Yes, smoking as a risk factor for low back
pain and sciatica
has been extensively studied. Experimental studies have
to the hypothesis that blood flow and nutrition to the disc
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,
activity is altered, and degenerative changes of the spine
specially of the lumbar region.
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
the key professional within medicine responsible for the
conservative care for mechanical disorders of the spine".
It was his
view "that if appropriate steps were not taken the
profession may never have another opportunity to achieve
But years later in the lates edition of the same book he
the opportunity is almost lost.
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.
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
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.
What exercises are the best to help and increase bone mass?
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.
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.
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.
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.
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
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.
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.
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.
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
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
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.
Can an X-ray be a substitute for a clinical evaluation and
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.
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.
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.
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.
Pain that is felt in an area other than the lesion.
Example: 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.
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).
pain can be Segmental or Multi-segmental
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