The Thinking Physical Therapy blog and Forward Thinking PT blog will be merging!

Thank you to everyone who has signed up to follow this blog. I am very excited that Joseph Brence over at  has asked me to join forces with him. He has a great blog with lots of excellent content. My goals as a blogger will not change, only the location of the posts will change. If you are not already following please consider switching over there. All my new posts will be published on that blog.

Thanks again for following and I hope to see you over at

Red Flags

The last thing any physical therapist (or any health care practitioner) wants to do is diagnose a patient with a musculoskeletal problem when they actually have something nasty like a tumor. To avoid this potentially costly error we take a thorough history and detailed exam, keeping a close eye out for red flags.  For patients with spinal pain there are 4 red flags (used to rule out spinal tumors) which are commonly cited and endorsed by the American Pain Society .

1) Unexplained weight lossRed flag

2)Being older than 50

3)Failure to improve after 1 month

4) A history of cancer

If a patient has one or more these red flags (there are others as well) they are considered to be at higher risk for having cancer and further testing should be considered. If red flags are not present, imaging such as x-rays and MRIs are often not indicated. But how useful are these red flags? A recent Cochrane review on the subject helps us answer that question.

Before we look at the details of the study it is important to remember what makes a good screening tool.  First the tool needs to increase the probability that a condition is present. Second there needs to be few false negatives (high sensitivity).

In this review, the authors identified 8 studies which examined 15 red flags from the history.  The sensitivity of the individual tests ranged from .5-.77. One study combined several red flags (age >50, history of cancer, weight loss and failure to improve with conservative treatment) and found the combination to have a sensitivity of 100%. The majority of the historical components examined did not significantly increase the post test probability of having cancer. The only exceptions were unexplained weight loss (increased from .3% to 1.2%) and previous history of cancer (increased from .3% to 4.6%).

5 physical exam tests were also identified and they had very low sensitivity and did not increase the post test probability.

The authors conclude that:

“Commonly suggested “red flags” for malignancy in clinical practice guidelines are: age > 50 years, no improvement in symptoms after one month, insidious onset, a previous history of cancer, no relief with bed rest, unexplained weight loss, fever, thoracic pain, or being systemically  unwell ( Koes 2010 ). These “red flags” are usually elicited through the initial assessment (history taking and physical examination), to decide which patients should be referred for imaging or specialist consultation. The limited evidence  available suggests that only one “red flag” when used in isolation, a previous history of cancer, meaningfully increases the likelihood of cancer. “Red flags” such as insidious onset, age > 50, and failure to improve after one month have high false positive rates suggesting that uncritical use of these “red flags” as a trigger to order further investigations will lead to unnecessary investigations that are themselves harmful, through unnecessary radiation and the consequences of these investigations themselves producing false-positive results. While the lack of evidence to support or refute the use of “red flags” is recognized, a more pragmatic solution is to consider the possibility of spinal malignan446202_spinal_tapcy (in light of its low prevalence in primary care) when a combination of recommended “red flags” are found to be positive.”

So it looks like other than a history of cancer, red flags are not all that helpful for determining when someone with spinal pain has an elevated risk of cancer. Hopefully, future studies will identify better screening tools.

Deconstruction of Reconstruction

Picture this scenario. Skippy, a 41 year old male software engineer comes into your clinic after tearing his right ACL when he slipped on a floppy disk at work. He lifts weights at the gym 3 days a week and runs 2 miles on the treadmill 2 days a week.  On his first visit Skippy asks “should I get my ACL reconstructed?”

SONY DSCWhat would you recommend?

In the recent past this would not have even been a question.  Still today, most patients who tear their ACL are encouraged to have it reconstructed. Without a reconstruction patients have been expected to have reduced function, knee instability, meniscus tears, osteoarthritis etc….

More recently studies have started to call into question the practice of automatically reconstructing ACLs  on every patient. Some patients are being classified as copers and are expected to function well with an ACL deficient knee.

A recent study by Frobell et al in BMJ adds to the mounting evidence which calls into question early and blanket ACL reconstruction. The authors followed a group (121) of patients (average age of 26 and “active”) who either had early ACL reconstruction or delayed optional surgery. 49% of the patients in the delayed group decided not to have an ACL reconstruction.

At the 5 year follow-up, outcomes for the two groups were similar. Early ACL reconstruction did not lead to improved outcomes or reduced incidence of subsequent meniscus injury.

” CONCLUSION: In this first high quality randomised controlled trial with minimal loss to follow-up, a strategy of rehabilitation plus early ACL reconstruction did not provide better results at five years than a strategy of initial rehabilitation with the option of having a later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone. These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.”

Do the results of this study change the recommendation you would give to Skippy?


Regional Interdependence

I recently read an article by Muth et al which looked at the effects of thoracic spine thrust manipulation on patients with signs of rotator cuff pathology. This study utilizes the concept of regional interdependence which has gained popularity over the last several years. This theory suggests that pain and dysfunction in one area of the body can be treated with interventions to adjacent regions. This concept is not new, however more recent studies have fueled its increased popularity by providing support for it. For example, treatment of the hip is thought to have an impact on knee and low back pain, and treatment aimed at the thoracic spine as been shown to have effects on shoulder and neck pain. These effects are often explained based on biomechanics however, the exact mechanism is still unclear.  It is possible that some of these effects can be explained by changes in biomechanics, although there are a few reasons why I remain skeptical about this explanation . First, many of these studies use manual therapy and chainexercise as an intervention. It is assumed that these interventions have an impact on the biomechanics of a joint however this hypothesis remains unproven. The often immediate effects of manual therapy may suggest that its actions go further than just local changes to a joint.  Although possible, I would not expect small changes in biomechanics at one joint to immediately result in reduced pain and improved function at a distant joint. It seems more plausible that a change in the nervous system (increased pain threshold etc.) would be more likely to result in this immediate effect.  If we consider exercises to either strengthen or stretch a muscle it may theoretically change biomechanics, however there are few examples of this in the literature.   The other major reason I am skeptical of the biomechanical explanation for regional interdependence is the consistent failure of studies to find a strong connection between biomechanical factors and patient symptoms. Even in cases where a correlation between mechanics and symptoms has been documented (for example shoulder pain and scapular dyskinesia) it is often unclear if the changes in biomechanics are the cause or a result of the problem.

The study by Muth et al built off other studies (here and here) which found a reduction in shoulder pain after thoracic spine manipulation (TSM). The goal of this study was to try and determine a mechanism for the reduction in shoulder pain after TSM. The authors took 30 subjects with shoulder pain and put them through a battery of tests including: scapular kinematic testing (using electromagnetic tracking), EMG (infraspinatus, upper/middle/lower trap, serratus), pain rating (during empty can test, Hawkins-Kennedy test,  Neer test and loaded elevation),  peak shoulder elevation force and a few shoulder function questionnaires.

As with previous studies they found a reduction in pain and an improvement in function after the TSM. This reduction in pain was not associated with changes in biomechanics. The only statistical significant change in scapular motion was a reduction in upward rotation after the TSM. Based on current thinking we would expect a reduction in upward rotation to decrease the subacromial space, result in more pressure on the cuff and cause increased pain.  At this point you are probably thinking “but what about thoracic motion”. Good thought but no, that did not change either.

The results of this study calls into question the biomechanical explanation for the improvements found after TSM.  I would not suggest that regional interdependence is never a result of biomechanical changes, however we should be careful not to assume the mechanism is biomechanical. It is important for us to consider the mechanism behind regional interdependence because often our understanding of mechanism dictates how we use the intervention. For example, TSM may not be used in a patient with shoulder pain who is found to have a normal or hypermobile thoracic spine. We assume that TSM is only effective in patients with a stiff thoracic spine because we believe the mechanism of action is increased thoracic extension (or motion in general).  If the patient has good extension with no stiffness there would be no reason to perform a TSM.  If we understand that the mechanism behind TSM may not be mechanical, we would avoid using only mechanical findings to dictate whether we performed a TSM or not.  At this point, all we know is that the presence of shoulder pain is an indication that TSM may be helpful.Shoulder

Another important issue to address about the Muth et al study (and many other studies looking at manual therapy) is that there was no sham treatment group. The absence of a sham treatment group makes it impossible to determine whether the benefits from TSM were due to a specific effect or a result of non-specific effects such as placebo or patient expectation.

To sum things up, TSM seems to provide short term improvements in pain and function for patients with shoulder pain. The mechanism behind these improvements does not appear to be biomechanical. We need more studies looking into the mechanism behind this, and other examples of regional interdependence, so we can more accurately match interventions to patients.

Welcome to the Thinking Physical Therapy Blog!

This is a test and announcement post rolled into one.

Mic in hand

The Thinking Physical Therapy blog will provide a platform for professors, researchers, clinicians and students to share their thoughts and expertise about the practice of physical therapy. The goal will be to promote excellence in physical therapy and to provide a medium for productive discourse on the many issues facing physical therapists. Topics will encompass many aspects of physical therapy including orthopedics, sports, manual therapy, cardiopulmonary, neurology, pharmacology, research and education.

No idea or opinion on this blog is exempt from critical appraisal, however personal attacks and unprofessional behavior will not be allowed.

Please feel free to join in the conversation and feedback or questions can be sent to Adam Rufa,