Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series

Study design

A case series of consecutive patients with chronic low back pain.

Background and purpose

In patients with chronic low back pain (CLBP), the importance of impairments at the hip joints is unclear. However, it has been postulated that impairments at the hip joints may contribute to CLBP. The purpose of this case series was to investigate the short-term outcomes in patients with CLBP managed with impairment-based manual therapy and exercise directed at the hip joints.

Methods

Eight consecutive patients (mean age: 43·9 years) with a primary report of CLBP (>6 months) without radiculopathy were treated with a standardized approach of manual physical therapy and exercise directed at bilateral hip impairments for a total of three sessions over approximately 1 week. At initial examination, all patients completed a numeric rating pain scale (NPRS), Oswestry disability index (ODI), fear-avoidance beliefs questionnaire (FABQ), and patient-specific functional scale (PSFS). At the second and third treatment sessions, each patient completed all outcome measures as well as the Global Rating of Change (GROC).

Results

Five of the eight (62·5%) patients reported ‘moderately better’ or higher (>+4) on the GROC at the third session, indicating a moderate improvement in self-reported symptoms. These five individuals also experienced a 24·4% reduction in ODI scores.

Discussion

This case series suggests that an impairment-based approach directed at the hip joints may lead to improvements in pain, function, and disability in patients with CLBP. A neurophysiologic mechanism may be a plausible explanation regarding the clinical outcomes of this study. A larger, well-controlled trial is needed to determine the potential effectiveness of this approach with patients with CLBP.     

Applying justice and commitment constructs to patient�Chealth care provider relationships

Objective

To examine patients’ experiences of fairness and commitment in the health care context with an emphasis on primary care providers.

Design

Qualitative, semistructured, individual interviews were used to gather evidence for the justice and commitment frameworks across a variety of settings with an emphasis on primary care relationships.

Setting

Rural, urban, and semiurban communities in Nova Scotia.

Participants

Patients (ages ranged from 19 to 80 years) with varying health care needs and views on their health care providers.

Methods

Participants were recruited through a variety of means, including posters in practice settings and communication with administrative staff in clinics. Individual interviews were conducted and were audiotaped and transcribed verbatim. A modified grounded theory approach was used to interpret the data.

Main findings

Current conceptualizations of justice (distributive, procedural, interpersonal, informational) and commitment (affective, normative, continuance) capture important elements of patient–health care provider interactions and relationships.

Conclusion

Justice and commitment frameworks developed in other contexts encompass important dimensions of the patient–health care provider relationship with some exceptions. For example, commonly understood subcomponents of justice (eg, procedural consistency) might require modification to apply fully to patient–health care provider relationships. Moreover, the results suggest that factors outside the patient–health care provider dyad (eg, familial connections) might also influence the patient’s commitment to his or her health care provider.     

Prenatal genetic counseling in cross-cultural medicine: A framework for family physicians

OBJECTIVE

To help family physicians practise effective genetic counseling and offer practical strategies for cross-cultural communication in the context of prenatal genetic counseling.

SOURCES OF INFORMATION

PubMed and the Cochrane Database of Systematic Reviews were searched. Most evidence was level II and some was level III.

MAIN MESSAGE

The values and beliefs of practitioners, no less than those of patients, are shaped by culture. In promoting a patient’s best interest, the assumptions of both the patient and the provider must be held up for examination and discussed in the attempt to arrive at a consensus. Through the explicit discussion and formation of trust, the health professionals, patients, and family members who are involved can develop a shared understanding of appropriate therapeutic goals and methods.

CONCLUSION

Reflecting on the cultural nature of biomedicine’s ideas about risk, disability, and normality helps us to realize that there are many valid interpretations of what is in a patient’s best interest. Self-reflection helps to ensure that respectful communication with the specific family and patient is the basis for health care decisions. Overall, this helps to improve the quality of care.     

The ability of a sustained within-session finding of pain reduction during traction to dictate improved outcomes from a manual therapy approach on patients with osteoarthritis of the hip

Objectives

The objectives of this study were to: (1) determine the association of a within-session finding after traction of the hip with self-report of well-being, pain, and self-report of function at 9 weeks; and (2) to determine if the interactions between the within-session finding and the outcome measure are different between groups of patients with hip OA who receive and who do not receive manual therapy.

Methods

Data were retrospectively analysed in 70 subjects who were part of a randomized control trial. Correlation analyses of within-session findings from the initial visit after traction of a concordantly painful hip were compared to self-report measures for function, pain, and well-being at 9 weeks. A comparison of slope coefficients between manual therapy and non-manual therapy groups was performed to determine the interactive aspects of the within-session finding.

Results

Although the correlations for the manual therapy group were higher than for the supervised neglect group, none of the correlational analyses for both groups was strong or significant. Significant differences in the slope coefficients for well-being and pain were found, suggesting that the interactions between the within-session findings and the targeted outcomes were different in the manual therapy group versus supervised neglect group.

Discussion

These findings suggest that within-session findings during the initial evaluation are not strongly related to a positive outcome after manual therapy, although the interaction of the finding of a within-session change and the use of manual therapy is more compelling than the finding in a sample of patients who did not receive manual therapy.     

Diagnoses of anxiety and depression in clinical-scenario patients: Survey of Saskatchewan family physicians

Objective

To investigate family physicians’ differential diagnoses of clinical-scenario patients presenting with symptoms of either generalized anxiety disorder (GAD) or a major depressive episode (MDE).

Design

Cross-sectional survey.

Setting

Saskatchewan.

Participants

A total of 331 family physicians practising in Saskatchewan as of December 2007.

Main outcome measures

Type and number of physicians’ differential diagnoses for a GAD-scenario patient and an MDE-scenario patient.

Results

The survey response rate was 49.7% (331 of 666 surveys returned). Most physicians suggested a diagnosis of anxiety (82.5%) for the GAD-scenario patient and a diagnosis of depression (84.2%) for the MDE-scenario patient. In descending order, the 5 most frequent differential diagnoses for the GAD-scenario patient were anxiety, hyperthyroidism, depression, panic disorder or attack, and bipolar disorder. The 5 most frequent differential diagnoses for the MDE-scenario patient were depression, anxiety, hypothyroidism, irritable bowel syndrome, and anemia. Neither a diagnosis of anxiety nor a diagnosis of depression was associated with physicians’ personal attributes (sex, age, and years in practice) or organizational setting (number of total patient visits per week, private office or clinic, solo practice, Internet access, and rural practice setting). However, physicians in solo practice suggested fewer differential diagnoses for the GAD-scenario patient than those in group practice; physicians in practice 30 years or longer suggested fewer differential diagnoses for the MDE-scenario patient than those in practice fewer than 10 years. On average, physicians suggested 3 differential diagnoses for each of the scenarios.

Conclusion

Most family physicians recognize depression and anxiety in patients presenting with symptoms of these disorders and consider an average of 3 differential diagnoses in each of these cases.     

Are patients with hyperlipidemia undertreated?: Study of patients admitted to hospital with coronary events

OBJECTIVE

To identify patients admitted to hospital with coronary events and to estimate their pre-admission coronary risk, including their lipid levels. Despite the available data and numerous guidelines, evidence indicates that many patients with hyperlipidemia are undertreated and are not achieving target lipid levels.

DESIGN

Retrospective chart review.

SETTING

Acute care community hospital in Winnipeg, Man.

PARTICIPANTS

A total of 153 patients who were diagnosed with acute myocardial infarction, unstable angina, or acute coronary syndrome upon admission.

METHOD

Each patient’s 10-year risk of developing coronary artery disease was calculated, and his or her risk status was established. Each patient’s low-density lipoprotein cholesterol (LDL-C) levels were recorded and categorized based on current Canadian guidelines.

RESULTS

Mean age of patients was 67.6 years; 60.8% were male. Patients in the low-risk category had a mean LDL-C level of 2.98 mmol/L (95% confidence interval [CI] 2.66 to 3.29), and patients in the moderate-risk category had a mean LDL-C level of 3.01 mmol/L (95% CI 2.74 to 3.28), both significantly lower (P < .05) than the LDL-C target levels for patients in those risk categories according to Canadian guidelines. The mean LDL-C level for patients in the very high-risk category, however, was 2.53 mmol/L (95% CI 2.35 to 2.71), above the recommended goal. Almost half the patients (48.3%) in thevery high-risk category had LDL-C levels that exceeded the goal. Slightly more than 1 in 3 patients in the very high-risk category was reported to be taking lipid-lowering agents.

CONCLUSION

Patients in the community who are at very high risk of havingcardiovascular events are undertreated with respect to attaining LDL-C target levels. These findings point to an opportunity to prevent patient morbidity and reduce the number of hospitalizations for cardiovascular events.     

Hip fracture prevention strategies in long-term care: a survey of Canadian physicians' opinions

OBJECTIVE

To garner Canadian physicians’ opinions on strategies to reduce hip fractures in long-term care (LTC) facilities, focusing on secondary prevention.

DESIGN

A cross-sectional survey using a mailed, self-administered, written questionnaire.

SETTING

Canada.

PARTICIPANTS

Family physician members of the Ontario Long-Term Care Association (n = 165) and all actively practising geriatricians registered in the Canadian Medical Directory (n = 81).

MAIN OUTCOME MEASURES

The strength of recommendations for fracture-reduction strategies in LTC and barriers to implementing these strategies.

RESULTS

Of the 246 physicians sent the questionnaire, 25 declined study materials and were excluded. Of the 221 remaining, 120 responded for a response rate of 54%. About two-thirds of respondents were family physicians (78 of 120) and the rest were mostly geriatricians. Most respondents strongly recommended the following secondary prevention strategies for use in LTC after hip fracture: calcium, vitamin D, oral aminobisphosphonates, physical therapy, and environmental modification (such as handrails). Most respondents either did not recommend or recommended limited use of etidronate, intravenous bisphosphonates, calcitonin, raloxifene, testosterone (for hypogonadal men), and teriparatide. Postmenopausal hormone therapy was discouraged or not recommended by most respondents. Support was mixed for the use of hip protectors, B vitamins, and folate. Barriers to implementation identified by most respondents included a lack of strong evidence of hip fracture reduction (for B vitamins and folate, cyclic etidronate, and testosterone), side effects (for postmenopausal hormone therapy), poor compliance (for hip protectors), and expense (for intravenous bisphosphonates and teriparatide). Some respondents cited side effects or poor compliance as barriers to using calcium and potent oral bisphosphonates.

CONCLUSION

Canadian physicians favour the use of calcium, vitamin D, potent oral bisphosphonates, physical therapy, and evironmental modifications for LTC residents after hip fracture. Further study at the clinical and administrative levels is required to find ways to overcome the specific barriers to implementation and effectiveness of these interventions.     

Combined bilateral asymmetric hip dislocation and anterior shoulder dislocation

BACKGROUND:

Traumatic bilateral hip dislocation is a rare condition. Anterior shoulder dislocation combined with this condition is even a rare occurrence. A 57-year-old man had bilateral asymmetric hip dislocation with a posterior wall fracture of the left acetabulum associated with right shoulder anterior dislocation caused by falling down from a cherry tree. Traumatic hip dislocation and anterior shoulder dislocation represent a true orthopedic emergency.

METHODS:

Closed reduction was performed immediately for three of the dislocated joints. Posterior wall fracture of the left acetabulum was treated with open reduction and internal fixation by screws. Because of the severity of associated complications like aseptic necrosis or posttraumatic osteoarthritis, efforts were made to ensure prompt diagnosis, therapy and prognosis.

RESULTS:

The patient was successfully treated by open reduction and internal fixation of the left acetabulum, and discharged from the hospital.

CONCLUSION:

Traumatic asymmetric hip dislocation and anterior shoulder dislocation are an orthopedic emergency and early diagnosis with immediate reduction of the dislocation is the key determinants of excellent result of treatment.KEY WORDS: Trauma, Asymmetric hip dislocation, Shoulder dislocation, Immediate therapy     

Nucleus pulposus deformation following application of mechanical diagnosis and therapy: a single case report with magnetic resonance imaging

Background

The McKenzie management strategy of mechanical diagnosis and therapy (MDT) is commonly used for the assessment and management of spinal problems. Within this system, ‘derangement syndrome’ is the most common classification, for which the conceptual model is an intra-discal displacement. However, the reduction of an intra-discal displacement by MDT has never been documented. The purpose of this study was to compare, using magnetic resonance imaging (MRI), the nucleus pulposus (NP) profiles before and after the use of this approach.

Patient characteristics

The patient was a 34-year-old female with a long history of right sided low back and buttock pain classified with ‘derangement syndrome’.

Examination

T2-weighted images of the L4–5 disc at initial assessment were compared with that at final assessment 1 month later. Initially, the MRI showed a portion of the NP displaced right and posteriorly towards the side of pain, and an overall NP position in the coronal plane shifted to the left.

Intervention

The patient was managed with a 1-month course of the McKenzie management strategy treatment.

Outcomes

One month later, the displaced portion of the NP was no longer present and the left-shifted NP was centrally located.

Discussion

These intervertebral disc changes coincided with centralization and abolition of symptoms. This case may support the conceptual model of MDT.     

Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management

Background

Proper management of thoracic outlet syndrome (TOS) requires an understanding of the underlying causes of the disorder. A comprehensive examination process, as described in Part 1 of this review, can reveal the bony and soft tissue abnormalities and mechanical dysfunctions contributing to an individual’s TOS symptoms.

Objective

Part 2 of this review focuses on management of TOS.

Conclusion

The clinician uses clinical examination results to design a rehabilitation program that focuses on correcting specific problems that were previously identified. Disputed neurogenic TOS is best managed with a trial of conservative therapy before surgical treatment options are considered. Cases that are resistant to conservative treatment may require surgical intervention. True neurogenic TOS may require surgical intervention to relieve compression of the neural structures in the thoracic outlet. Surgical management is required for cases of vascular TOS because of the potentially serious complications that may arise from venous or arterial compromise. Post-operative rehabilitation is recommended after surgical decompression to address factors that could lead to a reoccurrence of the patient’s symptoms.     

REHABILITATION AFTER HIP ARTHROSCOPY AND LABRAL REPAIR IN A HIGH SCHOOL FOOTBALL ATHLETE

Study Design:

Case Report

Background:

Femoral acetabular impingement (FAI) has been implicated in the etiology of acetabular labral tears. The rehabilitation of younger athletes following arthroscopic surgery for FAI and labral tears is often complex and multifactorial. A paucity of evidence exists to describe the rehabilitation of younger athletes who have undergone arthroscopic hip surgery.

Case Presentation:

This case report describes a four-phase rehabilitation program for a high school football player who underwent hip arthroscopy with a labral repair and chondroplasty.

Outcomes:

The player returned to training for football 16 weeks later and at the 4 month follow-up was pain free with no signs of FAI.

Discussion:

There is little evidence regarding the rehabilitation of younger athletes who undergo arthroscopic hip surgery. This case study described a four phase rehabilitation program for a high school football player who underwent hip arthroscopy and labral repair. The patient achieved positive outcomes with a full return to athletic activity and football. The overall success of these patients depends on the appropriate surgical procedure and rehabilitation program.

Key Words:

Femoral acetabular impingement (FAI), hip, hip impingement

Level of evidence:

4-Case report     

Bilateral Masseter and Internal Pterygoid Muscle Hypertrophy: A Diagnostic Challenge

Objective

To describe an unusual case of bilateral masseter and pterygoid muscle hypertrophy.

Clinical Presentation and Intervention

A 53-year-old female patient presented with a bilateral, painless swelling at the parotid areas without improvement after using antibiotics/systemic corticosteroids/nonsteroidal anti-inflammatory agents. Her medical history included thyroid nodules, but no dental/occlusal disorders were observed. The initial differential diagnosis included salivary gland/jaw bone/masseter pathology, but the CT/MRI revealed only an increase in the size of the masseter and pterygoid muscles. The patient was informed of the benign nature of the swelling and was advised to discontinue the use of nonsteroidal anti-inflammatory agents.

Conclusion

The bilateral hypertrophy of masseter muscles should be considered in differential diagnosis in cases of unilateral or bilateral swelling of the parotid or lateral mandible area.Key Words: Masseter muscles hypertrophy, Bilateral facial swelling