Deny Patient Requests" as an example of how to deny imaging to patients with lower back pain without inciting rebellion ( Arch Intern Med. 2010;170:381-388).
Daniel Wolfson, MHSA, executive vice president of the American Board of Internal Medicine Foundation, Philadelphia, Pennsylvania, picked up on this theme in an invited commentary.
"Srinivas et al recognize the problem of translating guidelines and comparative effectiveness research into practice, but they do not offer solutions," he wrote.
So, Wolfson has offered for consideration the efforts of the American Board of Internal Medicine Foundation, along with 9 medical specialist societies and Consumer Reports, to bring their lists of scientifically questionable medical practices to the attention of the general public.
Choosing Wisely features "Five Things Physicians and Patient Should Question," lists, which are geared to educating each society's physician members and their patients about the clinical appropriateness and costs of popular medical tests and therapies. The lists were announced simultaneously April 4.
"Choosing Wisely will test whether this type of campaign will spur translation of clinical recommendations into practice," Wolfson said.
Consistent with Dr. Srinivas's article, lists supported by the American Academy of Family Physicians and the American College of Physicians both advise against imaging of low back pain within the first 6 weeks unless red-flag conditions are suspected.
The authors and commentator have disclosed no relevant financial relationships.
Arch Intern Med. Published online June 4, 2012'

Retirado deMedscape Medical News, James Brice

09 junho, 2012

Barriers and MET: ‘feather-edge’ or stretched?

Palpating end-of-range barrier of the hip adductor muscles

The essence of Muscle Energy Technique (MET) is that it harnesses the energy of the patient (in the form of muscular effort) to achieve a therapeutic effect.  Goodridge (in Goodridge & Kuchera 1997) summarises the essential as follows: 
"Good results [with MET] depend on accurate diagnosis, appropriate levels of force, and sufficient localisation. Poor results are most often caused by inaccurate diagnosis, improperly localized forces, or forces that are too strong"
In order to achieve those requirements of accuracy and appropriate focusing of effort, the ideal barrier from which to commence the sequence needs to be identified.
Kappler &  Jones (2003) suggest that we consider joint restrictions from a soft tissue perspective. They suggest that, as the barrier is engaged, increasing amounts of force are necessary, as the degree of free movement decreases. They note that the word barrier may be misleading, if it is interpreted as a wall or rigid obstacle to be overcome with a push:
“As the joint reaches the barrier, restraints in the form of tight muscles and fascia, serve to inhibit further motion. We are pulling against restraints rather than pushing against some anatomic structure.”
If this is indeed the case, then methods such as MET - that address the soft tissue restraints – should help to achieve free joint motion. And it is at the moment that a‘ restraint’ to free movement is noted, that the barrier has actually been passed, also described as moving from ‘ease’ towards ‘bind’. The ‘feather-edge’ of resistance is a point that lies a fraction before that sense of ’bind’ or restriction is first noted, and it is suggested that it is from this point that any MET contraction effort should commence. (Stiles 2009)
Different barriers of resistance

An example
Stiles (2009) has described the following approach when preparing spinal articulation restrictions for MET application: 
In spinal regions, identify the segment(s) of greatest restriction by palpation, observation, motion evaluation etc. With the patient seated, use flexion or extension, together with side flexion, rotation and translation, to maintain the most dysfunctional segment, at the apex of the curve, at the restriction barrier (‘feather-edge’). Establish a counterforce, and instruct the direction for the patient to move towards, using minimal effort.
Stiles reports that a brief (3 to 5 seconds) firmly resisted patient effort, might involve – as examples - either lateral translation of the head/neck, or shoulder, or anterior or posterior translation of the abdomen or upper trunk. The contraction (resisted effort) usually needs to be maintained for a few seconds only, or (gently) for longer, before a brief – few seconds only- rest-period. After this relaxation moment, the new range/barrier in  previously restricted directions should be tested, with a new barrier engaged, and the process repeated, possibly using a different direction for the contraction effort. Stiles confirms his experience of what is a common clinical observation: 
Only a 30-40% improvement in mechanical function is required with MET because the corrective process will continue for several days.
Palpating for lumbar segmental restriction

Soft tissue tension determines the barrier
Parsons & Marcer (2005) note that active movement stops at the ‘physiological barrier.’ determined by the tension (‘bind’) in the soft tissues around the joint (e.g. muscles, ligaments, joint capsule), with normal ranges of movement of a joint (‘ease’) taking place within these physiological barriers. Factors such as exercise, stretching and age – as well as pathology or dysfunction - can modify the normal physiological range, however it is usually possible to passively ease a joint’s range beyond the physiological barrier, by stretching the supporting soft tissues until the anatomical limit of tension is reached.
Any movement beyond the anatomical barrier is likely to cause damage to the local soft tissues or joint surface. Joint restrictions, defined as ‘somatic dysfunction’ occur when normal ranges of movement are restricted, either due to compensatory, adaptive responses, to overuse for example, or to trauma.
Bolin (2010) describes identification of a barrier when using MET in a pediatric setting:
“[If when] evaluating the motion at the 3rd lumbar vertebra in neutral, flexion, and extension, a specific motion restriction can be identified for that particular structure (if dysfunction is present). If the evaluator finds the 3rd lumbar transverse process deeper on the right and more easily rotated on the left, the segment can further be tested in flexion and extension and a positional diagnosis (eg, LERSL) can be established.” 
The barrier would be engaged by having the patient: 
positioned seated, lumbar spine flexed to the Llevel, then rotated and side-bent to the right (See figure).The treatment is performed using a patient’s muscle energy (approximately 5 pounds [2 kilos] of force) to sit upright (extension, side bending, and rotation to left) from that position while an examiner resists. This force is held for 5 seconds, then the patient briefly relaxes; during the relaxation, the slack is taken up and a new barrier in FLEXION, right rotation, and right side bending is engaged. This process is typically performed 3 times.”
Note: No hint is given of forced engagement of the barrier.

Should restriction barriers always be ‘released’?
Clinically, it is worth considering whether restriction barriers ought to be released, in case they might be offering some protective benefit.
As an example, van Wingerden (1997) reported that both intrinsic and extrinsic support for the sacroiliac joint derive in part from hamstring (biceps femoris) status. Intrinsically, the influence is via the close anatomical and physiological relationship between biceps femoris and the sacrotuberous ligament. He states that: 
"Force from the biceps femoris muscle can lead to increased tension of the sacrotuberous ligament in various ways. Since increased tension of the sacrotuberous ligament diminishes the range of sacroiliac joint motion, the biceps femoris can play a role in stabilization of the sacroiliac joint" (Vleeming et al 1989).
Van Wingerden also notes that in low-back patients, forward flexion is often painful, as the load on the spine increases. This happens whether flexion occurs in the spine or via the hip joints (tilting of the pelvis). If the hamstrings are tight and short they effectively prevent pelvic tilting. ‘
"In this respect, an increase in hamstring tension might well be part of a defensive arthrokinematic reflex mechanism of the body to diminish spinal load."
If such a state of affairs is longstanding, the hamstrings will have shortened, influencing both the sacroiliac joint and the lumbar spine. The decision to treat tight (‘tethered’) hamstring should therefore take account of why it is tight, and consider that in some circumstances it might be offering beneficial support to the SIJ, or reducing low-back stress.

Contrary views regarding the appropriate barrier for MET commencement
The ‘feather-edge’ principle of barrier identification has been emphasized in the notes above. In some MET descriptions however a different approach is suggested.
Shoup (2006) describes MET - as used in treatment of hypertonic or shortened muscular structures – as follows:
The [practitioner] treats the hypertonic muscle by stretching the patient’s muscle to the restrictive barrier. Then the patient is asked to exert an isometric counterforce (contraction of a muscle against resistance while maintaining constant muscle length) away from the barrier, while the [practitioner] holds the patient in the stretched position. Immediately after the contraction, the neuromuscular unit is in a refractory or inhibited state, during which a passive stretch of the muscle may occur to a new restrictive barrier.
This model of MET usage mirrors that of van Buskirk (1990) who explains: 
In [patient] indirect ‘muscle energy’ the skeletal muscles in the shortened area are initially stretched to the maximum extent allowed by the somatic dysfunction. With the tissues held in this position the patient is instructed to contract the affected muscle voluntarily. This isometric activation of the muscle will stretch the internal connective tissues. Voluntary activation of the motor neurons to the same muscles also blocks transmission in spinal nociceptive pathways. Immediately following the isometric phase, passive extrinsic stretch is imposed, further lengthening the tissues towards the normal easy neutral position.”

More than two approaches
We have now seen descriptions of MET where the barrier commences from an easy ‘feather-edge’ position, as well as from a position in which the restraining soft tissues are actually stretched (a ‘bind’ barrier) at the start of the isometric contraction. This latter approach raises several clinical questions:

1.   If, as may be the case, the soft tissues held in a stretched position before being required to contract, are already hypertonic, and possibly ischemic, is there a risk that the contraction effort might provoke cramp? This would appear to be a possibility, or even a likelihood, in muscles such as the hamstrings. Would it not be a safer option to employ light contractions, starting with the muscle group at an easy end-of-range barrier, rather than at stretch?

2.   Would the requested contraction effort from the patient be more easily initiated and achieved, if the muscle (group) is in a mid-range or easy end-of-range position, rather than at an end-of-range involving stretch, at the start?

Both comfort and safety issues would appear to support the ‘ease’ barrier rather than a firmer ‘bind’ barrier – provided the outcomes were not compromised -  and clinical experience as well as numerous studies, offer support for the ‘ease’ option.
Both Janda (1990, 1993), and Lewit (1999) have described protocols for the use of MET that support the lighter-barrier approach. In the end each practitioner’s clinical experience will guide therapeutic decision making, supported by research evidence where this is available, or by the clinical experience of others. 
I have opted for the lighter-barrier option.

  • Bolin D 2010  The application of osteopathic treatments to pediatric sports injuries. Pediatric clinics of North America, 57 (3):775-794
  • Goodridge J, Kuchera W 1997 Muscle energy treatment techniques. In: Ward R (ed) Foundations of osteopathic medicine. Williams and Wilkins, Baltimore
  • Janda V 1990 Differential diagnosis of muscle tone in respect of inhibitory techniques. In: Paterson J K, Burn L (eds) Back pain, an international review. Kluwer, New York, pp 196–199
  • Kappler RE, Jones JM. 2003 Thrust (High-Velocity/Low-Amplitude) techniques. In Ward RC (Ed) Foundations for osteopathic medicine, 2/e. Philadelphia, Lippincott, Williams & Wilkins pp852-880
  • Lewit K 1999 Manipulation in Rehabilitation of the Locomotor System. 3rd edition. Butterworths, London
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  • Shoup D DO An Osteopathic Approach to Performing Arts MedicinePhys Med Rehabil Clin N Am 17 (2006) 853–864
  • Stiles E 2009 Muscle Energy Techniques IN: Franke H ED. The History of MET In: Muscle Energy Technique History-Model-Research . Verband der Osteopathen Deutschland, Wiesbaden
  • Van Buskirk R 1990 Nociceptive reflexes and the somatic dysfunction. Journal of the American Osteopathic Association 90(9): 792–809
  • van Wingerden J-P 1997 The role of the hamstrings in pelvic and spinal function. In: Vleeming A, Mooney V, Dorman T, Snijders C, Stoekart R (eds) Movement, stability and low back pain. Churchill Livingstone, New York
  • Vleeming A, Mooney A, Dorman T, Snijders C, Stoekart R 1989 Load application to the sacrotuberous ligament: influences on sacroiliac joint mechanics. Clinical Biomechanics 4: 204–209
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