By Peter Mraz

Now, in the time of spaghetti westerns, you used to always have the protagonist (the good guy) and the antagonist (the bad guy). Life was simple. The antagonist was ugly, rude, and mean, while the protagonist was tall, dark, and handsome. The roles were set in stone, and the story didn’t deviate from that. Kind of like the rehab social media space. BFR is either good or bad, either our handsome protagonist or our ugly antagonist.

But with the advance of cinema, we got our anti-hero. The anti-hero is a person who is bad, but you just can’t help yourself rooting for him. He has both good and bad in him. Being both the protagonist and antagonist in one. Picture Tony Soprano or Pablo Escobar. Now I want to present BFR in the same way. It’s neither totally good nor totally bad. It is our anti-hero for today’s blog.

BFR is currently a very hot topic. Some people think it’s the best thing since sliced bread, while others absolutely hate it. BFR was actually the topic of my Ba...

Introduction

Diffuse Idiopathic Skeletal Hyperostosis (DISH) and Ankylosing Spondylitis (AS) are two conditions that impact the spine, but they differ significantly in their underlying causes, progression, and clinical implications. Understanding each condition individually and then comparing them is key to accurate diagnosis and effective management.

Understanding DISH

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a non-inflammatory condition characterized by excessive bone formation in ligaments and tendons, particularly the anterior longitudinal ligament of the spine. This leads to ossifications that appear as flowing "candle wax" formations on imaging, spanning at least four contiguous vertebrae. DISH is more common in individuals over 50 and has a higher prevalence in men. Among individuals over 50, it occurs in about 25% of men and 15% of women, rising to 28% and 26%, respectively, in those over 80.

DISH is often asymptomatic, discovered incidentally during imaging for u...

Tandem spinal stenosis (TSS) is an underdiagnosed and poorly recognized condition characterized by narrowing of the spinal canal in at least two regions, most commonly the cervical and lumbar spine, with thoracic involvement often overlooked.

The prevalence of TSS varies widely, ranging from 7.6% to 60%, with higher rates observed in older male patients and those with degenerative spinal changes.

Tandem spinal stenosis has four subtypes—cervico-lumbar, cervico-thoracic, thoraco-lumbar, and cervico-thoraco-lumbar—each varying in prevalence and clinical presentation, underscoring the need for tailored diagnostic approaches.

Common causes include ossification of the posterior longitudinal ligament, ligamentum flavum, and degenerative changes of the spine. Tandem spinal stenosis can manifest as an asymptomatic radiographic finding or progress to severe myelopathy mixed with lower motor neuron signs. The most common is cervico-lumbar, followed by thoraco-cervical, with the other two s...

Have you ever seen or heard the word ‘ecological’ and not really known what it means when it comes to pain or rehab? If yes, then this is blog for you as I will aim to describe what it is in 10 minutes! The linked articles / chapters are hugely valuable so be sure to check them out!

 Ecological psychology is the branch of science looking cognition with a heavy component on the link between perception and action. And when it comes to people with pain, perception matters… a lot! It is a well-supported theory that the brain is actually a predictive processor, constantly generating hypotheses and expectations based on past experiences to anticipate and interpret incoming sensory information. Within an ecological-enactive approach to pain, pain does not only exist in the tissues (brain, joints, soft tissues e.t.c) but emerges through dynamic interactions between a person and their environment (and not just the physical one).

 Could it be that a part of the persistent pain process involves...

Spinal Red Flags

Sinister pathologies of the spine, aka red flags. Now, if reading that sentence sent shivers up your back like uttering the word ‘Lord Voldemort’ in a HPaz film, this blog might be for you. Fortunately, red flags account for <1% of all low back pain (LBP) (1) so for the vast majority we can apply the maxim of Dr Theodore Woodward, “when you hear hoofbeats, think of horses, not zebras”. However, this potentially means 1/100 LBP cases could be a sinister pathology and with LBP being the leading cause of disability worldwide to which patients seek healthcare advice, clinicians should take the trouble to learn about these red flags (or zebras) (2,3). 

For the purpose of this blog, I will discuss four sinister pathologies associated with LBP. But before that, what exactly is a red flag? Currently, there are 163 signs and symptoms designed to raise our ‘suspicion’. Although, when considered in isolation, they lack any robust diagnostic utility (4). So, what should we do...

Let’s tally up what information we have so far.

Caucasian female with a 5 year history of buttock, groin and anterior thigh pain. Reports being hypermobile. Unable to recall if breech birth or clicky hips, no matter. Not currently sporty or loading enough to be susceptible to a reactive tendinopathy and unlikely to have persistent tendinopathy given her history. No inflammatory sounding night pain, early morning stiffness or personal/first degree family history of inflammatory conditions.

Not responded to any rehabilitation efforts or medications so far. Frustrated. Questioning if things will ever change. Is it all in her head if the X-Ray says there is nothing wrong?

Clinically appears hypermobile on Beightons score, we know that has positive associations with DDH. Excessive rotation profile at the hip. Symptoms are reproduced on hip joint testing.

At this point I would be thinking there is enough evidence to suspect DDH. If we hadn’t of had an X-Ray then maybe the best thing for ...

Welcome back – be sure to read the first instalment of this blog before cracking on! READ HERE

Right then, clinical exam time. We are fully equipped with our differential diagnoses and index of suspicion that for Jade is a little higher for DDH than others. What are the things we need to look out for on our exam that will raise it further or nip this thought train in the bud? This is how I would approach it.

• Before I get Jade on the plinth – lets have a look at her Beighton’s score. She is skeletally mature and well into her 20’s so we’re definitely looking for more than a 5 or 6 out of 9 to be suspicious of global soft tissue laxity (there is no universal agreement on cut off). Jade scores a 7, it’s just her elbows that let her down from an A*/100%!
• Usual functional tasks e.g. squatting, bending. I’m not bothered about technique because I’m an ecologically informed therapist and know this doesn’t matter (don’t @ me). I’m more looking at if she is fearful or avoidant of certain po
...

“I am 39 now in constant pain... my hip often gives way without warning.... I feel like an old lady... What does the future now hold for me?”

 The above is a quote taken directly from a paper that interviewed people living with Developmental Dysplasia of the Hip (DDH) and I think is a great way to start this blog as it illustrates the impact this condition has on the individuals living with it and is a reminder that we should be able to make positive impacts. From the off, I would really recommend reading THIS paper which provides an insight into just how much symptoms related to DDH can affect the social aspect of life from pre-post op. The guys at the BCP have correctly given me a word count for this blog as I can go on a bit, so I won’t go too much further into the lived experience side of things, but as I said… READ THESE PAPERS! (Edit: )

 I would argue that as physiotherapists, patients with DDH are coming through our doors frequently, but that the proportion with an actual diag...

In the previous blogs (read here and here) we talked about the multi factorial etiology of PFP and the need to focus on getting our differential right. Education is key in the management along with communication and addressing the psychosocial factors. It is mind boggling to know that up to 500 factors can contribute to development and sustaining PFP (ref). Therefore, it is recommended that, when it comes to the management of PFP, it should be a combination of more than one treatment approach focusing on strength and managing load, addressing flexibility issues and central sensitization and retraining gait mechanics and control. (ref). Demonstrating the integrated approach of interventions with proven efficacy (Lack et al, 2018)

PATIENT EDUCATION

Patient education remains the cornerstone for the management of patellofemoral pain including providing information and reassurance. It should include proper explanation of the potential contributing factors and the prognosis along w...

RISK FACTORS: MULTIMODAL ETIOLOGY

As if the above factors were not enough, we got some more factors which are considered to be risk factors in contributing to the onset of this condition. These are structural causes which are divided into distal, local and proximal deficits. These include foot posture while running (ref) , reduced Quad strength (ref), delayed VMO activation (ref), weakness in eccentric hip abduction and hip external rotation (ref). It is seen that someone with PFP will show a combination of these local, proximal and distal factors making looking for the cause of pain that much more complex.

BIOMEDICAL OR BIOPSYCHOSOCIAL APPROACH ?

There seems to be no consensus at the moment on what causes PFP. Most likely, it is a combination of many factors, both structural and psychosocial. It has been shown that PFP seems to get better without any change in the alignment of structures which were initially thought as misaligned and evidently the cause of pain. (ref) The concept ...