Has the term "clinical reasoning" become a cliche? In the video below, NAIOMT founding member, Erl Pettman, discusses the role of clinical reasoning with Brett Windsor, and shares his advice for young PTs.
"Clinical reasoning is much like puzzles. The people who love puzzles as a child, they're going to be the clinical reasoners of tomorrow."
Clinical Fellowship Program,
low back pain,
What can we say? Low back pain is pervasive among our patients. And as PT's, it can be a tough nut to crack. Here are few insights gathered by our faculty of practicing clinicians over the years, that can help guide you in assessing and treating your patients who are struggling with it.
low back pain
What could be causing a patient's painful restriction in right extension quadrant? In the manual therapy video below, NAIOMT's Stacy Soappman explores how to determine whether a patient is experiencing a mobility issue or a stability issue.
low back pain,
This week we recommend taking a look at the following abstract:
Koppenhaver SL et al.
The association between dry needling-induced twitch response and change in pain and muscle function in patients with low back pain: a quasi-experimental study.
Objective: To investigate the relationship between dry needling-induced twitch response and change in pain, disability, nociceptive sensitivity,and lumbar multifidus muscle function, in patients with low back pain (LBP).
Design: Quasi-experimental study.Setting Department of Defense Academic Institution.
Participants: Sixty-six patients with mechanical LBP (38 men, 28 women, age: 41.3 [9.2] years).
Interventions: Dry needling treatment to the lumbar multifidus muscles between L3 and L5 bilaterally.
Main outcome measure:s Examination procedures included numeric pain rating, the Modified Oswestry Disability Index, pressure algometry,and real-time ultrasound imaging assessment of lumbar multifidus muscle function before and after dry needling treatment. Pain pressurethreshold (PPT) was used to measure nocioceptive sensitivity. The percent change in muscle thickness from rest to contraction was calculatedto represent muscle function. Participants were dichotomized and compared based on whether or not they experienced at least one twitchresponse on the most painful side and spinal level during dry needling.
Result:s Participants experiencing local twitch response during dry needling exhibited greater immediate improvement in lumbar multifidusmuscle function than participants who did not experience a twitch (thickness change with twitch: 12.4 %, thickness change without twitch:5.7 %, mean difference adjusted for baseline value, 95%CI: 4.4 [1 to 8]%). However, this difference was not present after 1-week, andthere were no between-groups differences in disability, pain intensity, or nociceptive sensitivity.
Conclusions: The twitch response during dry needling might be clinically relevant, but should not be considered necessary for successfultreatment.
To pop, or not to pop? That has long been a questions among clinicians who utilize spinal manipulation. Is the cavitation, or audible pop, necessary to achieve a "successful" manipluation? While some literature indicates that it may not be necessary, this remains a viable question.
In an almost synonymous fashion, achieving a local twitch response (LTR) has been viewed by some as one of the primary goals with dry needling as it has been associated with better treatment outcomes (1,2). The local twitch response has been shown to be associated with a decrease in nociceptive and inflammatory chemicals (1,3-6), increased blood flow (7), and decrease pain (8) to name a few. In some circles, the LTR considered as the hallmark of a successful dry needling treatment. Recently, the authors sought to investigate the association between the LTR and changes in pain and function in patients with lumbar pain.
Outcome measures included numeric pain rating, Modified Oswestry Disability Index, pressure algometry and real time ultrasound imaging (RUSI) of the lumbar multifidus function before and after dry needling treatment. Muscle function was defined as the percent change in multifidus muscle thickness from rest to contraction measured via (RUSI). The presence of a LTR during dry needling treatment was deemed to have occurred if at least one visible or palpable twitch was observed by the examiner or reported by the participant.
Following treatment, subjects were dichotomized into two groups: those experiencing a LTR and those
not experiencing a LTR on the most painful multifidus identified during baseline assessment. Data analysis revealed that those patients experiencing a LTR exhibited greater
immediateimprovement in lumbar multifidus muscle function than those patients that did not experience a LTR. This difference, although present immediately after treatment, was not present at a 1 week follow up assessment. Additionally there were no between-group differences in disability, pain intensity or nociceptive sensitivity as measured by pressure algometry.
The first investigation to look at the clinical importance of the LTR led authors to conclude that the LTR
may be clinically relevant, but should not be considered as the hallmark of a successful treatment. Regardless of your opinions on this topic, the outcomes of this investigation point to a bigger picture. Our manual techniques have temporal effects. In other words, if
all you are doing is dry needling with your patient, you're missing a big piece of the clinical puzzle. Most of our patients will have a host of
other impairments, i.e. joint dysfunction, poor motor control, faulty movement patterns, limited dural mobility, etc. that dry needling may or may not be able to address. This begs the question......where does dry needling fit into the overall management of your patient?
1. Dommerholt J, Mayoral del Moral O, Grobli C. Trigger point dry needling.
J Man Manip Ther. 2006;14(4):70E-87E
2. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger points. The importance of the local twitch response. Am J Phys Med Rehabil. 1994;73(4):256-263.
3. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr Pain Headache Rep. 2012;16(5):439-444.
4. Huguenin LK. Myofascial trigger points: the current evidence. Phys Ther Sport. 2004;5(1).
5. Shah JP, Phillips T, Danoff JV, Gerber LH. A novel microanalytical technique for assaying soft tissue demonstrates significant quantitative biochemical differences in 3 clinically distinct groups: normal, latent, and active. Arch Phys Med Rehabil. 2003;84(9):E4.
6. Shat JP, Phillips TM, Danoff, JV, Gerber LH. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J App Physiol. 2005;99(5):1977-1984.
7. Jimbo S, Atsuta Y, Kobayashi T, Matsuno T. Effects of dry needling at tender points for neck pain (Japanese: Katakori): near-infrared spectroscopy for monitoring muscular oxygenation of the trapezius. J Orthop Sci. 2008;13(2):101-106.
Abstract of the Week,
low back pain,
By the age of 26 I had been fighting some type of back pain for years. It had become a normal way of life. I still was able to do most of anything I wanted to until “The Day.” While replacing our garage door, I went to lift the old door when it happened, a big pop in my back. Four hours later I was unable to get out of bed. I was experiencing what we know as a “classic disc protrusion.” For the next two weeks I was bed ridden. After that I went back to work using a cane for about a month to keep weight off my left leg.
Manual Physical Therapy,
low back pain