A hand PT specialist protocol

[bernard]

Hi SomaSimplers,

I received yesterday a woman with a diagnose of bilateral elbow tendinopathies/tis (more than 1 year). The right R side was cured with surgery => pain unchanged!
She presents too, cervical problem for 5 years, shoulders problems, lumbar problem with sciatica since many years.
Depressed because she can't return to work => at home since January 2003!

She had over 45 sessions with a hand PT specialist. I know this one for his brutal approach and his big tongue (more than me :? ). He is well known by all surgeons who are sending him quite all MS patients.

The woman was sent with THE protocol. The TOP and accepted now in all suites of tendons problems in the area (5 millions inhabitants).

Here is its contents:

Work with hands in external rotation all the time (I'm not joking).
Transversal massage (CYRIAX) => 5/6/10 times/day!!!
Icing on tendon =>3/4/5 times/day
stretching extension/flexion 3/6 times/day
eccentric work with 1.5 kg => flexion/extension 30/60 repeats reference STANISH 1986

He is a hand specialist but he is not a friend of mine. :oops:

[bernard]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3720143

Clin Orthop. 1986 Jul;(208):65-8.

Eccentric exercise in chronic tendinitis.

Stanish WD, Rubinovich RM, Curwin S.

Chronic tendinitis, particularly of the Achilles tendon, frequently outwits traditional programs of therapy including surgery and/or prolonged immobilization. A hypothesis proposes that disruption of the tendon, micro or macro, occurs under specific conditions of eccentric loading. In order for the healing tendon to be adequately rehabilitated, the treatment program must include specific eccentric strength rebuilding exercises.

PMID: 3720143 [PubMed - indexed for MEDLINE]

[bernard]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12519601

Cochrane Database Syst Rev. 2002;(4):CD003528.

Update of:

* Cochrane Database Syst Rev. 2002;(1):CD003528.


Deep transverse friction massage for treating tendinitis.

Brosseau L, Casimiro L, Milne S, Robinson V, Shea B, Tugwell P, Wells G.

School of Rehabilitation Sciences, University of Ottawa, 451 Smyth, Room 3060, Ottawa, ON, Canada, K1H8M5. LBROSSEA@UOTTAWA.CA

BACKGROUND: Deep transverse friction massage (DTFM) is one of several physiotherapy interventions suggested for the management of tendinitis pain.
OBJECTIVES: To assess the efficacy of DTFM for treating tendinitis.
SEARCH STRATEGY: We searched the MEDLINE, EMBASE, HealthSTAR, Sports Discus, CINAHL, the Cochrane Controlled Trials Register, PEDro, the specialized registry of the Cochrane musculoskeletal group and the Cochrane field of Physical and Related Therapies up to the end of June 2002. The reference list of the trials and key experts in the area were also consulted for additional studies.
SELECTION CRITERIA: All randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing therapeutic ultrasound with control or another active intervention in patients with all types of tendinitis, such as iliotibial band friction syndrome and extensor carpi radialis tendinitis (i.e. tennis elbow or lateral epicondylitis or lateralis epicondylitis humeri), were selected.
DATA COLLECTION AND ANALYSIS: Two reviewers determined the studies to be included based upon the inclusion and exclusion criteria (LB, VR). Data were independently abstracted by two reviewers (VR, LB), and checked by a third reviewer (BS) using a pre-developed form of the Cochrane Musculoskeletal Group. The two reviewers, using a validated checklist, assessed the methodological quality of the RCTs and CCTs independently. The pooled analysis was performed using weighted mean differences (WMDs) for continuous outcomes.
MAIN RESULTS: One RCT included patients with ITBFS. DTFM combined with rest, stretching exercises, cryotherapy and therapeutic ultrasound was compared to the control group (rest, stretching exercises, cryotherapy and therapeutic ultrasound only). This trial showed no statistical difference in the three types of pain relief measured after four consecutive sessions of DTFM combined with other physiotherapy modalities for runners. There was a clinically important relative percentage difference in pain while running of 22%. A RCT on ECRT showed no statistical difference in pain relief, grip strength and the three types of functional status measured after 9 consecutive sessions within 5 weeks of DTFM compared with other physiotherapy modalities.
REVIEWER'S CONCLUSIONS: DTFM combined with other physiotherapy modalities did not show consistent benefit over the control of pain, or improvement of grip strength and functional status for patients with ITBFS or for patients with ECRT. These conclusions are limited by the small sample size of the included RCTs. No conclusions can be drawn concerning the use or non use of DTFM for the treatment of ITBFS. Future trials, utilizing specific ITBFS methods and adequate sample sizes are needed, before conclusions can be drawn regarding the specific effect of DTFM on tendinitis.

Publication Types:

* Meta-Analysis
* Review


PMID: 12519601 [PubMed - indexed for MEDLINE]

[bernard]

http://bmj.bmjjournals.com/cgi/content/full/323/7309/382

Tendinopathies are an important group of lesions with a broad spectrum of overlapping characteristics that can pose a diagnostic and therapeutic challenge. Although local corticosteroid injections are one of the most common treatments, there is no good evidence to support their use. This is due to either a true lack of effect or a lack of good trials. More research is warranted into the characteristics of specific tendinopathies and the biochemical, cellular, and clinical effects of corticosteroids on these lesions.

[bernard]

Hi Folks,

Back to the lady,

We had 4 sessions for now and I tried to put away (I did) the protocol. Since the woman was highly suffering from LBP and cervical problems then I worked with breathing and muscular relaxation. I had no time in the first session to do much more. She felt good/well and arriving to the second session, she started to cry because she recognised that she wasted almost one year with unsuccessful cares and now in a single session her back is quite pain free.

She said having no improvement over the tendinopathies but I replied that she stops NSAIDs and pain didn't grow and movements recovered their full amplitudes. It is a good start.

Arriving to the four session, she was in pain but she helped her son to move in his new house (4 travels and a lot and lot of hands work)... She was smiling a bit and understanding that it was quite normal and it will be recover in a few days.

[bernard]

Hi SomaSimplers,

I wrote to the surgeon this email (transaltion is approximative :cry: )=>

Attention to: dr.guigal@cliniqueduparclyon.com centre.kines@cliniqueduparclyon.com


Doctor,

I thank you for having entrusted me the reeducation of Mrs D* H* whom is presenting a bilateral tendinopathy problem of the elbows. The treatment was started in early January and we carried out 5 sessions.

Protocol COMTET/PERNOT had been proposed like a basis of treatment and we have as far as possible, tried to apply it.

However, Mrs D*H* had had some preceding attempts with a fellow-member, with persisting pain between sessions and very little functional improvement.

Initial examination, in addition to problems of pain and loss of ROM joint, Mrs H* presented also some neuropathic component on forearms (these pain being worsened in lying supine and aren't related to movements).

We found, also, a great stiffness of the torso. The muscles of the scapular belt are tended and painful. Mrs H* indicating an old cervicalgy, worsened since her arms problems.

Mrs H* presented also a severe LBP.

We tried under these conditions, to pacify the whole painful zones, with a more global approach containing active muscular relaxation and breathing. These techniques are often effective and may be observed at home by the patient. We reduced the anticipation muscular component found at the lumbar level.

These simple techniques made possible a decreasing of the neuropathic component of the pain of upper members.

Taking account some current knowledge about the tendinopathies,

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3720143

http://bjsm.bmjjournals.com/cgi/content/full/36/4/239

"Gentle static stretching by pulling, holding, and releasing the gastrocnemius-soleus complex is the best way of stretching."

printable version = > www.somasimple.com/pdf_files/achilles_tendinopathy.pdf

one about the deep transverse massage,

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12519601

"DTFM combined with other physiotherapy modalities did not show consist benefit over the control of bread, gold improvement of grip strength and functional status for patient"

One on the anti-inflammatory drug standard and tendinopathy,

http://bmj.bmjjournals.com/cgi/content/full/323/7309/382

"Tendinopathies are significant year group of lesions with has broad spectrum of overlapping characteristics that edge installations has diagnosis and therapeutic challenge. Room Although corticosteroid injections are one of the most common treatments, there is No good evidence to support to to their use. This is due to either has true lack of effect gold has lack of good trials. More research is warranted into the characteristics of specific tendinopathies and the biochemical, cellular linen linen, and clinical effects of corticosteroids one these lesions. "

We tried to reduce the pain by neuro-mobilizations of the upper limbs according to techniques' of D. BUTLER (www.noigroup.com) and related improvements (www.somasimple.com/forums) = > simplification of protocols and earlier reduction of the pain. This last site (in English) being opened to all those which are interested by pain and allows exchanges at an international level.

Following three sessions, Mrs H*, presents only few lumbar and cervical pain, and has a complete mobility of the upper limbs. However this mobility remains, still normally, painful because of problem duration.

We remain fully at your listening for any further information and will keep you informed of evolution of treatment.

Replying directly to the patient who claimed an improvement, he said that I was vulgar and uncivil and the whole PT team (bone & joints) was laughing on floor reading the letter. They found me simply ridiculous.

It's a long way...

[Thomas]

Dear Bernard,

Bravo ! What your unenlightened (ignorant) doctor :evil: has is a case of insecurity or blind arrogance. Of course we find it all the more laughable that this patient is treated 45 times with no improvement with a totally ridiculous protocol. ("keep hands in external rotation always") What a joke.

The bone and joint PT's also demonstrate their lack of professionalism with your thoughtful approach. I love your approach and have learned tons ( a hell of a lot) from your insights.

With regards..................Thomas

[nari]

Bernard, quite a story, but not uncommon.

Patients frequently show more sense and loyalty than peers and colleagues.

I still find Moseley's work on the levels of understanding of pain between PTs and patients amazing, if not disturbing.

If a trained patient can understand pain concepts better than a physiotherapist can - something is a bit wrong.

Unravelling the barriers...the actual and perceived ability of patients and health professionals to understand the neurophysiology of pain..
the Journal of Pain, Vol 4, no 4 (May) 2003; pp 184-189.

I think it explains how intelligence is not the issue - a willingness to learn new things and consolidate on top of old knowledge, is.


Nari

[bernard]

Nari,

I agree there and we have already the paper in The Sound of Silence.

http://www.somasimple.com/private/Moseley02.pdf

[flaviovitor]

Hi Bernard,

I loved your letter.

I have ever written anything alike to a physician. Here, doctors don't say anything to patients, NO COMMENTARIES!!! Do you believe it?

It means that this kind of professional likes to earn money at the expense of the persistent unhealthy ones. This professional is unethical and do not contribute to sharing the science in clinical practice.

Don't give up Bernard.


Flávio Vitor.