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The Injured Runner:
An Evidence-Based Approach
         Part One: Running Injuries



    Allan Besselink, PT, Dip. MDT

 ...
Background

                                     Physical therapist (1988)
                                 ●



         ...
Evidence




                                           3
Allan Besselink, PT, Dip. MDT
Evidence-Based Medicine


“The plural of anecdote is not data”
                                (Frank Kotsonis)


“In God ...
Evidence-Based Medicine

    “The conscientious, explicit, and judicious
    use of current best evidence in making
    de...
Evidence-Based Medicine

But, one problem exists -


      Evidence is of no use if it is not integrated and
  –
      uti...
Belief Systems

     The impact of the provider's belief systems
     may be greater than the evidence


     Ross (1994):...
Belief Systems




                                            8
Allan Besselink, PT, Dip. MDT
Belief Systems


  “The inability to challenge our belief systems
  in the face of good scientific evidence is the
  prima...
Belief Systems


It is a very uncomfortable struggle to integrate
evidence into your thinking – especially if it is
contra...
Thinking

                                 “To arrive at a contradiction
                                 is to confess an...
Evidence ...

                                          … regardless of it's
                                          imp...
Lessons Learned: Back Pain

                                    What assessments?
                                ●


    ...
Evidence




                                           14
Allan Besselink, PT, Dip. MDT
A Brief History Of
                      Running Injuries
Perceived causes:




                                          ...
A Brief History Of
                      Running Injuries
Perceived causes:
             Muscle imbalances
         –

   ...
A Brief History Of
                      Running Injuries


30+ years of scientific evidence would indicate:


           ...
A Brief History Of
                          Running Injuries
    James SL, Bates BT, Osternig LR. Injuries to runners. Am...
“Normal”

                                     “Malalignment is a
                                     term that should be...
In the meantime ...

What do patients continue to hear from doctors,
chiropractors, and physical therapists treating
injur...
Evidence




                                           21
Allan Besselink, PT, Dip. MDT
MRI And Imaging

Perceived value of imaging in the assessment
process
Does the cost of imaging outweigh the
benefits?
Is i...
MRI And Imaging

    Krampla WW, Newrkla SP, Kroener AH, Hruby WF.
●

    Changes on magnetic resonance tomography in the ...
MRI And Imaging

    Schueller-Weidekamm C, Schueller G, Uffmann M, Bader
●

    TR. Does marathon running cause acute les...
MRI And Imaging

    Guten GN, Kohn HS, Zoltan DJ. 'False positive' MRI of the
●

    knee: a literature review study. WMJ...
MRI And Imaging

    Lessons learned from back pain: 70% of
●

    asymptomatics have a positive MRI
    If a patient has ...
In the meantime ...


What will physicians and chiropractors have the
patient do as a first line of assessment?
          ...
Evidence




                                           28
Allan Besselink, PT, Dip. MDT
Assessment Techniques

Perceived value in the clinical reasoning
process


Three primary approaches:
             Palpatio...
Palpation

    Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson
●

    VM, Murphy LS, Reinsch S. Reliability of spinal...
Asymmetry

    Badii M, Shin S, Torreggiani WC, Jankovic B, Gustafson
●

    P, Munk PL, and Esdaile JM. Pelvic bone asymm...
Sacroiliac Joint

    Sturesson B, Selvik G, Udén A. Movements of the
●

    sacroiliac joints. A roentgen stereophoto-gra...
Assessment Techniques


    Palpation-based assessment techniques are
●

    inherently unreliable
    What are the ramifi...
Motion/Provocation

    Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S,
●

    Telje T. The reliability of selected...
Repeated Movements

    Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H.
●

    Efficacy of flexion and extension tr...
Centralization

    Werneke MW, Hart DL, Resnik L, Stratford PW, Reyes A.
●

    Centralization: prevalence and effect on ...
Assessment Techniques


Movement-based and provocation-based
assessment techniques – reliability and validity


Centraliza...
In the meantime …


What do doctors, chiropractors, massage
therapists, and physical therapists continue to
utilize as a p...
Evidence




                                           39
Allan Besselink, PT, Dip. MDT
Treatment Interventions

Perceived Causes:
                        Muscle imbalances
                      ●


           ...
Treatment Interventions

Treatment Interventions:
                        Modalities
                      ●


           ...
Treatment Interventions

Treatment Interventions:
                        Orthotics and heel lifts
                      ●...
Treatment Interventions

Systematic reviews
             Modalities (ultrasound, electrical stimulation)
         –

     ...
Treatment Interventions

Based on the scientific literature regarding
treatment interventions, what do chiropractors,
mass...
Community Standards


Accepted Community Standards Of Care
(what providers and patients consider “acceptable”)
           ...
Problem


  ACSC and EBSC are not the same!


  ACSC has unfortunately become “gold
  standard” with patients




        ...
Responsibility

We continue to tell payors that evidence and
outcomes are important …


We continue to tell legislators th...
Responsibility

We continue to tell patients that evidence and
outcomes are important …


Our professional association con...
But In The Words Of Gandhi ...


                                “We must be the change
                                we...
Challenge Your Thinking!


                                “We can't solve
                                problems by usi...
For More Information:

                                    Smart Sport International
                                ●



...
Photo Credits
All photos Creative Commons (Attribution-No Derivative)
         #3, 14, 21, 28, 39, 94 “Evidence” on Flickr...
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The Injured Runner: An Evidence-Based Approach. Part One: Running Injuries

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Presentation to the Capital Area District of the Texas Physical Therapy Association 3/24/2009

Published in: Health & Medicine, Education
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The Injured Runner: An Evidence-Based Approach. Part One: Running Injuries

  1. 1. The Injured Runner: An Evidence-Based Approach Part One: Running Injuries Allan Besselink, PT, Dip. MDT Director, Smart Sport International Smart Life Institute Austin, Texas
  2. 2. Background Physical therapist (1988) ● McKenzie Diploma (1998) ● USA Track and Field ● Endurance sports coach ● (running, triathlon) Educator (PT; PTA) ● Author - “RunSmart: A ● Comprehensive Approach To Injury-Free Running” (2008) 2 Allan Besselink, PT, Dip. MDT
  3. 3. Evidence 3 Allan Besselink, PT, Dip. MDT
  4. 4. Evidence-Based Medicine “The plural of anecdote is not data” (Frank Kotsonis) “In God we trust – all others bring data” (Nik Bogduk) 4 Allan Besselink, PT, Dip. MDT
  5. 5. Evidence-Based Medicine “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: What it is and what it isn't. Br Med J, 1996; 312:71–72. 5 Allan Besselink, PT, Dip. MDT
  6. 6. Evidence-Based Medicine But, one problem exists - Evidence is of no use if it is not integrated and – utilized in the assessment and treatment algorithm Evidence must also extend to consumer awareness – 6 Allan Besselink, PT, Dip. MDT
  7. 7. Belief Systems The impact of the provider's belief systems may be greater than the evidence Ross (1994): “Our beliefs are the truth; – The truth is obvious; – Our beliefs are based on real data; – The data we select are the real data” – 7 Allan Besselink, PT, Dip. MDT
  8. 8. Belief Systems 8 Allan Besselink, PT, Dip. MDT
  9. 9. Belief Systems “The inability to challenge our belief systems in the face of good scientific evidence is the primary limiting factor in the advancement of both health care and coaching, as well as human performance and injury prevention” (Besselink 2008) 9 Allan Besselink, PT, Dip. MDT
  10. 10. Belief Systems It is a very uncomfortable struggle to integrate evidence into your thinking – especially if it is contrary to your current beliefs 10 Allan Besselink, PT, Dip. MDT
  11. 11. Thinking “To arrive at a contradiction is to confess an error in one’s thinking; to maintain a contradiction is to abdicate one’s mind and to evict oneself from the realm of reality” (Rand) 11 Allan Besselink, PT, Dip. MDT
  12. 12. Evidence ... … regardless of it's impact on the provider's bottom line or their personal beliefs It is an issue of cost, of efficacy, and of autonomy. 12 Allan Besselink, PT, Dip. MDT
  13. 13. Lessons Learned: Back Pain What assessments? ● What treatments? ● Well-established clinical ● guidelines Use the lessons learned from back pain research! 13 Allan Besselink, PT, Dip. MDT
  14. 14. Evidence 14 Allan Besselink, PT, Dip. MDT
  15. 15. A Brief History Of Running Injuries Perceived causes: 15 Allan Besselink, PT, Dip. MDT
  16. 16. A Brief History Of Running Injuries Perceived causes: Muscle imbalances – Lack of flexibility – Incorrect footwear – Leg length discrepancy – Foot structure – Too much speed work – Asymmetry and mal-alignment – 16 Allan Besselink, PT, Dip. MDT
  17. 17. A Brief History Of Running Injuries 30+ years of scientific evidence would indicate: No specific correlation between anatomic mal- alignment or variations in the lower extremity and any specific pathological entities or predisposition to any “overuse syndromes” 17 Allan Besselink, PT, Dip. MDT
  18. 18. A Brief History Of Running Injuries James SL, Bates BT, Osternig LR. Injuries to runners. Am ● J Sports Med 1978; 6: 40-50. Jacobs SJ, Berson BL. Injuries to runners: a study of ● entrants to a 10,000 meter race. Am J Sports Med 1986; 14: 151-155 McQuade K. A case-control study of running injuries: ● comparison of patterns of runners with and without running injuries. JOSPT 1986; 8: 81. Lysholm J, Wiklander J. Injuries in runners. Am J Sports ● Med 1987; 15: 168-171. 18 Allan Besselink, PT, Dip. MDT
  19. 19. “Normal” “Malalignment is a term that should be reserved for gross abnormalities, two standard deviations outside the norm” (Reid 1992) 19 Allan Besselink, PT, Dip. MDT
  20. 20. In the meantime ... What do patients continue to hear from doctors, chiropractors, and physical therapists treating injured runners? Muscle imbalances ● Lack of flexibility ● Incorrect footwear ● Leg length discrepancy ● Foot structure ● Too much speed work ● Asymmetry and mal-alignment ● 20 Allan Besselink, PT, Dip. MDT
  21. 21. Evidence 21 Allan Besselink, PT, Dip. MDT
  22. 22. MRI And Imaging Perceived value of imaging in the assessment process Does the cost of imaging outweigh the benefits? Is imaging relevant and pertinent as a first line of assessment? 22 Allan Besselink, PT, Dip. MDT
  23. 23. MRI And Imaging Krampla WW, Newrkla SP, Kroener AH, Hruby WF. ● Changes on magnetic resonance tomography in the knee joints of marathon runners: a 10-year longitudinal study. Skeletal Radiol 2008; 37(7):619-26. Stahl R, Luke A, Ma CB, Krug R, Steinbach L, Majumdar ● S, Link TM. Prevalence of pathologic findings in asymptomatic knees of marathon runners before and after a competition in comparison with physically active subjects-a 3.0 T magnetic resonance imaging study. Skeletal Radiol 2008; 37(7):627-38. 23 Allan Besselink, PT, Dip. MDT
  24. 24. MRI And Imaging Schueller-Weidekamm C, Schueller G, Uffmann M, Bader ● TR. Does marathon running cause acute lesions of the knee? Evaluation with magnetic resonance imaging. Eur Radiol 2006; 16(10): 2179-85. Boos N, Rieder R, Schade V, Spratt KF, Semmer N, Aebi ● M. 1995 Volvo Award in clinical sciences. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine 1995; 20(24):2613-25. 24 Allan Besselink, PT, Dip. MDT
  25. 25. MRI And Imaging Guten GN, Kohn HS, Zoltan DJ. 'False positive' MRI of the ● knee: a literature review study. WMJ 2002; 101(1):35-8. Sein ML, Walton J, Linklater J, Harris C, Dugal T, ● Appleyard R, Kirkbride B, Kuah D, Murrell GA. Reliability of MRI assessment of supraspinatus tendinopathy. British Journal of Sports Medicine 2007; 41(8). 25 Allan Besselink, PT, Dip. MDT
  26. 26. MRI And Imaging Lessons learned from back pain: 70% of ● asymptomatics have a positive MRI If a patient has a positive MRI, what does it tell ● us? Similar data exists for shoulders and knees ● Well-established clinical guidelines would ● indicate that this should not be a first line of assessment 26 Allan Besselink, PT, Dip. MDT
  27. 27. In the meantime ... What will physicians and chiropractors have the patient do as a first line of assessment? MRI – Radiographs – CT scans – 27 Allan Besselink, PT, Dip. MDT
  28. 28. Evidence 28 Allan Besselink, PT, Dip. MDT
  29. 29. Assessment Techniques Perceived value in the clinical reasoning process Three primary approaches: Palpation-based – Movement-based – Provocation-based – 29 Allan Besselink, PT, Dip. MDT
  30. 30. Palpation Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson ● VM, Murphy LS, Reinsch S. Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine 2004; 29(19). van Trijffel E, Anderegg Q, Bossuyt PM, Lucas C. Inter- ● examiner reliability of passive assessment of intervertebral motion in the cervical and lumbar spine: a systematic review. Manual therapy 2005; 10(4): 256-269. 30 Allan Besselink, PT, Dip. MDT
  31. 31. Asymmetry Badii M, Shin S, Torreggiani WC, Jankovic B, Gustafson ● P, Munk PL, and Esdaile JM. Pelvic bone asymmetry in 323 study participants receiving abdominal ct scans. Spine 2003; 28(12): 1335-1339. Patients without back pain – 82.7% asymmetrical; 5% > 5mm – previous reports of 24 – 91% (in back pain – patients) Can this be palpated? – 31 Allan Besselink, PT, Dip. MDT
  32. 32. Sacroiliac Joint Sturesson B, Selvik G, Udén A. Movements of the ● sacroiliac joints. A roentgen stereophoto-grammetric analysis. Spine 1989; 14(2): 162-5. 2.5 degrees of rotation, 0.7 mm of translation – No difference between asymptomatic and – symptomatic joints 32 Allan Besselink, PT, Dip. MDT
  33. 33. Assessment Techniques Palpation-based assessment techniques are ● inherently unreliable What are the ramifications if two people can't ● agree on what they feel – and do so consistently? If there is questionable inter-rater reliability, ● then what is the level of validity? 33 Allan Besselink, PT, Dip. MDT
  34. 34. Motion/Provocation Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S, ● Telje T. The reliability of selected motion- and pain provocation tests for the sacroiliac joint. Manual Therapy 2007; 12(1): 72-79. Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley ● JH, Laslett M, Bogduk N. Systematic review of tests to identify the disc, sij or facet joint as the source of low back pain. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2007; 16(10): 1539-1550. 34 Allan Besselink, PT, Dip. MDT
  35. 35. Repeated Movements Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H. ● Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine 1993; 18(13): 1839-49. Kilpikoski S, Airaksinen O, Kankaanpää M, Leminen P, ● Videman T, Alen M. Interexaminer reliability of low back pain assessment using the McKenzie method. Spine 2002; 15; 27(8): E207-14. 35 Allan Besselink, PT, Dip. MDT
  36. 36. Centralization Werneke MW, Hart DL, Resnik L, Stratford PW, Reyes A. ● Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method. J Orthop Sports Phys Ther 2008; 38(3):116-25. Skytte L, May S, Petersen P. Centralization: its prognostic ● value in patients with referred symptoms and sciatica. Spine 2005; 30(11): E293-9. Aina A, May S, Clare H. The centralization phenomenon of ● spinal symptoms--a systematic review. Man Ther 2004; 9(3): 134-43. 36 Allan Besselink, PT, Dip. MDT
  37. 37. Assessment Techniques Movement-based and provocation-based assessment techniques – reliability and validity Centralization as a prognostic indicator Repeated movement testing as reliable as MRI but with far less cost! 37 Allan Besselink, PT, Dip. MDT
  38. 38. In the meantime … What do doctors, chiropractors, massage therapists, and physical therapists continue to utilize as a primary form of assessment and upon which they base their clinical reasoning? Palpation-based assessment techniques – 38 Allan Besselink, PT, Dip. MDT
  39. 39. Evidence 39 Allan Besselink, PT, Dip. MDT
  40. 40. Treatment Interventions Perceived Causes: Muscle imbalances ● ● Lack of flexibility ● Incorrect footwear ● Leg length discrepancy ● Foot structure ● Too much speed work ● Asymmetry and mal-alignment 40 Allan Besselink, PT, Dip. MDT
  41. 41. Treatment Interventions Treatment Interventions: Modalities ● ● Active Release Therapy/Graston ● Strain-Counterstrain ● SI joint manipulation 41 Allan Besselink, PT, Dip. MDT
  42. 42. Treatment Interventions Treatment Interventions: Orthotics and heel lifts ● ● Shoes ● Core stabilization ● Stretching ● Aquajogging 42 Allan Besselink, PT, Dip. MDT
  43. 43. Treatment Interventions Systematic reviews Modalities (ultrasound, electrical stimulation) – Spinal manipulation – ART/Graston – Orthotics – Stretching – Core stabilization – 43 Allan Besselink, PT, Dip. MDT
  44. 44. Treatment Interventions Based on the scientific literature regarding treatment interventions, what do chiropractors, massage therapists, and physical therapists continue to utilize? 44 Allan Besselink, PT, Dip. MDT
  45. 45. Community Standards Accepted Community Standards Of Care (what providers and patients consider “acceptable”) vs Evidence-Based Standards Of Care (clinical guidelines; outcomes-driven) 45 Allan Besselink, PT, Dip. MDT
  46. 46. Problem ACSC and EBSC are not the same! ACSC has unfortunately become “gold standard” with patients 46 Allan Besselink, PT, Dip. MDT
  47. 47. Responsibility We continue to tell payors that evidence and outcomes are important … We continue to tell legislators that evidence and outcomes are important … We continue to tell students that evidence and outcomes are important … 47 Allan Besselink, PT, Dip. MDT
  48. 48. Responsibility We continue to tell patients that evidence and outcomes are important … Our professional association continues to advocate it ... 48 Allan Besselink, PT, Dip. MDT
  49. 49. But In The Words Of Gandhi ... “We must be the change we wish to see in the world” 49 Allan Besselink, PT, Dip. MDT
  50. 50. Challenge Your Thinking! “We can't solve problems by using the same kind of thinking we used when we created them.” (Einstein) 50 Allan Besselink, PT, Dip. MDT
  51. 51. For More Information: Smart Sport International ● www.smartsport.info Smart Life Institute ● www.smartlifeinstitute.com “Consumer's Guide To Health” ● Every second Tues at 8:00pm CT www.blogtalkradio.com/abesselink “RunSmart: A Comprehensive Approach To ● Injury-Free Running” www.lulu.com/abesselink 51 Allan Besselink, PT, Dip. MDT
  52. 52. Photo Credits All photos Creative Commons (Attribution-No Derivative) #3, 14, 21, 28, 39, 94 “Evidence” on Flickr by billaday – #8 “Counterstatement to what sean calls 'evidence'” on Flickr by astera – snowwhite #12 “Choose your evidence carefully” on Flickr by rocket ship – #49 “Il y a 60 ans, Gandhi assassinéquot; on Flickr by ah zut – #13, 51: Allan Besselink – All others understood to be public domain/fair use and all attempts have – been made to identify all image owners and licenses 52 Allan Besselink, PT, Dip. MDT

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