Research | What would you advise? | Beware Neurological Mousetraps
Research & Your Advice
For the past 3 weeks I have been conducting a systematic scoping review for my PhD on the topic of "The relationship between sleep posture and waking spinal symptoms of pain, stiffness and bothersomeness". A scoping review is similar to a systematic review, except it is better suited for new areas of research and areas in which the aim is to identify gaps in our current knowledge base. What's amazing to me, is that as a clinician I have been doling out advice about corrective sleep postures for years and yet there is basically nothing with a research base, on which to construct this education. Hence the scoping review and my PhD.
There is a reasonable body of evidence in relation to sleep systems (pillow, mattress and base), i.e. that a medium firm mattress is better that firm and both are better than a soft (sagging) mattress. In regards to pillows (be they normal or contoured shape, memory foam or normal foam) results in regards to quality of sleep is similar, except for a feather pillow which is to be avoided, but no research that uses validated measures to evaluate changes in sleep posture on waking spinal symptoms; think acute wry neck. Do you advise clients how they should sleep and on what basis?
Anyway, the point behind the sleep posture scoping review is to systematically comb the current research landscape using electronic databases (we used 8) and grey literature sources using a structure of key words, MeSH terms and combinations, we arrived at 4168 references. These then needed to be scanned in Endnote to remove duplicates, of which I went through and checked each manually to make sure they were actually duplicates – seriously, this process was as painful as watching paint dry on a wet and cold afternoon, total of 2093 checked.
The remainder were then imported into another program called Covidence. Here two or more independent reviewers get to decide if each of the remaining articles fall within set eligibility criteria and vote a Yes, No or Maybe for each article. That is what I have been doing all weekend, in between trips to feed the poddy calf, pull some weeds in the vege garden, cook dinner, clean the car – basically anything for a physical break!!! Hats off to researchers doing this full time. Another reviewer will independently repeat the same process and then we get to discuss any discrepancies in our voting.
While this all sounds very structured and organised (it is!!) I am amazed at the variance in articles that were caught up in our searching process. I learnt that there is a lot of literature around the subject of bed posture post lumbar punctures, the use of blood patches posts lumbar puncture, changes in CSF volumes and posture dura puncture headaches, that caudia equina symptoms tend to be worse in supine, ischaemic bed sores and that nurses develop back pain in association with increased postural loads during transferring of clients. Then every 400th reference would come along with something about fossilised dinosaur bones e.g. Yu, Chao Reconstruction of the skull of Diplodocus and the phylogeny of the Diplodocidae (Dinosauria: Sauropoda). A new primitive eucryptodiran turtle from the Upper Jurassic Phu Kradung Formation of the Khorat Plateau, NE Thailand. How does that happen?
Beware Neurological Mousetraps
Here a couple of neurological related abstracts I came across while searching, that are very pertinent to those of us in primary contact practitioner roles.
1. Shimada, Y.; Miyakoshi, N.; Kasukawa, Y.; Hongo, M.; Ando, S.; Itoi, E. Clinical features of cauda equina tumors requiring surgical treatment Tohoku Journal of Experimental Medicine 2006;209(1):1-6 DOI:http://dx.doi.org/10.1620/tjem.209.1
In this study, we evaluated the clinical features of cauda equina tumors requiring surgical treatment. Medical records of 28 patients with cauda equina tumors (13 men and 15 women) undergoing surgical treatment were retrospectively reviewed. The majority of histological diagnoses indicated schwannoma (23 cases, 82%), and the remaining 5 indicated ependymoma, neurofibroma, meningioma, and ganglioneuroblastoma. In 86% of the cases, the initial symptom was pain in the lower back and/or lower extremities. Preoperatively, half of the patients had symmetrical pain in the lower back or lower extremities, severe pain in the supine position, or pain that was increased by coughing. One third of the patients needed morphine to control nocturnal pain. Tumor size, as determined by magnetic resonance imaging (MRI), correlated with preoperative symptom duration (r = 0.66, p < 0.001). These findings indicate that symmetrical lower back pain and/or pain that radiates to both lower extremities and increases in the supine position are characteristic of cauda equina tumors. The correlation between symptom duration and tumor size indicates that earlier diagnosis of this tumor is necessary. Earlier diagnosis based on these characteristic symptoms should make use of further examinations such as MRI.
2. Lomaglio, Melanie; Canale, Bob Differential diagnosis and recovery of acute bilateral foot drop in a patient with a history of low back pain: A case report Physiotherapy Theory and Practice 2017;33(6):508-514 DOI: https://dx.doi.org/10.1080/09593985.2017.1323358
BACKGROUND AND PURPOSE: Acute bilateral foot drop is rare and may be due to peripheral or central lesions. The purpose of this case report was to describe the differential diagnosis and recovery of a patient with low back pain (LBP) that awoke with bilateral foot drop., CASE DESCRIPTION: A 39-year-old man with a history of LBP awoke with a steppage gait pattern. Spinal imaging and tapping were negative for sinister pathologies. A subsequent history taken by the physical therapist uncovered that the patient had previously taken a narcotic and slept in a kneeling position to relieve his LBP. Strength and sensory testing revealed isolated impairments in the fibular nerve distribution, and bilateral fibular palsy was suspected and later confirmed with electrophysiological studies. Surgical fibular nerve decompression was performed, and the patient underwent physical therapy. OUTCOMES: Five months later the patient demonstrated antigravity strength and a partial return of sensation. By 17 months, his Lower Extremity Functional Scale had improved from 17/80 to 78/80, revealing a near complete recovery. DISCUSSION: The patient's history of LBP was a "red herring" that delayed the diagnosis and caused undue stress to the patient. This case stresses the importance of a thorough history and clinical examination.
Special Private Practitioners Offer
If you found these abstracts interesting, I have put together several resources about the 'masquerading' behaviour of tumors and how to structure your examination to optimise your clinical reasoning process. You can read more about these online resources (video, audiobook, ebook) here or make the most of a special private practitioner bundle put together here "Private Practitioner's Bundle", that includes the Masqueraders resources and "7 Key Pillars in Private Practice".
"I just read 7 Pillars, and I think this is fantastic and extremely relevant for my current situation. The information you have presented has eased a lot of my anxieties by simplifying some of the hurdles I have already encountered in my 3 short months of working as a new grad and has given me very helpful tools to take on board. For me personally, the pillars two and three about confirming expectations and functional outcomes were the most helpful. In particular, the way you have explained the importance of the way intervention should be communicated (in a language that resonates with the patient and their functional goals) is excellent. The way you have explained things has made me realise that good communication with patients is vital in order to help maximise their compliance and motivation with achieving their personal goals. Just like you have mentioned with a few good examples, we need to communicate in a way which speaks our patient's language, which resonates with their goals so they feel validated and they are much more likely to buy in. Great advice!" Leah Noonan (Physiotherapist)
Tomorrow is a very special day, thank you to our ANZACs past and present.