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  Is smoking a risk factor for low back pain?

  Yes, smoking as a risk factor for low back pain and sciatica
has been extensively studied. Experimental studies have given support
to the hypothesis that blood flow and nutrition to the disc are diminished
in smokers (Ernst E., Holm S, Nachemson A et. al.), the ph of the disc is
lowered, the mineral content of the vertebrae is decreased, the fibrinolytic
activity is altered, and degenerative changes of the spine are increased
specially of the lumbar region.

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  How do you see the future for manual therapists?

In the first edition of "Physical Therapy of the Low Back"
published in 1987 Robin A. McKenzie suggested "that over the next
few years, physical therapists would have the opportunity to become
the key professional within medicine responsible for the delivery of
conservative care for mechanical disorders of the spine". It was his
view "that if appropriate steps were not taken the physical therapy
profession may never have another opportunity to achieve this goal".
But years later in the lates edition of the same book he suspects
the opportunity is almost lost.

I absolutely agree with Mr. McKenzie and I also believe that the same can happen to the rest of us in the manual therapy profession, if we don't move away from assessment systems based on the detection of asymmetry by observation and/or palpation of joint motion to detect hyper-or hypomobility. Its my view as well as others in the profession that not only there is no credible support in the scientific literature for these types of assessment systems, but its is fairly simple to disprove them.

Chiropractic, on the other hand is flourishing. Education for chiropractors is moving toward the traditional medical training model, and more medical professionals are involved in their education. Through their political lobbing chiropractors have succeeded in having legislation bar or make it illegal for physical therapists to practice manipulation in some states in the US.

It is my view that we manual therapists must get trained in methods that are based in science and in logic and not just pure opinions if we want to continue to grow and progress.

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  What exercises are the best to help and increase bone mass?

There are two types of exercises that I recommend for building and maintaining bone mass and density: weight-bearing and resistance exercises. Weight-bearing exercises are those in which the bones and muscles work against gravity for example: walking, weight lifting, low impact aerobics, stair climbing, dancing, and hiking.

The second types of exercises are resistance exercises or muscular strengthening exercises that improve muscle mass and strengthen bone. These activities include weight lifting, such as free weights or resistive bands or weight machines.

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  What is the cause of low back pain?

  Any structure that has a nerve supply can cause pain, but most back pain is caused by either dysfunction or pathology at the intervertebral disc, facet joint, or surrounding ligaments.

However, virtually every structure in the low back has at one time or another been implicated as a possible source of back pain. Throughout the 20th century, certain structures have periodically been popularised as the leading source of back pain; some concepts have disappeared, others persist, while still others have come and go almost seasonally. When old ideas have proved unsatisfactory, any new theory that is in any way promising is rapidly adopted, even if it has not proven to be effective.
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  What is the sequence of muscle contraction in arm elevation?

  Elevation of the arm begins with abduction of the humerus, which is initiated by supraspinatus contraction which raises it by approximately 10 degrees, from there the arm is positioned in an angle where the deltoid takes over producing a rotatory force to continue the movement. The rotator cuff muscles prevent upward shearing of the head of the humerus in the glenoid fossa. These all act isometrically as stabilizer with the exception of supraspinatus, which shortens concentrically. Deltoid also works concentrically, the principal force being exerted by its middle multipennate fibers, with the anterior and posterior fibers acting as guides to control the plane of abduction.

This is why we believe that the resisted test for the supraspinatus tendon must be done with the arm in neutral (0 to 5 degrees of abduction) and not at 90 degrees of abduction with the thumb down (recommended by some instructors in the field) which does not differentiates between supraspinatus tendonitis, deltoid dysfunction and subdeltoid bursitis.

Elevation of the arm continues once 30 degrees of abduction has been reached, lateral rotation of the scapula begins, turning the glenoid fossa upwards to increase the total range of movement. For every 15 degrees of abduction from this point onwards, approximately 10 degrees occurs at the shoulder joint and 5 degrees by lateral rotation of the scapula. This lateral rotation of the scapula is produced by the concentric contraction of the upper and lower fibres of trapezius, and the lower half of serratus anterior. Other muscles assist these two in holding the scapula againts the thoracic wall.

As movement at the shoulder joint approaches 90 degrees (a total position of 120 degrees of abduction), there is lateral rotation of the humerus to prevent it: (1) from coming into contact with the coracoacromial arch and (2) stopping any further movement--a locked position.

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  Is ultrasound an effective treatment for musculoskeletal disorders?

  Most of the randomized controlled studies are inconclusive, but "there is evidence that ultrasound therapy is ineffective in the treatment of soft tissue shoulder disorders" (van der Heijden et al. 1997); There is also strong evidence that ultrasound is not an effective treatment for neck or lower back pain that is symptomatic relief or less disability and work loss.
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  To treat or not to treat?

  Needless to say, there can be no justification for physical treatment unless that treatment is known to accelerate the natural history of the condition or to assist in the recovery of function. We believe that all patients are entitled to comprehensive guidance and education in the appropriate strategies to assist in the healing process and to regain normal painless function.
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  Is there any treatment or rehabilitation program for an anterior cruciate ligament tear other than surgery?

  Yes. The first therapeutic exercises that we recommend to our patients once the swelling and pain have subsided are quadriceps strengthening utilizing closed-chain exercises, (exercise in which the limb is restrained against an immobile object) such as mid-range squads. The main reason why we choose closed-chain exercises versus open-chain ones is the fact that the anterior cruciate ligament primary function is to restrain the anterior translation of the tibia on the femur, and we believe that open-chain exercises such as isotonic knee extension, creates too great of a stress on the anterior cruciate ligament therefore harming it.
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  Can an X-ray be a substitute for a clinical evaluation and examination?

  No, a characteristic shared by the moving soft tissues is their radiotranslucency (their ability not to be seen in a radiograph). The tissues we are talking about are the joint capsule, ligaments, fasciae, muscles, tendons, bursae, discs, dura mater, dural sheaths and nerve roots. Any of these structures can cause pain. None of them, inflamed or otherwise, can be diagnosed on the radiograph. If a soft tissue causes the pain, the x- ray can show only one of two things. First, it may reveal the bones are normal; therefore it allows the patient to be open to a misplaced diagnosis of neurosis or psychogenic pain (pain caused by the mind). On the other hand the X-ray may disclose some symptomless abnormalities or natural degenerative changes which is then incorrectly regarded as the source of pain. In this case the radiograph is positively misleading, a problem not necessarily avoided by recourse to more modern imaging techniques.

For example, many patients with a stiff neck are diagnosed with a cervical osteoarthrosis or cervical spondylosis. But the patient history reveals that the patient's pain started only last month, whereas the osteophytes have been in existence for a decade or more. Likewise the osteophytes remain unchanged after the pain vanishes a couple of months later. In fact cervical osteoarthrosis is a natural change that is commonly found on those over 40 years of age and of itself is frequently symptomless. The cause of the pain probably lies elsewhere.

Before effective treatment can be administered, the defective tissue must be singled out. If not, any therapy will be at its best a waste of time and at its worst harmful.

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  What is the best treatment for shoulder pain?

  The best treatment for shoulder pain is the treatment that no only matches the tissue at fault, but also the stage of the lesion; for example a capsular lesion may need graded stretching where a tendonitis may need isometric exercises plus friction massage.
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  Can we identify a supraspinatus tendonitis by a positive resisted abduction test alone?

  No, because a bursitis will also show positive on resisted abduction; therefore we need an accessory tests to differentiate.
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  Which are the Main Origins of Pain?

  The Different Possible Origins of Pain and their Symptoms are:

1. Mechanical

Movement has an affect on symptoms. (May produce, reduce or increase symptoms.)
Intermittent pain / may be constant with major displacements.
No chemical prescription proves effective. (Medication may help up to 30 %.)
Mechanical forces activating nociceptive receptors.

2. Chemical

Constant pain.
Trauma (Up to 20 days after injury.)
Inflammation or infection. (Swelling; redness; heat; tenderness.
No mechanical treatment proved effective. (No movement found to reduce or eliminate pain.)

3. Psychogenic

Patient provides ambiguous or inconsistent answers during examination.
Findings are not constant or consistent.
Patient exaggerates symptoms.
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  What is Referred Pain?

  Pain that is felt in an area other than the lesion.

A patient is treated for thigh pain, and receives treatment for the quadriceps muscles. The reason? Pain is felt there. If we perform a functional examination, it becomes clear that resisted knee extension (which tests the quadriceps’ contractile ability) shows negative therefore proves that the function of the quadriceps muscle is not disturbed.

Further examination, this time the lumbar spine, shows that the patient is not able to perform lumbar extension without pain, and that repetitive lumbar flexion increases and peripheralizes the symptoms, which are referred into
the thigh (L-2 dermatome). We would conclude, that the lesion lies in the lumbar spine, most likely discogenic (L-2).

Referred pain can be Segmental or Multi-segmental

Depending on where the lesion lies. It will refer segmentally if the lesion lies on a unilateral structure. Example: zygapophysial joint, bursa, muscle,
nerve trunk etc. It will refer multi-segmentally if the lesion lies on a central structures example: dura mater, posterior longitudinal ligament, and posterior annulus fibrosus etc.

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