Structured postoperative physiotherapy in patients with cervical radiculopathy: 6-month outcomes of a RCT

Cervical Spine and Nerves

Structured physiotherapy has been suggested as treatment before as well as after surgery to improve clinical outcomes in patients with cervical radiculopathy (CR), but randomized clinical trials to inform evidence-based clinical guidelines for the treatment of patients with CR after surgery are lacking. The aim of this study was to compare the results of structured postoperative physiotherapy combining neck-specific exercises with a behavioral approach to a standard postoperative approach in patients who had undergone surgery for cervical disc disease with CR at 6 months after surgery.

Patients with cervical disc disease and persistent CR who were scheduled for surgery were randomized preoperatively to structured postoperative physiotherapy (n = 101) or a standard postoperative approach (n = 100). The latter included pragmatic physiotherapy in accordance with the usual Swedish postoperative care. Outcome measures included patient-reported neck disability as measured with the Neck Disability Index (NDI), intensity and frequency of neck and arm pain, global outcome of treatment, and expectation fulfillment, as well as enablement. RESULTS Patients who received structured postoperative physiotherapy reported greater expectation fulfillment (p = 0.01), and those who attended at least 50% of the treatment sessions reported less neck pain frequency (p = 0.05), greater expectation fulfillment (p = 0.001), and greater enablement (p = 0.04) compared with patients who received the standard postoperative approach. No other difference between treatment groups was found (p > 0.15). The NDI and neck and arm pain intensity were improved in both groups at 6 months after surgery (p < 0.001). Additional use of postoperative physiotherapy was reported by 61% of the patients who received the standard postoperative approach.

The results from this first randomized clinical trial of postoperative physiotherapy showed only minor additional benefit of structured postoperative physiotherapy compared with standard postoperative approach 6 months postoperatively in patients who underwent surgery for cervical disc disease with CR. Patients who received structured postoperative physiotherapy reported higher expectation fulfillment, and many patients in the standard postoperative approach group perceived a need for additional treatments after surgery, suggesting that patients with CR are in need of further postoperative support. The results confirm that neck-specific exercises are tolerated postoperatively by patients with CR, but more studies of postoperative physiotherapy are needed to inform clinical guidelines for this patient group.


Top 5 Fridays! 5 Step Hamstring Eccentric Progression

We know that performing eccentric hamstring exercises such as the Nordic Hamstring Exercise can be beneficial in hamstring strain rehabilitation and injury risk reduction. The problem is, you don’t always have a partner willing to hold your legs down while performing the Nordic Hamstring Exercise.

Eccentric Hamstring Progression

Here are a few variations of eccentric hamstring exercises that do not require a partner:
1️⃣ Hamstring Walkouts:
🔸 This is a very basic exercise in which you maintain a bridge position while slowly walking your feet out a little bit at a time until your legs are straight. This causes to hamstrings to work throughout their range of motion.
🔸 Step your feet right back up to the starting position to take away the concentric component.
2️⃣ Sliders:
🔸 Here, you are going to have a slider under one heel. Perform a bridge, lift one leg up, then slowly straighten the working leg. Drop your hips down to the floor and start at the beginning.
🔸 You may feel a little hamstring cramping when you first start performing this exercise. That is totally normal!
3️⃣ Sliders on Floor:
🔸 In this variation, all you need is a tile or wood floor and a sock!
🔸 Lift your hips into a bridge position, lift one leg up into the air, and slowly extend the working leg. Let your hips drop to the floor and return to starting position.
4️⃣ Physio Ball:
🔸 Same idea as the sliders, bridge up, lift one leg into the air, and slowly extend the working leg. Put your other leg back on the ball to bring it back to the starting position. (2 legs in 1 leg out).
🔸 For more of a challenge, curl the ball back in with only the working leg. This will work both the concentric and eccentric phases.
5️⃣ TRX:
🔸 In this variation, both heels are in the loop of the TRX. Bridge your hips up, then slowly extend your legs out to a straight position. Drop your hips down before bringing your knees back up.
🔸To make this more challenging, stay in a bridged position during both the concentric and eccentric portions.

Thanks to Dr. Nicole Canning, DPT, CSCS – @dr.nicolept on instagram for the video!

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The Many Faces of COPD

COPD Day Logo

World COPD Day is organized by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in collaboration with health care professionals and COPD patient groups throughout the world. Its aim is to raise awareness about chronic obstructive pulmonary disease (COPD) and improve COPD care throughout the world.

Each year GOLD chooses a theme and coordinates preparation and distribution of World COPD Day materials and resources. World COPD Day activities are organized in each country by health care professionals, educators, and members of the public who want to help reduce the burden of COPD.

The first World COPD Day was held in 2002. Each year organizers in more than 50 countries worldwide have carried out activities, making the day one of the world’s most important COPD awareness and education events.

What is COPD?
COPD is a complex interaction between chronic bronchitis, emphysema and asthma which is primarily caused by prolonged exposure to tobacco smoke. Other risk factors such as exposure to pollution, occupational dusts and chemicals.

This video explains the complex process involved in COPD.

As Always Exercise is Crucial
Encouraging patients with COPD to stop smoking is critical to their success and outcomes in terms of mortality and lung function but a driver towards this change is exercise. Regardless of smoking cessation or not, exercise plays a crucial role in enabling quality of life in those with COPD and has been well documented to do so. This article could linger on the point of exercise for ever but the focus should be about something often overlooked. This being inhaler technique.

The Trouble with Inhaler Techniques
As this WSJ report explains inhaler technique is fraught with multiple steps and often rate, depth and timing of breath are often incorrect which means LABA and SABA inhalers are made redundant by the user and this has multiple implications in the care of the individual.

The correct technique, as shown below, is essential to those using inhalers. This week let’s make sure we are aware of the correct technique so that we enable our patients to independently manage their exacerbation. Oh, or use a spacer!

Immediate effect of passive static stretching vs resistance exercises on postprandial blood sugar in T2DM

Diabetes Equipment, Insulin Pen And Glucose Level Blood Test

The prevalence of diabetes is rapidly rising all over the globe at an alarming rate. In India, more than 61.3 million people have been presently diagnosed with type 2 diabetes mellitus. It is possible to control the circulating blood glucose levels by reducing life style risk factors through physical activities comprising of muscle stretches, aerobic training, resistance exercises (REs), yoga, etc. The aim of this study is to identify and compare the immediate effect of passive static stretching (PSS) versus RE on blood glucose level in individuals with type 2 diabetes mellitus.

The study included 51 participants between the age of 40–65 years with type 2 diabetes mellitus, to study the immediate effect of 60-min PSS (n=25) and 60-min RE (n=26). The outcome measure was blood glucose level which was checked by glucometer (free-style neo). Blood sugar was assessed at 3 points of time that included fasting blood sugar level, 2 hr after the meal and immediately after the exercise regimen.

Results of this study showed significant reduction in blood glucose level in subjects according to glucometer with PSS (P=0.000) and RE (P=0.00). However, both groups demonstrated equal effect in terms of lowering blood sugar level immediately after the exercise. The conclusion is both PSS and RE are effective in reducing postprandial blood glucose level in type 2 diabetes mellitus and must be prescribed for the patients who demonstrate difficulty in controlling post prandial spike.

Dear Physio – I Can Take it From Here

This is just a short piece, a reflective piece, about a value that makes up the very core of what I believe in and what I strive to achieve as a Physiotherapist – empowering my patients with the knowledge and the skills they need to make them independent. This year has been hectic, trying to understand and adapt to working in America and personally accomodating to a new workload after studying for nearly two years. I’d be lying if I said I wasn’t tired or that I didn’t get lost in the daily grind. But not today! Today I am going to take a moment to reflect and to celebrate 🙂
These past few weeks have reminded me of a very special part of treating patients – discharging them. For months now I have worked intensely to help the small patient population I have contact with. After investing so much time in their development and progress, it is a magical moment when they come to me and say “I am not 100% better, but, I know what the problem is, I know how to make it better, what I need now is time to follow through on my goals and I can take it from here.” 
What a pleasure it is to hear that. I know that no one will ever be 100% when it comes to discharge and I am fine with that. Firstly, I don’t set “being 100% pain free” as a goal and secondly, I think we all suffer from pain at some point in time. What I feel is more important is for patients to functional normally and in the most ideal way for their lives.


It all starts at the beginning. Where life is altered by pain or injury and when patient’s seek out care because they don’t function in their normal way anymore. It can be tough sometimes to get the ball rolling, to retrain movement patterns and daily habits, to get pain levels under control, and to motivate patients to begin to drive their own recovery. The first step is showing patients what the problem is, setting milestones that help them identify with their own recovery process, and then guiding them through rehab until they reach step 2. 


Once pain is no longer driving their willingness to come to therapy, who is?
Sure ain’t me. As I’ve said once before – I will sit beside you on this journey to recovery, but I will not drive you there. So step 2 is all about recognising what other barriers need to be overcome or goals need to be achieved before the patient can be functionally unrestricted. 


Once you are functioning well – do you know how to stay that way?
At this point in time I hope that my patients are developing a sound knowledge about how their bodies present/move/behave when they are both feeling good and feeling bad. Developing this self awareness is a key step towards understanding their bodies better and identifying where their rehab needs to go for them to be 100%.


If you’re staying good and doing what you love – do you still need my help?
It is definitely sad to say goodbye sometimes but we have to set them free. This past week has been sprinkled with discharge assessments. Patients who come in smiling because they only have good news to report. They are playing the sports they love, they can use exercises to manage any niggles that may come up, they are no longer thinking about their injury or their body part, and they see the end goal in sight. And this is when I ask – do you still need my help to get to the end? And with a smile, they reply, I can take it from here. 
So to my patients who shared these moments with me – thank you. Thank you for the months you invested in your own life. Thank you for driving the rehab in the direction you chose. Thank you for the endless open conversations trouble shooting problems and setting personal goals. Thank you for stepping up and being the lead part in your own story. Without this attitude, this approach would not be possible. 
And to my readers. Don’t take for granted the immense impact we can have on someone’s life as physiotherapists. Not for one second to I think I can help everyone and that everyone will get there, I am not that naive. But I am experienced enough to take a moment to celebrate the wins, because they make it all so worth while. 
The journey is always the reward.

Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog “Rayner & Smale”. Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams. Sian currently works full time at TherapydiaSF as a physical therapist and clinical pilates instructor. 

twitter @siansmale
instagram @siansmale_SF

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

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New Institutionalization in Long-Term Care After Hospital Discharge to Skilled Nursing Facility.

Skilled nursing facility

Approximately half of individuals newly admitted to long-term care (LTC) nursing homes (NHs) experienced a prior hospitalization followed by discharge to a skilled nursing facility (SNF). The objective was to examine characteristics associated with new institutionalizations of older adults on this care trajectory.

This was achieved through a retrospective cohort study of medicare fee-for-service beneficiaries admitted to 7,442 SNFs in 2013 (N = 597,986). The authors used demographic and clinical characteristics from Medicare data and the Minimum Data Set. We defined “new institutionalization” as LTC NH residence for longer than 90 non-SNF days, starting within 6 months of hospital discharge.

For individuals who survived 6 months after hospital discharge, the overall rate of new LTC institutionalizations was 10.0% (N = 59,736). Older age, white race, being unmarried, Medicaid eligibility, higher income, more comorbidities, cognitive impairment, depression, functional limitations, hallucinations and delusions, aggressive behavior, incontinence, and pressure ulcers were associated with higher adjusted odds of new LTC institutionalization. In analyses stratified according to race and ethnicity, higher income was associated with lower odds of LTC institutionalization for whites (odds ratio (OR) = 0.92, 95% confidence interval (CI) = 0.89-0.96) and greater odds for blacks (OR = 1.40, 95% CI = 1.27-1.55) and Hispanics (OR = 1.44, 95% CI = 1.25-1.66). Moderate or severe depression, functional limitations, hallucinations and delusions, aggressive behavior, and being unmarried were stronger risk factors for LTC for cognitively intact individuals than for those with moderate to severe cognitive impairment. Being unmarried and having more comorbidities were stronger predictors in those aged 66 to 70 than in those aged 81 to 85 and 91 and older.

Associations between risk factors and new LTC institutionalizations varied according to race and ethnicity, age, and level of cognitive function. Programs that target older adults at greater risk may be an effective strategy for reducing new institutionalizations and fostering aging in place.

The Motion Guidance Concept

This blog is intended to discuss the overall concept of the Motion Guidance system.

To start with, lets discuss some relevant background research regarding proprioception, injury, learning, and how all this ties into the unique visual feedback system that your clinic can incorporate to help assist patients.
When considering how people learn, lets look at some general information about auditory, experiential, and visual learners. According to Bradford et al,  “Verbal learners, a group that constitutes about 30% of the general population, learn by hearing. They benefit from class lectures and from discussion of class materials in study groups or in oral presentations, but chafe at written assignments. Experiential learners – about 5% of the population – learn by doing and touching, and clinical work, role-playing exercises, and moot court are their best instructional modalities. Visual learners – the remaining 65% of the population – need to see what they are learning” (1)
Are we missing out by not making exercise more "visual" for our patients???
Are we missing out by not making exercise more “visual” for our patients???
Although this research applies to more of a classroom setting, we can extrapolate these results and apply them to the context of rehabilitation and motor learning. In lieu of this information, if goals in rehabilitating your patient are directed at teaching your patient about body awareness, movement, and understanding their movement strategies or position, we may be missing a crucial part of our education by not using visual feedback.
Research has also noted that the use of “external cues” for motor-learning (ie mirrors, targets, etc) are superior to the use of “internal cues” (ie instruction on how to move during a task) (2). Visual feedback with the Motion Guidance laser device offers a much superior external cue than targets or mirrors, as the feedback is instant and the cue is something the person can directly follow and understand, without the unnecessary cognitive processes of verbal instruction: they see it.
There has been much conversation on the need for compliance during home exercise programs, and during rehab in general as well. What might increase compliance? For a start, the activity needs to make sense as in what the purpose of doing it is, as well as be stimulating. Laser visual feedback covers both these areas: it offers an instant assessment of movement, while instantly allowing the visualization of progress and movement control. This may be especially important among the cohort of youth athletes, who are more likely to view exercise with laser visual feedback as a game, but the concept applies to everyone, as the majority of persons across all age groups are visual learners.
Our bodies have inherent mechanisms to allow us to know where we are in space. This includes vision, tactile sensation, and proprioceptive sensation. Laser guided visual feedback rehabilitation covers all grounds, to create a learning experience that is all encompassing of these mechanisms. Research has shown that our brain’s representation of our body undergoes changes when we are injured. This has been labeled “cortical smudging” or “altered-body mapping” by educators on the topic (3). Essentially, after injury, our discrimination of the injured body part is globally diminished, in all inherent mechanisms. This includes 2-point discrimination (being able to accurately feel and discern pin-prick sensation), as well as “joint positional awareness.” Joint Positional Awareness (JPE) is our ability to understand where our body is in space. Trevelean et al (4) have conducted numerous studies concluding that after whiplash, subjects have difficulty discerning their head position when tested with visual feedback from a laser pointer.
This phenomenon has also been noted in lower back pain patients (5), knee pain (6) as well as shoulder pain patients (7), and the concept applies to every body part. Can we use this knowledge to help us rehabilitate our patient’s condition? Yes! It is as simple as adding visual feedback to movement, and practicing joint positional awareness, motor control, and movement strategy. What can assist in changing the cortex, the brain’s “body-map”? Afferent inputs! These can be both positively or negatively reinforced, by practicing normal fluid movements, or maladaptive antalgic movements, respectively. If motor commands are not compatible with somatosensory feedback, and this continues persistently, we are left with a dysfunctional system under the influence of pain.
Our brain's understanding of our body is organized, and can undergo changes via neuroplasticity. 

Our brain’s understanding of our body is organized,
and can undergo changes via neuroplasticity. 
There are a boat-load of ways to influence proprioception. These may include manual therapy (tactile afferent input), taping (the research seems to conclude that, while not actually changing biomechanical interfaces, beneficial results exist due to a change in how we (our brain) “views” the body part under the influence of a novel stimuli. This doesn’t make it a sham per say, as any means in disrupting a pain full habitual experience can be beneficial to the person physically and psychologically. We can influence cortical reorganization by applying specific exercises that emphasize joint repositional awareness, and specific neuromuscular control (such as attempting to move a body part guided by visual feedback with a laser pointer, with the goal of precision and accuracy.) Again, it is as simple as practicing these tasks.  
Visual feedback training for lumbo-pelvic awareness: pelvic tilting

Visual feedback training for lumbo-pelvic awareness: pelvic tilting
Here is an example of using the Motion Guidance laser pointer device with cervical JPE:

The Motion Guidance concept is, by nature, a creative concept that can be applied to any body part, to yield instant positional awareness. Functions may include “static functions”, where the laser is kept centered while the body moves (such as keeping the laser centered while performing a “bird dog” exercise, or dynamic (such as moving the laser as far as possible upward and downward during lumbopelvic ROM exercise):

“dynamic functions” can be endlessly: a few examples would be neck in tracking patterns for cervical motor control, shoulder working on ROM, and lower chain loading control:

Beyond clinic use, clinicians can offer their patients home-units to train with visual feedback at home, based on the specific need of the patient, at the discretion of the care provider. This is where compliance may be enhanced, as the visual feedback training is innately understood, and requires no additional feedback other than instructions on what the goals are.

Motion Guidance patient packs can be purchased in bulk at discount rates, and offered to patients through your clinic, as a means of not only giving your patient a tool that may help retain between session learning objectives, but also gain clinic revenue.


Patient packs are sold in sets of 5, for clinicians to distribute to patients.
For further video examples of applying the concept to cervical, shoulder, lumbar, lower chain, and general balance applications, browse our YouTube Channel.

Dr. Tal Blair via Motion Guidance

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic…