Post a word documentation (one-page synopsis) of your Literature Presentation here.
“Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee” Deyle, et al. What problems did the researchers set out to study, and why?
The researchers found very few investigations that include both subjective and objective measures of the effectiveness of treatments for osteoarthritis of the knee. Beneficial interventions may decrease the need for more invasive treatments. The purpose of this study was to evaluate the effectiveness of physical therapy for osteoarthritis of the knee applied by physical therapists who have formal training in manual therapy. Who participated in the study?
83 patients with osteoarthritis of the knee participated in this study. 15 men and 27 women with a mean age of 60 were randomly assigned to receive treatment and 19 men and 22 women with a mean age of 62 years were randomly assigned to the placebo group. Inclusion criteria included a diagnosis of osteoarthritis of the knee based on the criteria developed by Altman and colleagues, be eligible for military health care, have had no surgical procedure on either lower extremities in the past 6 months, and have no physical impairment unrelated to the knee that would prevent the completion of the study. Participants were also required to live within a 1 hour drive of the clinic and were instructed to not take any new medication for osteoarthritis. What new information does the study offer?
One year after the study, patients in the placebo group had more knee surgeries than patients in the treatment group. 20% of the 41 patients in the placebo group had undergone a TKA compared to the 5% of the 42 patients in the treatment group. Patients with knee osteoarthritis who were treated with both manual physical therapy and exercise had statistically significant improvements in self-perceptions of pain, stiffness, and functional ability and the distance walked in 6 minutes. This type of treatment may defer or decrease the need for surgical intervention. How did researchers go about this study?
Participants were referred by physicians to physical therapy from various clinics, but they had to be eligible for military health care. Patients were assigned blank folders numbered from 1-100 and the therapists drew a folder, which determined group assignment. There were two groups, a treatment group and a control or placebo group. The treatment group received a combination of manual physical therapy and supervised exercise. The placebo group received ultrasound at a sub-therapeutic intensity. Neither group was aware of the treatment the other was receiving. The WOMAC Index and the 6 minute walk test were used as functional tests. How might the results of this study apply to physical therapist practice?
These studies might apply to a physical therapist because it is important to know what types of treatment have proven literature behind them. This study confirms that through muscle strengthening and manual therapy there is improvement in a patients pain levels and functional abilities. The exercises used included:
ROM: Long sitting knee midflexion to end range extension 2x 30 second bouts with 3 second hold in extension ----- and ------ Stationary Bike, 5 min
Exercise: Static quad set in knee extension, standing terminal knee extension, seated leg press, dips weight lessened, and step ups
Because osteoarthritis has become such a common problem with the aging population, it will be important for new PT’s to continue to stay involved in the literature and what methods are working for increasing function. According to this article, manual therapy and exercise help to defer or decrease the need for surgical intervention. The decrease in surgical intervention helps decrease patients risk of infection/complication, as well as decrease the cost of time spent in the hospitals. While this may not be the case for all patients, this type of treatment may very well be the first line when a person is faced with the diagnosis of osteoarthritis. What are the limitations of the study, what further research is needed?
The limitations of the study included that the dropout rate for the trial was higher in the treatment group. The researchers do not believe that the treatment itself had negative outcomes, leading to patient’s withdrawing from the study, but I think this should be something that was a follow up study. If the exercises were too difficult or caused too much pain this could have caused a higher attrition rate.
Another area that might need to be addressed is were the benefits only lasting a year or would the benefits affect the patient for a longer time period. That question also raises the question of if the patient is going to end up having a TKA is it more beneficial for the patient to have it done younger, rather then giving exercises and pushing the surgery back 5-10 years where health my be more declined.
Deyle, G., Henderson N., Matekel, R., Ryder, M., Garber, M., Alllison, S. (2000). Effectiveness of manual physical therapy and exercise in osteoatrthritis of the knee. A randomized controlled trial. Annals of Internal Medicine, 132(3), 173-81.
Written by: David Kempin and Laura Sweeney
Progressive strength training in older patients after hip fracture: a randomised controlled trial
HILDE SYLLIAAS, THERESE BROVOLD, TORGEIR BRUUNWYLLER, ASTRID BERGLAND
What problem did the researchers set out to solve and why? Immobilization after major surgery and during hospitalization can cause a severe decline in muscle strength and functioning. While physical training seems to improve strength and functional performance in hip fracture patients, evidence is insufficient with respect to best practices in rehabilitating hip fracture in older adults. Therefore, the aim of this study was to assess the effect of a 3 month strength training program of progressive resistance exercise training on balance, strength, mobility, iADLs, and self-rated health in older home-dwelling hip fracture patients. Who participated in the study? 150 hip fracture patients who were 12 weeks post fracture were eligible to participate in the study. All patients were age 65 or older, living at home, able to undergo physical therapy for the hip fx, and scored at least 23/30 on the Mini-Mental State Examination (MMSE). How did the researchers go about this study?
Hip fracture patients, starting at 12 weeks post fracture, were followed for 12 weeks without any intervention. Then in a 2:1 fashion, the patients were randomly divided into either an intervention or control group. Those in the intervention group would later be randomized into further intervention or control groups for another 12 weeks. 3 month phase (3-6 weeks post fracture):
1 rep max (RM) was measured for 2 different exercises (knee flexion & knee extension)
10-15 minute warm-up on treadmill or stationary bicycle
45-60 minute exercise session depending on patient’s ability and tolerance
3 sets of 15 repetitions at 70% of the participant’s 1 RM
1 RM was re-measured every 3rd week and number of repetitions was reduced from 12 to 10, maintaining at least 8 reps
Patients completed 4 exercises: Standing knee flexion, lunge (pass forward), sitting knee extension, and leg extension
Patients attended exercise sessions 2x per week and completed a home exercise program 1x per week
HEP: standing knee flexion, lunge (pass forward)
Patients advised to walk 30 minutes/day if able
Patients in the control group were asked to maintain their current lifestyle with no restrictions. Measurements were taken after the 3 month intervention. What new information does this study offer? Many studies have researched the effects of immobilization on muscle strength, endurance, and functional performance. Also, it has been found that physical training is the best way to combat these effects. However, this study is a first to only focus on progressive strength training as an intervention for hip fracture patients. How might the results of this study apply to physical therapist practice? This study found highly significant effects of progressive strength training on balance as well as strength, gait distance and functional performance in older hip fracture patients. This suggests that an older home dwelling population that have sustained a hip fracture can benefit from an extended strength-training program. Hip fracture patients are a large population that frequently will be seen in a physical therapy clinical setting so this study’s findings are relevant to the therapists that will be treating such patients. What are the limitations of the study and what further research is needed? The intervention group may have had greater social contact than the control group. The improvements could have resulted from a ‘placebo-effect’ and additional contact rather than from the exercises. Exercise intervention studies appeal to healthier and more motivated individuals. Any exercises or any other interventions as well as levels of physical activity for the control group were not discussed. The inclusion criteria were limited to older people living on their own without moderate and severe cognitive symptoms. This criterion suggests that conclusions about the training results may not be extended beyond older hip fracture populations living at home. Further research of this intervention could be applied to other populations or the same population of older people with hip fractures that were not living at home which were excluded from this study.
This summary was written by Brandon Smith, Kelci McFarland, Shannon Lynch
Sylliaas, H., Brovold, T., Wyller, T., & Bergland, A. (2011). Progressive strength training in older patients after hip fracture: a randomised controlled trail. Age and Aging, 40, 221-227.
The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial
KHALIL KHAYAMBASHI, PT, PhD1 • ZEYNAB MOHAMMADKHANI, MS2 • KOUROSH GHAZNAVI, MD3MARK A. LYLE, PT, OCS4 • CHRISTOPHER M. POWERS, PT, PhD5 This article summary was written by Sarah Lickteig and Rick Hill What problem did the researchers set out to solve and why?
The researchers in this study wanted to see if by isolating the hip and only strengthening the external rotators and the abductor muscles they could decrease patellofemoral pain (PFP), increase health status, and increase hip strength. They did this because to their knowledge, they believe they are the first study to isolate the hip musculature and relate it to PFP, while also involving a control group. Also they wanted to see how much of an effect the hip musculature had on PFP.
Who participated in the study?
The participants were 28 females diagnosed with bilateral patellofemoral pain syndrome (PFPS) and had symptoms for more than 6 months. They also had not previously received physical therapy. Initially there were 67 participants, but only 28 fit the inclusion criteria.
What new information does this study offer?
By strengthening the hip external rotators and hip abductors, PFP pain is decreased bilaterally, health status is increased and hip strength is increased. Strengthening of the quads or other musculature is not necessary to improve these areas in females with B PFPS.
How did the researchers go about this study?
The researchers randomly assigned the 28 participants into two different groups, a control group and an exercise group. The control group was instructed to take Omega-3 and Calcium every day for eight weeks. The exercise group was given two exercises to perform in the lab three times a week for eight weeks. Their program consisted of one hip abduction exercise and one hip external rotation exercise, each consisting of a theraband wrapped around the patient’s ankle and tied to a beam for resistance. Each group was measured in all three areas (strength, pain, and health status) prior to the intervention and post intervention (8 weeks later). The exercise group was also measured 6 months later for follow-up.
How might the results of this study apply to physical therapist practice?
The results can be helpful for PTs because PFPS is a common diagnosis in the outpatient clinic. This study shows that hip strengthening should definitely be included in the POC and the HEP for patients with PFPS, regardless of whether or not quad or hamstring strengthening is done.
What are the limitations of the study and what further research is needed?
The study had a small, homogeneous set of subjects. The control group was not measured for pain, health status, or hip strength six months later. They did not quantify strength in the exercise group at the six month follow-up. The researcher taking measurements was not blinded. The possible confound of self-administered pain medication by the subjects.
Reference http://www.jospt.org/issues/articleID.2650,type.1/article_detail.asp
Khayambashi, K., Mohammadkhani, Z., Ghaznavi, K., Lyle, M. A., & Powers, C. M. (2012). The effects of isolated hip abductor and external rotator muscle strengthening on pain, health status, and hip strength in females with patellofemoral pain: a randomized controlled trial. The Journal of orthopaedic and sports physical therapy, 42(1), 22-9. doi:10.2519/jospt.2012.3704
An alternative approach to treating lateral epicondylitis. A Randomized, placebo-controlled, double-blinded study
Angie Moody, Madeline McCann
What problems did the researchers set out to study and why?
The researchers of this study, Mohammad Reza Nourbakhsh and Frank J Fearon, were trying to investigate chronic lateral epicondylitis . Previous research of this subject has suggested that local tender points in the lateral elbow can cause pain when palpated, stretched, or during muscle contractions of repetitive movements of the wrist and elbow. Noxious electrical stimulation can be used as a treatment of trigger points. The purpose was to investigate the effect of noxious electrical stimulation on pain, grip strength, and functional status on patients with chronic lateral epicondylitis.
How did the researchers go about the study and who participated?
The design of the study was randomized, placebo-controlled and double-blinded. Subjects were between the ages of 24 and 72 and were involved in heavy or repetitive arm movements. All subjects had received unsuccessful treatment previously for lateral epicondylitis. Subjects were randomly assigned to either the treatment or placebo group. The treatment group had 10 participants and received low frequency electrical stimulation with intensity as tolerated. The placebo group had 8 participants and received low frequency electrical stimulation with intensity set at 0. Outcome data was collected prior to the intervention in both groups including grip strength, pain, and functional status. Researchers used a dynamometer to measure grip strength in the affected arm. A Numeric Rating Scale was used to assess pain intensity and any activity limitations due to pain and a similar scale was used to assess activity limitation. The functional outcomes were measured with an adapted Patient-Specific Functional Scale. The subjects each chose 3 activities that were affected by their lateral epicondylitis and then were instructed to rate the level of difficulty on a scale of 0-10. For the treatment group, the researchers palpated painful areas on the lateral epicondyle region and searched for the tender points with a probe electrode. After they found the tender points they administered electrical stimulation. The subjects in the placebo group went through the same procedure; however, the intensity was kept at zero.
What new information does this study have to offer?
The results of the study showed a significant difference in grip strength, pain rating, activity limitations due to pain, and functional status between the intervention and placebo. The treatment group had significant increased grip strength, decreased pain intensity, and increased functional level as compared to the placebo group.
How might the results of this study apply to PT practice?
The results of this study provide an alternative treatment for chronic lateral epicondylitis. This study also suggests that the pathophysiology of lateral epicondylitis may be more related to tender points rather than from inflammation. Additionally, a follow up of participant indicated this treatment can be beneficial to patients after 6 months following treatment.
What are the limitations of this study, and what future research is needed?
The study had a relatively small sample size of only 18 participants. The small sample size decreases the generalizability of these findings to a larger population. Additionally two subjects dropped out of the treatment group and the researchers did not perform intention to treat analysis. Future research should aim to replicate these findings on a larger, more heterogeneous sample. Future research could also study the effects of noxious electrical stimulation in combination with therapeutic exercise for lateral epicondylitis.
Reference:
Reza Nourbakhsh, M., & Fearon, F. J. (2008). An alternative approach to treating lateral epicondylitis. A randomized, placebo-controlled, double-blinded study. Clinical rehabilitation, 22(7), 601-9. doi:10.1177/0269215507088447 Katie Barta, Christine Chollet, Brandon Walker
Operative versus non-operative management following Rockwood grade III acromioclavicular separation: a meta-analysis of the current evidence base
Intro/Materials & Methods
Acromioclavicular dislocations can be determined based on degree and direction of displacement using Rockwood’s classification. Generally grades I and II are treated conservatively while grades V and VI are treated surgically. This article discusses a grade III separation which “is classified as a superior displacement of the lateral end of the clavicle of one clavicular diameter or 1cm on the anteroposterior radiograph, whilst grade IV is described as a separation of the acromioclavicular joint with the distal clavicle displaced posterior into the trapezial fascia.” There is not a general consensus for the management of grades III and IV treatment and whether they should be treated surgically or conservatively. This review examined the outcomes of those patients with grade III dislocations treated conservatively against those treated surgically.
In order to be included in this systematic review, studies had to include a comparison of patients with an acute, closed grade III dislocation treated conservatively and those treated surgically. Randomized control trials and non-randomized controlled trials were used. To be included, studies had to have at least one outcome of interest. In this case, the main outcome was Constant score. Secondary outcomes were also included. In order to find studies of interest, various electronic databases were searched using MeSH terms and Boolean operators. The reference lists of possible studies were reviewed and authors were contacted for information on any additional studies. Two reviewers examined the various studies and compared them to the set eligibility requirements before they could be included in the review. Studies were then scored using the PEDro scale. Heterogeneity was appraised using the chi-square test and a meta-analysis was done when outcomes could be pooled. Risk difference was the effects measure for dichotomous outcomes and the effect measure for continuous outcomes was mean difference. A P of <.005 and confidence intervals of 95% were used.
Results
Of the potential 724 citations identified, six of the studies were eligible for this study. In total, there were 380 participants divided into the operative and non-operative groups. Participants in the operative group had fixations using wire or screw fixations methods and all repaired the coracoclavicular and acromioclavicular ligaments. In the non-operative group, management was not well described or specific, however a general type was given: sling, taping technique or casting. Time frame for immobilization was also variable ranging from 2 to 4 weeks or until pain and symptoms were gone.
Results of the meta-analysis were overall inconclusive. The primary outcome of the study, the “constant score”, did show that operative management had better functional outcomes than non-operative outcomes for management of a grade III acromioclavicular separation (p=0.03). This statistic, though, is based off of only one study. Outcomes that did not have significance were throwing ability, strength, pain, and ossification of the coracoclavicular ligament or acromioclavicular joint (p>0.05). Other outcomes that were significant were poor cosmetics with non-operative (p<0.0001), greater sick leave time following operative (p<0.0001) and higher rate of infection with operative management (p=0.03).
Discussion
The main finding is that there is no significant difference in clinical or radiological outcomes. Non-operative treatment was associated with worse cosmetic outcomes and less sick leave. The included studies have limited validity because of no group randomization, assessors were not masked, and inadequate sample size. One of the more recent papers showed that operative treatment had better outcomes than non-operative treatment. Future research may show results that tend to be in favor of operative treatment due to improvements in operative techniques. Most of the included studies did not distinguish hand dominance related to side of injury, and this could be an important variable when considering functional outcome assessment. Another potential confounding variable is the time between injury and surgery, as patients who have acute surgery are likely to show better outcomes than those with delayed repairs. Based on the findings of this study, anatomical alignment alone is not reason enough to justify surgery of grade III AC separations because no significant difference in functional outcomes was found. Some authors suggest that surgical treatment may be better than non-surgical treatment for patients who intend to return to sport or have physically demanding jobs, but this idea is not supported by this study because of the young average age of the patients and the common mechanism of injury being sports and occupational related. Non-surgical treatment may be viewed as the better treatment because there is no functional difference, and it is associated with decreased time of sick leave. However, non-operative treatments strategies were not well defined. The risk of complications, specifically infection, is one of the disadvantages of operative treatment, but the infection rate after AC repair is relatively low. A comparison of cost effectiveness between the 2 treatment strategies was not completed, but it should be. It is expected that the non-operative treatment is cheaper because of decreased sick leave, and the increased cost of hospitalization and operation associated with surgery. Bottom line, there is no difference in strength, pain, or throwing ability between the 2 treatments, but surgery resulted in increased sick leave and better cosmetic results. More large RCTs are needed to produce good evidence.
Citation
Smith, T. O., Chester, R., Pearse, E. O., & Hing, C. B. (2011). Operative versus non-operative management following Rockwood grade III acromioclavicular separation: a meta-analysis of the current evidence base. Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology, 12(1), 19-27. doi:10.1007/s10195-011-0127-1
What problems did the researchers set out to study, and why? The researchers set out to determine if symptoms of carpal tunnel syndrome (CTS) and associated functional limitations could be relieved by ischemic compression therapy used on trigger points (TrPs). CTS is the most common nerve entrapment syndrome, causing paresthesia and numbness along the median nerve distribution in the hand (thumb, index, middle, and half the ring finger), due to compression of the median nerve at any number of sites along its route. Intervention starts with conservative treatment including wrist support, anti-inflammatory medications, and a change in activities. If symptoms do not resolve within six months, cortisone injections are used and CT release surgery is considered. In patients with CTS, the median nerve is twice its normal size when it enters the CT, possibly due to edema caused by noxious myofascial sites along its route from the axilla, running adjacent to the biceps, and descending the hollow of the elbow under the pronator teres and bicipital aponeurosis. TrPs cause a continual partial contraction of the muscle, resulting in higher oxygen and glucose consumption, demanding more blood flow. At night, when blood flow decreases, lactic acid builds up and accentuates the contraction, irritating the nerve.
Who participated in the study? Subjects in the study were between the ages of 20 and 60 years old, must have suffered from numbness in the hand that affects the median nerve distribution (in the thumb, index finger, middle finger, and half the ring finger), must have suffered on a daily basis for a minimum of three months, must demonstrate positive signs on at least two of the following tests/physical signs: Tinnel test, Phalen test, or sleep problems caused by the hand discomfort, and each subject must agree to a course of 15 chiropractic treatments at no cost to the subject. The only exclusion criteria included was a history of surgery to the upper limb or neck, pregnancy, and presence of a systemic pathology possibly related to CTS such as hypothyroidism, diabetes, and rheumatoid arthritis. The 55 included subjects were randomly assigned to either an experimental or control group, at a 2:1 ratio (37 experimental and 18 control). Patients were blinded to their treatment group.
What new information does this study offer? Ischemic compression therapy at TrPs along the median nerve route is an affective method of relieving symptoms and functional limitation associated with CTS. The results were found to be significant for both questionnaires at each follow up assessment in the experimental group, and a significant difference was found between the two groups about perceived improvement, with the experimental group finding more improvement.
How did the researchers go about this study? TrPs targeted in the experimental group were along the biceps, axilla, pronator teres, and bicipital aponeurosis. Each subject had TrPs in the biceps and bicipital aponeurosis, and most in the pronator teres and axilla. The control group received treatment for TrPs in the posterior region of the clavicle, deltoid, and center of the scapula. These were far enough from the median nerve not to have an effect but close enough to seem a plausible treatment to subjects. Pressure was applied for 5–15 seconds to each identified TrP. Thumb tip pressure was applied for 5 seconds every 2 centimeters along the biceps. For TrPs in the pronator teres, biceps aponeurosis, and axilla, pressure was maintained for 15 seconds. Outcomes were assessed by a two part validated questionnaire specific to CTS that is known to be reproducible and internally consistent, since CTS patients usually consult a clinician due to severity of symptoms and the difficultly they have with tasks of daily life. Part one defines functional status and part two assesses severity of symptoms. In addition, a scale ranging from 0-100% was used to determine subjects’ perceived improvement. Data was collected pre- and post- treatment for both groups, and 30 days and six months later for the experimental group.
How might the results of this study apply to physical therapist practice? Physical therapists can use trigger point release/massage at the locations identified along the median nerve route to treat patients suffering from CTS symptoms. This is a conservative treatment to be used initially to not only relieve symptoms, but also treat the cause of the compression. This treatment could potentially prevent surgery in CTS patients.
What are the limitations of the study, and what further research is needed? A major limitation of the study was the sample size; further, the control group was especially small. The control group was not followed up with long term, as the experimental group was, so there is no way to determine if the CTS spontaneously resolved by then. Further, the control group was immediately crossed over and offered experimental treatment following the conclusion of the placebo treatment. This yielded results in favor of the experimental treatment, but not enough time was allowed to wash out any placebo effect. Future research should include a larger sample, a placebo group parallel to the experimental, and a long term follow up. Additional research could investigate different types of TrP therapy and treatment dosage, to determine the most effective and efficient treatment for CTS patients.
What problem did the researchers set out to solve and why? Researchers noted that there have been studies documenting successful outcomes with surgical interventions for SLAP tears but there is very little information regarding nonoperative outcomes, so they created this study.
Who participated in the study? 39 patients diagnosed with superior labrum anterior posterior (SLAP) lesions were included and there were 8 exclusion criteria.
How did the researchers go about this study? All patients diagnosed with a SLAP lesion within the researcher’s institution were surveyed before and after non-operative treatment. The outcome measures included Short Form 36 (SF-36), European Quality of Life measure (EuroQol), visual analog pain scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and simple shoulder test (SST). Upon diagnosis, all participants underwent a physical therapy program, which included posterior capsular stretching and scapular stabilization exercises and all patients were prescribed NSAIDs.
Statistically significant functional improvement was observed following non-operative treatment (p < .001). Decreased pain was found in patients after non-operative treatment (p < .043), as well as increased quality of life (p < .009). Finally, all patients reporting themselves as active prior to injury returned to athletics within 6 months via the non-surgical approach although only 71% reported participating at a level equal to or greater than pre-injury.
What new information does this study offer? This study offers outcome information on non-operative treatments for labral SLAP tears.
What are the limitations of the study and what further research is needed? Limitations of the study included a survey response rate of only 16.39%, only 19 of the patients had non-operative intervention, and the non-operative treatments were not standardized. There were also a significantly higher portion of men in the study (14 men to 5 women), and the follow up time had a very large range of anywhere between 12 months to 6 years. Outcome scores are based on the group of 19 people that underwent non-operational treatment, but of the additional 20 that received the same non-operational treatment it was unsuccessful and those patients had to undergo surgery. Finally, because no arthroscopy was done, the nature of the non-surgical patient’s diagnoses cannot be verified. Further research would identify the extent of the SLAP tears of non-operative treatment patients, it would receive a greater portion of returned surveys, and there should be more research on motivation levels of competitive versus recreational athletes (i.e. do competitive athletes opt for surgery thinking it’s the best choice?)
How might the results of this study apply to physical therapist practice? This research has various implications for the physical therapy profession. To begin, it validates the prescription of PT as a conservative treatment for SLAP lesions. There was a significant improvement from baseline pre and post treatment in function, pain and quality of life. Physical therapy can be deemed an effective treatment because of this. Next, a specific treatment protocol has been validated as effective: posterior capsular stretching and scapular stabilization. Unfortunately, researchers did not document or standardize how much or specific exercises to achieve these goals. Nonetheless, a general treatment consisting of these elements is effective. Next, PT’s can estimate a return to sport within 6 months following conservative treatment. Additionally, patients can expect to attend an average of 18 sessions to achieve the outcomes seen. Finally, only 71% reported participating at a level equal to or greater than pre injury. This may suggest that for the highest-level athletes, conservative treatment may not be the best option.
Synopsis written by Kayla Ubel, Brenda Hozie, and Ethan Quinn
Reference:
Edwards SL, L. J. (2010). Nonoperative treatment of superior labrum anterior posterior tears: improvements in pain, function, and quality of life. The American Journal of Sports Medicine, 1456-1461.
Ann Bonsignore and Luke Giefer Shoulder-strengthening exercise with an orthosis for multi-directional shoulder instability: Quantitative evaluation of rotational shoulder strength before and after the exercise program
Junji Ide, MD; Satoshi Maeda, MD; Makio Yamaga, MD; Keizo Morisawa, MD; and Katsumasa Takagi, MD
What problems did the researchers set out to study, and why?
Multidirectional shoulder instability is marked by the presence of symptomatic inferior instability in addition to anterior and/or posterior instability. The main goals of a rehabilitation program have been strengthening the rotator cuff and scapular stabilizer. The scapula can be further stabilized by using an orthosis that increases the scapular inclination, which prevents inferior displacement of the humeral head. The researchers set out to study if using an orthosis in the exercise program could correct multidirectional shoulder instability, and to evaluate the treatment outcome and changes in shoulder strength of the patients who participated in the rehabilitation program.
Who participated in the study?
46 patients (73 shoulders) with a diagnosis of involuntary multidirectional shoulder instability What new information does this study offer?
This study found that the combination of a rehabilitation program with an orthosis had better outcomes on the modified Rowe grading system than the rehabilitation program without an orthosis. In particular, the scores for function, pain, numbness, and stability were significantly improved.
How did the researchers go about this study?
Patients were evaluated before and after the 8-week rehabilitation program with regard to shoulder function, pain, numbness, stability and range of motion by using the modified Rowe grading system. The rehabilitation program was focused on strengthening the rotator muscles, scapula stabilizers, and scapulothoracic muscles. Rotational shoulder strength was measured using an isokinetic dynamometer.
How might the results of this study apply to physical therapist practice?
Shoulder-strengthening exercise with an orthosis was shown to be beneficial for patients with multidirectional shoulder instability. However, individuals who continue to participate in sports that require repetitive overhead motion or who have generalized ligamentous laxity are unlikely to respond to conservative treatment. Physical therapists need to keep this in mind when asking patients about function (throwing or overhead work).
What are the limitations of the study, and what further research is needed?
This study had a relatively small sample size. A further comparative study of the exercise groups with and without the orthosis may be needed to clarify the effectiveness of the orthosis. Research into other vulnerable planes of motion could also be explored such as abduction. It would also be better to have a more diverse participant population, rather than one that averages 20 years of age.
Works Cited
Ide, J., Maeda, S., Yamaga, M., Morisawa, K., & Takagi, K. (2003). Shoulder-strengthening exercise with an orthosis for multidirectional shoulder instability: Quantitative evaluation of rotational shoulder strength before and after the exercise program. Journal of Shoulder and Elbow Surgery, 12 (4), 342-345.
The short-term effects of treating plantar fasciitis with a temporary custom foot orthosis and stretching What problem did the researchers set out to solve and why?
Determine the effectiveness of a temporary custom foot orthoses (TCFO) followed by a stretching program treatment of plantar fasciitis.
Who participated in the study?
15 participants responded to recruitment flyers
13 women, 2 men
Avg age: 37.3?
No previous treatment
Symptoms duration >4 weeks
At least 2 of the following:
Symptom reproduction with palpation of the proximal plantar fascia
Positive Windlass test
First-step pain after inactivity
Exclusion criteria
Lumbar radiculitis, radiculopathy, myelopathy, history of foot/ankle fracture, with/without presence of ORIF hardware, pregnancy, rheumatic disease, tarsal tunnel syndrome
2 hour training provided for investigators on how to perform examination and casting of TCFO
Examination
History of problem
Aggravating/easing factors
Ankle ROM
Special tests: Tinel’s tarsal tunnel test, palpation of plantar fascia, lower quarter screening, foot type
TCFO fabricated by placing foot in near-end range plantar flexion and inversion
TCFO asked to be worn at all times throughout first 2 weeks
After 2 weeks: Gradually weaned off TCFO use and begin stretching program (2x/day)
Plantar fascia stretch
Calf stretch
Ankle AROM exercises
Participants evaluated in the clinical at initial exam, 2 weeks, 4 weeks
12 week follow up via e-mail, telephone, or mail
What new information does this study offer? This study gives clinicians beginning evidence for the use of a short term TCFO in treating plantar fasciitis prior to a supplemental stretching program. In addition, it shows that these TCFO are just for short-term use and are easy and inexpensive to make.
What are the limitations of the study, and what further research is needed? Limitations of this study include the small sample size of only 15 patients and not having a control group. In the small sample size, the patient demographics were not very diverse and so not very representative of the full population. Also, the study did not look into how long each person had been having heel pain, just that they had it for a minimum of 4 weeks. If someone had pain for longer, then maybe this could have been cause for variation. In addition, the results could have been affected by the patients knowing they were a part of a study and thus be more biased towards its effect. The study did not make sure that the patients were wearing their orthosis all the time during weight bearing or performing their stretches twice a day. Lastly, the 12 week follow-up was not in person whereas the other follow-ups were and this may have had an effect on the results. These factors limit the study’s external and internal validity.
The authors of the study mentioned that further research is needed including randomized controlled trials that compare the TCFO versus stretching alone or comparing the TCFO to custom or over-the counter orthoses. Other possible studies include long term effects of frequency and duration of the stretching program after the use of a TCFO, optimal duration of orthosis wear, and possibly coming up with a clinical prediction rule for who would be best for a TCFO.
Functional Outcome Measurement Scale This article presented several outcome measures including the Foot and Ankle Ability Measure (FAAM), the Numeric Pain Rating Scale (NPRS), and the Global Rating of Change (GRC). The most important and functional of these is the FAAM. There are 2 subscales of the FAAM: the activities of daily living subscale (FAAM-A) and the sports subscale (FAAM-S). The scale is a 29-item self-report measure that has been shown to be a valid and responsive outcome measure in a physical therapy. The minimal clinically important difference (MCID) is 8 points for the FAAM-A and 9 points for the FAAM-S. A copy of the scale is included in the article.
Summary by: Mallory Mahoney & Lauren Mulsow
Reference: Drake, M., Bittenbender, C., & Boyles, R. E. (2011). The short-term effects of treating plantar fasciitis with a temporary custom foot orthosis and stretching. The Journal of orthopaedic and sports physical therapy, 41(4), 221-31. doi:10.2519/jospt.2011.3348
Open Versus Closed Chain Kinetic Exercises After Anterior Cruciate Ligament Reconstruction A Prospective Randomized Study Accelerated therapy after an ACL reconstructive surgery is known to be beneficial, but there is still debate as to whether a closed chain exercise program is better than an open chain one. A closed chain exercise is one where the body is moving on a fixed foot. They are usually performed near full extension, which compresses the joint and provides stability. This is also a more functional position that can help develop proprioception. This is compared to open chain activities. These include exercises where the lower extremity is free and moving on a fixed body, for example, seated knee extension machine. These exercises are normally done in 30-90 degrees of flexion. This position has little to no compressive forces on the joint; however, the shear forces are increased.
This study found 100 patients who underwent ACL reconstruction with a patellar tendon autograft. All knees were put in a 0-90 degree motion brace after surgery, and performed continuous passive motion from 0-60 degrees for 12 hours a day until discharge. The exercise protocols for each group are seen below. The closed chain group used the Sport Cord to add resistance.
Time
Open Chain Exercises
Time
Closed Chain Exercises
0-3 weeks
Isometrics and hamstring concentric and eccentric isotonics
0-8 weeks
Two leg 1/3 knee bends, seated leg press, hamstring curl
3 weeks
30⁰ of flexion straight leg raises
6 weeks
Stationary bike, proprioception
6 weeks
Light quadriceps isotonics, stationary bike, proprioception training
8 weeks
One leg 1/3 knee bends, forward and backward walking against resistance, jog against resistance
8 weeks
Isokinetic hamstrings
12 weeks
Slow, deep lateral jumping against resistance, previous exercises with added resistance
12 weeks
Unrestricted quadricep eccentric and concentric activity
16 weeks
Free weight leg press, squats, sport specific exercises
16 weeks
Treadmill jogging, forward and backward running, single-leg deep knee bends
24 weeks
Progressive running and sport specific
24 weeks
Isokinetic quad training; progressive resistance training
9 months
Noncutting sport activities
7-8 months
Progressive running and sport specific training
12 months
Unrestricted sports
9 months
Noncutting sport activities
12 months
Unrestricted sports
At the final follow up the mean deficits were 1 degree of extension, and 2 degrees of flexion between both groups. The functional outcome measures increased as well. The Lysholm score improved from 67 to 87, and the Tegner activity level went from 4 to 6. There were no significant differences between groups in the pivot shift, Lachman, KT side to side differences, or extension or flexion deficits. However, patellofemoral pain that restricted activity was significantly higher in the open chain group (38%), compared to 15% in closed chain group nine months post-op. The closed chain group rated their therapy as good or excellent 97% of the time, compared to 80% in the open chain. Also, 72% of the closed chain group reported that they returned to sport sooner than expected, compared to 33% of the open chain group. This study supports the statement that closed chain exercises in an accelerated therapy program are safe and effective for post-op ACL reconstructions. Reference
Bynum, E.B., Barrack, R.L, & Alexander, A.H. (1995). Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction: a prospective randomized study. American Journal of Sports Medicine, 23(4), 401-406.
“Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee”
Deyle, et al.
What problems did the researchers set out to study, and why?
The researchers found very few investigations that include both subjective and objective measures of the effectiveness of treatments for osteoarthritis of the knee. Beneficial interventions may decrease the need for more invasive treatments. The purpose of this study was to evaluate the effectiveness of physical therapy for osteoarthritis of the knee applied by physical therapists who have formal training in manual therapy.
Who participated in the study?
83 patients with osteoarthritis of the knee participated in this study. 15 men and 27 women with a mean age of 60 were randomly assigned to receive treatment and 19 men and 22 women with a mean age of 62 years were randomly assigned to the placebo group. Inclusion criteria included a diagnosis of osteoarthritis of the knee based on the criteria developed by Altman and colleagues, be eligible for military health care, have had no surgical procedure on either lower extremities in the past 6 months, and have no physical impairment unrelated to the knee that would prevent the completion of the study. Participants were also required to live within a 1 hour drive of the clinic and were instructed to not take any new medication for osteoarthritis.
What new information does the study offer?
One year after the study, patients in the placebo group had more knee surgeries than patients in the treatment group. 20% of the 41 patients in the placebo group had undergone a TKA compared to the 5% of the 42 patients in the treatment group. Patients with knee osteoarthritis who were treated with both manual physical therapy and exercise had statistically significant improvements in self-perceptions of pain, stiffness, and functional ability and the distance walked in 6 minutes. This type of treatment may defer or decrease the need for surgical intervention.
How did researchers go about this study?
Participants were referred by physicians to physical therapy from various clinics, but they had to be eligible for military health care. Patients were assigned blank folders numbered from 1-100 and the therapists drew a folder, which determined group assignment. There were two groups, a treatment group and a control or placebo group. The treatment group received a combination of manual physical therapy and supervised exercise. The placebo group received ultrasound at a sub-therapeutic intensity. Neither group was aware of the treatment the other was receiving. The WOMAC Index and the 6 minute walk test were used as functional tests.
How might the results of this study apply to physical therapist practice?
These studies might apply to a physical therapist because it is important to know what types of treatment have proven literature behind them. This study confirms that through muscle strengthening and manual therapy there is improvement in a patients pain levels and functional abilities. The exercises used included:
- Stretching: Standing Calf Raise, Supine Hamstring Stretch, Prone Quad Stretch --- 3x 30 second holds
- ROM: Long sitting knee midflexion to end range extension 2x 30 second bouts with 3 second hold in extension ----- and ------ Stationary Bike, 5 min
- Exercise: Static quad set in knee extension, standing terminal knee extension, seated leg press, dips weight lessened, and step ups
Because osteoarthritis has become such a common problem with the aging population, it will be important for new PT’s to continue to stay involved in the literature and what methods are working for increasing function. According to this article, manual therapy and exercise help to defer or decrease the need for surgical intervention. The decrease in surgical intervention helps decrease patients risk of infection/complication, as well as decrease the cost of time spent in the hospitals. While this may not be the case for all patients, this type of treatment may very well be the first line when a person is faced with the diagnosis of osteoarthritis.What are the limitations of the study, what further research is needed?
The limitations of the study included that the dropout rate for the trial was higher in the treatment group. The researchers do not believe that the treatment itself had negative outcomes, leading to patient’s withdrawing from the study, but I think this should be something that was a follow up study. If the exercises were too difficult or caused too much pain this could have caused a higher attrition rate.
Another area that might need to be addressed is were the benefits only lasting a year or would the benefits affect the patient for a longer time period. That question also raises the question of if the patient is going to end up having a TKA is it more beneficial for the patient to have it done younger, rather then giving exercises and pushing the surgery back 5-10 years where health my be more declined.
Deyle, G., Henderson N., Matekel, R., Ryder, M., Garber, M., Alllison, S. (2000). Effectiveness of manual physical therapy and exercise in osteoatrthritis of the knee. A randomized controlled trial. Annals of Internal Medicine, 132(3), 173-81.
Written by: David Kempin and Laura Sweeney
Progressive strength training in older patients after hip fracture: a randomised controlled trial
HILDE SYLLIAAS, THERESE BROVOLD, TORGEIR BRUUNWYLLER, ASTRID BERGLANDWhat problem did the researchers set out to solve and why?
Immobilization after major surgery and during hospitalization can cause a severe decline in muscle strength and functioning. While physical training seems to improve strength and functional performance in hip fracture patients, evidence is insufficient with respect to best practices in rehabilitating hip fracture in older adults. Therefore, the aim of this study was to assess the effect of a 3 month strength training program of progressive resistance exercise training on balance, strength, mobility, iADLs, and self-rated health in older home-dwelling hip fracture patients.
Who participated in the study?
150 hip fracture patients who were 12 weeks post fracture were eligible to participate in the study. All patients were age 65 or older, living at home, able to undergo physical therapy for the hip fx, and scored at least 23/30 on the Mini-Mental State Examination (MMSE).
How did the researchers go about this study?
Hip fracture patients, starting at 12 weeks post fracture, were followed for 12 weeks without any intervention. Then in a 2:1 fashion, the patients were randomly divided into either an intervention or control group. Those in the intervention group would later be randomized into further intervention or control groups for another 12 weeks.
3 month phase (3-6 weeks post fracture):
- 1 rep max (RM) was measured for 2 different exercises (knee flexion & knee extension)
- 10-15 minute warm-up on treadmill or stationary bicycle
- 45-60 minute exercise session depending on patient’s ability and tolerance
- 3 sets of 15 repetitions at 70% of the participant’s 1 RM
- 1 RM was re-measured every 3rd week and number of repetitions was reduced from 12 to 10, maintaining at least 8 reps
- Patients completed 4 exercises: Standing knee flexion, lunge (pass forward), sitting knee extension, and leg extension
- Patients attended exercise sessions 2x per week and completed a home exercise program 1x per week
- HEP: standing knee flexion, lunge (pass forward)
- Patients advised to walk 30 minutes/day if able
Patients in the control group were asked to maintain their current lifestyle with no restrictions.Measurements were taken after the 3 month intervention.
What new information does this study offer?
Many studies have researched the effects of immobilization on muscle strength, endurance, and functional performance. Also, it has been found that physical training is the best way to combat these effects. However, this study is a first to only focus on progressive strength training as an intervention for hip fracture patients.
How might the results of this study apply to physical therapist practice?
This study found highly significant effects of progressive strength training on balance as well as strength, gait distance and functional performance in older hip fracture patients. This suggests that an older home dwelling population that have sustained a hip fracture can benefit from an extended strength-training program. Hip fracture patients are a large population that frequently will be seen in a physical therapy clinical setting so this study’s findings are relevant to the therapists that will be treating such patients.
What are the limitations of the study and what further research is needed?
The intervention group may have had greater social contact than the control group. The improvements could have resulted from a ‘placebo-effect’ and additional contact rather than from the exercises. Exercise intervention studies appeal to healthier and more motivated individuals. Any exercises or any other interventions as well as levels of physical activity for the control group were not discussed. The inclusion criteria were limited to older people living on their own without moderate and severe cognitive symptoms. This criterion suggests that conclusions about the training results may not be extended beyond older hip fracture populations living at home. Further research of this intervention could be applied to other populations or the same population of older people with hip fractures that were not living at home which were excluded from this study.
This summary was written by Brandon Smith, Kelci McFarland, Shannon Lynch
Sylliaas, H., Brovold, T., Wyller, T., & Bergland, A. (2011). Progressive strength training in older patients after hip fracture: a randomised controlled trail. Age and Aging, 40, 221-227.
The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial
KHALIL KHAYAMBASHI, PT, PhD1 • ZEYNAB MOHAMMADKHANI, MS2 • KOUROSH GHAZNAVI, MD3MARK A. LYLE, PT, OCS4 • CHRISTOPHER M. POWERS, PT, PhD5
This article summary was written by Sarah Lickteig and Rick Hill
What problem did the researchers set out to solve and why?
The researchers in this study wanted to see if by isolating the hip and only strengthening the external rotators and the abductor muscles they could decrease patellofemoral pain (PFP), increase health status, and increase hip strength. They did this because to their knowledge, they believe they are the first study to isolate the hip musculature and relate it to PFP, while also involving a control group. Also they wanted to see how much of an effect the hip musculature had on PFP.
Who participated in the study?
The participants were 28 females diagnosed with bilateral patellofemoral pain syndrome (PFPS) and had symptoms for more than 6 months. They also had not previously received physical therapy. Initially there were 67 participants, but only 28 fit the inclusion criteria.
What new information does this study offer?
By strengthening the hip external rotators and hip abductors, PFP pain is decreased bilaterally, health status is increased and hip strength is increased. Strengthening of the quads or other musculature is not necessary to improve these areas in females with B PFPS.
How did the researchers go about this study?
The researchers randomly assigned the 28 participants into two different groups, a control group and an exercise group. The control group was instructed to take Omega-3 and Calcium every day for eight weeks. The exercise group was given two exercises to perform in the lab three times a week for eight weeks. Their program consisted of one hip abduction exercise and one hip external rotation exercise, each consisting of a theraband wrapped around the patient’s ankle and tied to a beam for resistance. Each group was measured in all three areas (strength, pain, and health status) prior to the intervention and post intervention (8 weeks later). The exercise group was also measured 6 months later for follow-up.
How might the results of this study apply to physical therapist practice?
The results can be helpful for PTs because PFPS is a common diagnosis in the outpatient clinic. This study shows that hip strengthening should definitely be included in the POC and the HEP for patients with PFPS, regardless of whether or not quad or hamstring strengthening is done.
What are the limitations of the study and what further research is needed?
The study had a small, homogeneous set of subjects. The control group was not measured for pain, health status, or hip strength six months later. They did not quantify strength in the exercise group at the six month follow-up. The researcher taking measurements was not blinded. The possible confound of self-administered pain medication by the subjects.
Reference
http://www.jospt.org/issues/articleID.2650,type.1/article_detail.asp
Khayambashi, K., Mohammadkhani, Z., Ghaznavi, K., Lyle, M. A., & Powers, C. M. (2012). The effects of isolated hip abductor and external rotator muscle strengthening on pain, health status, and hip strength in females with patellofemoral pain: a randomized controlled trial. The Journal of orthopaedic and sports physical therapy, 42(1), 22-9. doi:10.2519/jospt.2012.3704
An alternative approach to treating lateral epicondylitis.
A Randomized, placebo-controlled, double-blinded study
Angie Moody, Madeline McCann
What problems did the researchers set out to study and why?
The researchers of this study, Mohammad Reza Nourbakhsh and Frank J Fearon, were trying to investigate chronic lateral epicondylitis . Previous research of this subject has suggested that local tender points in the lateral elbow can cause pain when palpated, stretched, or during muscle contractions of repetitive movements of the wrist and elbow. Noxious electrical stimulation can be used as a treatment of trigger points. The purpose was to investigate the effect of noxious electrical stimulation on pain, grip strength, and functional status on patients with chronic lateral epicondylitis.
How did the researchers go about the study and who participated?
The design of the study was randomized, placebo-controlled and double-blinded. Subjects were between the ages of 24 and 72 and were involved in heavy or repetitive arm movements. All subjects had received unsuccessful treatment previously for lateral epicondylitis. Subjects were randomly assigned to either the treatment or placebo group. The treatment group had 10 participants and received low frequency electrical stimulation with intensity as tolerated. The placebo group had 8 participants and received low frequency electrical stimulation with intensity set at 0. Outcome data was collected prior to the intervention in both groups including grip strength, pain, and functional status. Researchers used a dynamometer to measure grip strength in the affected arm. A Numeric Rating Scale was used to assess pain intensity and any activity limitations due to pain and a similar scale was used to assess activity limitation. The functional outcomes were measured with an adapted Patient-Specific Functional Scale. The subjects each chose 3 activities that were affected by their lateral epicondylitis and then were instructed to rate the level of difficulty on a scale of 0-10. For the treatment group, the researchers palpated painful areas on the lateral epicondyle region and searched for the tender points with a probe electrode. After they found the tender points they administered electrical stimulation. The subjects in the placebo group went through the same procedure; however, the intensity was kept at zero.
What new information does this study have to offer?
The results of the study showed a significant difference in grip strength, pain rating, activity limitations due to pain, and functional status between the intervention and placebo. The treatment group had significant increased grip strength, decreased pain intensity, and increased functional level as compared to the placebo group.
How might the results of this study apply to PT practice?
The results of this study provide an alternative treatment for chronic lateral epicondylitis. This study also suggests that the pathophysiology of lateral epicondylitis may be more related to tender points rather than from inflammation. Additionally, a follow up of participant indicated this treatment can be beneficial to patients after 6 months following treatment.
What are the limitations of this study, and what future research is needed?
The study had a relatively small sample size of only 18 participants. The small sample size decreases the generalizability of these findings to a larger population. Additionally two subjects dropped out of the treatment group and the researchers did not perform intention to treat analysis. Future research should aim to replicate these findings on a larger, more heterogeneous sample. Future research could also study the effects of noxious electrical stimulation in combination with therapeutic exercise for lateral epicondylitis.
Reference:
Reza Nourbakhsh, M., & Fearon, F. J. (2008). An alternative approach to treating lateral epicondylitis. A randomized, placebo-controlled, double-blinded study. Clinical rehabilitation, 22(7), 601-9. doi:10.1177/0269215507088447
Katie Barta, Christine Chollet, Brandon Walker
Operative versus non-operative management following Rockwood grade III acromioclavicular separation: a meta-analysis of the current evidence base
Intro/Materials & Methods
Acromioclavicular dislocations can be determined based on degree and direction of displacement using Rockwood’s classification. Generally grades I and II are treated conservatively while grades V and VI are treated surgically. This article discusses a grade III separation which “is classified as a superior displacement of the lateral end of the clavicle of one clavicular diameter or 1cm on the anteroposterior radiograph, whilst grade IV is described as a separation of the acromioclavicular joint with the distal clavicle displaced posterior into the trapezial fascia.” There is not a general consensus for the management of grades III and IV treatment and whether they should be treated surgically or conservatively. This review examined the outcomes of those patients with grade III dislocations treated conservatively against those treated surgically.
In order to be included in this systematic review, studies had to include a comparison of patients with an acute, closed grade III dislocation treated conservatively and those treated surgically. Randomized control trials and non-randomized controlled trials were used. To be included, studies had to have at least one outcome of interest. In this case, the main outcome was Constant score. Secondary outcomes were also included. In order to find studies of interest, various electronic databases were searched using MeSH terms and Boolean operators. The reference lists of possible studies were reviewed and authors were contacted for information on any additional studies. Two reviewers examined the various studies and compared them to the set eligibility requirements before they could be included in the review. Studies were then scored using the PEDro scale. Heterogeneity was appraised using the chi-square test and a meta-analysis was done when outcomes could be pooled. Risk difference was the effects measure for dichotomous outcomes and the effect measure for continuous outcomes was mean difference. A P of <.005 and confidence intervals of 95% were used.
Results
Of the potential 724 citations identified, six of the studies were eligible for this study. In total, there were 380 participants divided into the operative and non-operative groups. Participants in the operative group had fixations using wire or screw fixations methods and all repaired the coracoclavicular and acromioclavicular ligaments. In the non-operative group, management was not well described or specific, however a general type was given: sling, taping technique or casting. Time frame for immobilization was also variable ranging from 2 to 4 weeks or until pain and symptoms were gone.
Results of the meta-analysis were overall inconclusive. The primary outcome of the study, the “constant score”, did show that operative management had better functional outcomes than non-operative outcomes for management of a grade III acromioclavicular separation (p=0.03). This statistic, though, is based off of only one study. Outcomes that did not have significance were throwing ability, strength, pain, and ossification of the coracoclavicular ligament or acromioclavicular joint (p>0.05). Other outcomes that were significant were poor cosmetics with non-operative (p<0.0001), greater sick leave time following operative (p<0.0001) and higher rate of infection with operative management (p=0.03).
Discussion
The main finding is that there is no significant difference in clinical or radiological outcomes. Non-operative treatment was associated with worse cosmetic outcomes and less sick leave. The included studies have limited validity because of no group randomization, assessors were not masked, and inadequate sample size. One of the more recent papers showed that operative treatment had better outcomes than non-operative treatment. Future research may show results that tend to be in favor of operative treatment due to improvements in operative techniques. Most of the included studies did not distinguish hand dominance related to side of injury, and this could be an important variable when considering functional outcome assessment. Another potential confounding variable is the time between injury and surgery, as patients who have acute surgery are likely to show better outcomes than those with delayed repairs. Based on the findings of this study, anatomical alignment alone is not reason enough to justify surgery of grade III AC separations because no significant difference in functional outcomes was found. Some authors suggest that surgical treatment may be better than non-surgical treatment for patients who intend to return to sport or have physically demanding jobs, but this idea is not supported by this study because of the young average age of the patients and the common mechanism of injury being sports and occupational related. Non-surgical treatment may be viewed as the better treatment because there is no functional difference, and it is associated with decreased time of sick leave. However, non-operative treatments strategies were not well defined. The risk of complications, specifically infection, is one of the disadvantages of operative treatment, but the infection rate after AC repair is relatively low. A comparison of cost effectiveness between the 2 treatment strategies was not completed, but it should be. It is expected that the non-operative treatment is cheaper because of decreased sick leave, and the increased cost of hospitalization and operation associated with surgery. Bottom line, there is no difference in strength, pain, or throwing ability between the 2 treatments, but surgery resulted in increased sick leave and better cosmetic results. More large RCTs are needed to produce good evidence.
Citation
Smith, T. O., Chester, R., Pearse, E. O., & Hing, C. B. (2011). Operative versus non-operative management following Rockwood grade III acromioclavicular separation: a meta-analysis of the current evidence base. Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology, 12(1), 19-27. doi:10.1007/s10195-011-0127-1
Garrett Blattner, Brianna Cowley, Sarah Jarvis
The Bottom Line
[Hains, G., Descarreaus, M., Lamy, A.M., Hains, F. (2010). A randomized controlled (intervention) trial of ischemic compression therapy for chronic carpal tunnel syndrome. The Journal of the Canadian Chiropractic Association; 54(3): 155–163.]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921781/?tool=pmcentrez&rendertype=abstract
What problems did the researchers set out to study, and why?
The researchers set out to determine if symptoms of carpal tunnel syndrome (CTS) and associated functional limitations could be relieved by ischemic compression therapy used on trigger points (TrPs). CTS is the most common nerve entrapment syndrome, causing paresthesia and numbness along the median nerve distribution in the hand (thumb, index, middle, and half the ring finger), due to compression of the median nerve at any number of sites along its route. Intervention starts with conservative treatment including wrist support, anti-inflammatory medications, and a change in activities. If symptoms do not resolve within six months, cortisone injections are used and CT release surgery is considered.
In patients with CTS, the median nerve is twice its normal size when it enters the CT, possibly due to edema caused by noxious myofascial sites along its route from the axilla, running adjacent to the biceps, and descending the hollow of the elbow under the pronator teres and bicipital aponeurosis. TrPs cause a continual partial contraction of the muscle, resulting in higher oxygen and glucose consumption, demanding more blood flow. At night, when blood flow decreases, lactic acid builds up and accentuates the contraction, irritating the nerve.
Who participated in the study?
Subjects in the study were between the ages of 20 and 60 years old, must have suffered from numbness in the hand that affects the median nerve distribution (in the thumb, index finger, middle finger, and half the ring finger), must have suffered on a daily basis for a minimum of three months, must demonstrate positive signs on at least two of the following tests/physical signs: Tinnel test, Phalen test, or sleep problems caused by the hand discomfort, and each subject must agree to a course of 15 chiropractic treatments at no cost to the subject. The only exclusion criteria included was a history of surgery to the upper limb or neck, pregnancy, and presence of a systemic pathology possibly related to CTS such as hypothyroidism, diabetes, and rheumatoid arthritis. The 55 included subjects were randomly assigned to either an experimental or control group, at a 2:1 ratio (37 experimental and 18 control). Patients were blinded to their treatment group.
What new information does this study offer?
Ischemic compression therapy at TrPs along the median nerve route is an affective method of relieving symptoms and functional limitation associated with CTS. The results were found to be significant for both questionnaires at each follow up assessment in the experimental group, and a significant difference was found between the two groups about perceived improvement, with the experimental group finding more improvement.
How did the researchers go about this study?
TrPs targeted in the experimental group were along the biceps, axilla, pronator teres, and bicipital aponeurosis. Each subject had TrPs in the biceps and bicipital aponeurosis, and most in the pronator teres and axilla. The control group received treatment for TrPs in the posterior region of the clavicle, deltoid, and center of the scapula. These were far enough from the median nerve not to have an effect but close enough to seem a plausible treatment to subjects. Pressure was applied for 5–15 seconds to each identified TrP. Thumb tip pressure was applied for 5 seconds every 2 centimeters along the biceps. For TrPs in the pronator teres, biceps aponeurosis, and axilla, pressure was maintained for 15 seconds. Outcomes were assessed by a two part validated questionnaire specific to CTS that is known to be reproducible and internally consistent, since CTS patients usually consult a clinician due to severity of symptoms and the difficultly they have with tasks of daily life. Part one defines functional status and part two assesses severity of symptoms. In addition, a scale ranging from 0-100% was used to determine subjects’ perceived improvement. Data was collected pre- and post- treatment for both groups, and 30 days and six months later for the experimental group.
How might the results of this study apply to physical therapist practice?
Physical therapists can use trigger point release/massage at the locations identified along the median nerve route to treat patients suffering from CTS symptoms. This is a conservative treatment to be used initially to not only relieve symptoms, but also treat the cause of the compression. This treatment could potentially prevent surgery in CTS patients.
What are the limitations of the study, and what further research is needed?
A major limitation of the study was the sample size; further, the control group was especially small. The control group was not followed up with long term, as the experimental group was, so there is no way to determine if the CTS spontaneously resolved by then. Further, the control group was immediately crossed over and offered experimental treatment following the conclusion of the placebo treatment. This yielded results in favor of the experimental treatment, but not enough time was allowed to wash out any placebo effect. Future research should include a larger sample, a placebo group parallel to the experimental, and a long term follow up. Additional research could investigate different types of TrP therapy and treatment dosage, to determine the most effective and efficient treatment for CTS patients.
Brigham and Women's Hospital Hand Symptom Severity Scale and Functional Status Scale
academic.regis.edu/clinicaleducation/pdf's/CTSSxFxScales%20(3).doc
Nonoperative treatment of superior labrum anterior posterior tears: improvements in pain, function, and quality of life.
Edwards SL, Lee JA, Bell JE, Packer JD, Ahmad CS, Levine WN, Bigliani LU, Blaine TA.
What problem did the researchers set out to solve and why?
Researchers noted that there have been studies documenting successful outcomes with surgical interventions for SLAP tears but there is very little information regarding nonoperative outcomes, so they created this study.
Who participated in the study?
39 patients diagnosed with superior labrum anterior posterior (SLAP) lesions were included and there were 8 exclusion criteria.
How did the researchers go about this study?
All patients diagnosed with a SLAP lesion within the researcher’s institution were surveyed before and after non-operative treatment. The outcome measures included Short Form 36 (SF-36), European Quality of Life measure (EuroQol), visual analog pain scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and simple shoulder test (SST). Upon diagnosis, all participants underwent a physical therapy program, which included posterior capsular stretching and scapular stabilization exercises and all patients were prescribed NSAIDs.
Statistically significant functional improvement was observed following non-operative treatment (p < .001). Decreased pain was found in patients after non-operative treatment (p < .043), as well as increased quality of life (p < .009). Finally, all patients reporting themselves as active prior to injury returned to athletics within 6 months via the non-surgical approach although only 71% reported participating at a level equal to or greater than pre-injury.
What new information does this study offer?
This study offers outcome information on non-operative treatments for labral SLAP tears.
What are the limitations of the study and what further research is needed?
Limitations of the study included a survey response rate of only 16.39%, only 19 of the patients had non-operative intervention, and the non-operative treatments were not standardized. There were also a significantly higher portion of men in the study (14 men to 5 women), and the follow up time had a very large range of anywhere between 12 months to 6 years. Outcome scores are based on the group of 19 people that underwent non-operational treatment, but of the additional 20 that received the same non-operational treatment it was unsuccessful and those patients had to undergo surgery. Finally, because no arthroscopy was done, the nature of the non-surgical patient’s diagnoses cannot be verified. Further research would identify the extent of the SLAP tears of non-operative treatment patients, it would receive a greater portion of returned surveys, and there should be more research on motivation levels of competitive versus recreational athletes (i.e. do competitive athletes opt for surgery thinking it’s the best choice?)
How might the results of this study apply to physical therapist practice?
This research has various implications for the physical therapy profession. To begin, it validates the prescription of PT as a conservative treatment for SLAP lesions. There was a significant improvement from baseline pre and post treatment in function, pain and quality of life. Physical therapy can be deemed an effective treatment because of this. Next, a specific treatment protocol has been validated as effective: posterior capsular stretching and scapular stabilization. Unfortunately, researchers did not document or standardize how much or specific exercises to achieve these goals. Nonetheless, a general treatment consisting of these elements is effective. Next, PT’s can estimate a return to sport within 6 months following conservative treatment. Additionally, patients can expect to attend an average of 18
sessions to achieve the outcomes seen. Finally, only 71% reported participating at a level equal to or greater than pre injury. This may suggest that for the highest-level athletes, conservative treatment may not be the best option.
Synopsis written by Kayla Ubel, Brenda Hozie, and Ethan Quinn
Reference:
Edwards SL, L. J. (2010). Nonoperative treatment of superior labrum anterior posterior tears: improvements in pain, function, and quality of life. The American Journal of Sports Medicine, 1456-1461.Ann Bonsignore and Luke Giefer
Shoulder-strengthening exercise with an orthosis for multi-directional shoulder instability: Quantitative evaluation of rotational shoulder strength before and after the exercise program
Junji Ide, MD; Satoshi Maeda, MD; Makio Yamaga, MD; Keizo Morisawa, MD; and Katsumasa Takagi, MD
What problems did the researchers set out to study, and why?
Multidirectional shoulder instability is marked by the presence of symptomatic inferior instability in addition to anterior and/or posterior instability. The main goals of a rehabilitation program have been strengthening the rotator cuff and scapular stabilizer. The scapula can be further stabilized by using an orthosis that increases the scapular inclination, which prevents inferior displacement of the humeral head. The researchers set out to study if using an orthosis in the exercise program could correct multidirectional shoulder instability, and to evaluate the treatment outcome and changes in shoulder strength of the patients who participated in the rehabilitation program.
Who participated in the study?
46 patients (73 shoulders) with a diagnosis of involuntary multidirectional shoulder instability
What new information does this study offer?
This study found that the combination of a rehabilitation program with an orthosis had better outcomes on the modified Rowe grading system than the rehabilitation program without an orthosis. In particular, the scores for function, pain, numbness, and stability were significantly improved.
How did the researchers go about this study?
Patients were evaluated before and after the 8-week rehabilitation program with regard to shoulder function, pain, numbness, stability and range of motion by using the modified Rowe grading system. The rehabilitation program was focused on strengthening the rotator muscles, scapula stabilizers, and scapulothoracic muscles. Rotational shoulder strength was measured using an isokinetic dynamometer.
How might the results of this study apply to physical therapist practice?
Shoulder-strengthening exercise with an orthosis was shown to be beneficial for patients with multidirectional shoulder instability. However, individuals who continue to participate in sports that require repetitive overhead motion or who have generalized ligamentous laxity are unlikely to respond to conservative treatment. Physical therapists need to keep this in mind when asking patients about function (throwing or overhead work).
What are the limitations of the study, and what further research is needed?
This study had a relatively small sample size. A further comparative study of the exercise groups with and without the orthosis may be needed to clarify the effectiveness of the orthosis. Research into other vulnerable planes of motion could also be explored such as abduction. It would also be better to have a more diverse participant population, rather than one that averages 20 years of age.
Works Cited
Ide, J., Maeda, S., Yamaga, M., Morisawa, K., & Takagi, K. (2003). Shoulder-strengthening exercise with an orthosis for multidirectional shoulder instability: Quantitative evaluation of rotational shoulder strength before and after the exercise program. Journal of Shoulder and Elbow Surgery , 12 (4), 342-345.The short-term effects of treating plantar fasciitis with a temporary custom foot orthosis and stretching
What problem did the researchers set out to solve and why?
Who participated in the study?
How did the researchers go about this study?
What new information does this study offer?
This study gives clinicians beginning evidence for the use of a short term TCFO in treating plantar fasciitis prior to a supplemental stretching program. In addition, it shows that these TCFO are just for short-term use and are easy and inexpensive to make.
What are the limitations of the study, and what further research is needed?
Limitations of this study include the small sample size of only 15 patients and not having a control group. In the small sample size, the patient demographics were not very diverse and so not very representative of the full population. Also, the study did not look into how long each person had been having heel pain, just that they had it for a minimum of 4 weeks. If someone had pain for longer, then maybe this could have been cause for variation. In addition, the results could have been affected by the patients knowing they were a part of a study and thus be more biased towards its effect. The study did not make sure that the patients were wearing their orthosis all the time during weight bearing or performing their stretches twice a day. Lastly, the 12 week follow-up was not in person whereas the other follow-ups were and this may have had an effect on the results. These factors limit the study’s external and internal validity.
The authors of the study mentioned that further research is needed including randomized controlled trials that compare the TCFO versus stretching alone or comparing the TCFO to custom or over-the counter orthoses. Other possible studies include long term effects of frequency and duration of the stretching program after the use of a TCFO, optimal duration of orthosis wear, and possibly coming up with a clinical prediction rule for who would be best for a TCFO.
Functional Outcome Measurement Scale
This article presented several outcome measures including the Foot and Ankle Ability Measure (FAAM), the Numeric Pain Rating Scale (NPRS), and the Global Rating of Change (GRC). The most important and functional of these is the FAAM. There are 2 subscales of the FAAM: the activities of daily living subscale (FAAM-A) and the sports subscale (FAAM-S). The scale is a 29-item self-report measure that has been shown to be a valid and responsive outcome measure in a physical therapy. The minimal clinically important difference (MCID) is 8 points for the FAAM-A and 9 points for the FAAM-S. A copy of the scale is included in the article.
Summary by: Mallory Mahoney & Lauren Mulsow
Reference:
Drake, M., Bittenbender, C., & Boyles, R. E. (2011). The short-term effects of treating plantar fasciitis with a temporary custom foot orthosis and stretching. The Journal of orthopaedic and sports physical therapy, 41(4), 221-31. doi:10.2519/jospt.2011.3348
Open Versus Closed Chain Kinetic Exercises After Anterior Cruciate Ligament Reconstruction A Prospective Randomized Study
Accelerated therapy after an ACL reconstructive surgery is known to be beneficial, but there is still debate as to whether a closed chain exercise program is better than an open chain one. A closed chain exercise is one where the body is moving on a fixed foot. They are usually performed near full extension, which compresses the joint and provides stability. This is also a more functional position that can help develop proprioception. This is compared to open chain activities. These include exercises where the lower extremity is free and moving on a fixed body, for example, seated knee extension machine. These exercises are normally done in 30-90 degrees of flexion. This position has little to no compressive forces on the joint; however, the shear forces are increased.
This study found 100 patients who underwent ACL reconstruction with a patellar tendon autograft. All knees were put in a 0-90 degree motion brace after surgery, and performed continuous passive motion from 0-60 degrees for 12 hours a day until discharge. The exercise protocols for each group are seen below. The closed chain group used the Sport Cord to add resistance.
At the final follow up the mean deficits were 1 degree of extension, and 2 degrees of flexion between both groups. The functional outcome measures increased as well. The Lysholm score improved from 67 to 87, and the Tegner activity level went from 4 to 6. There were no significant differences between groups in the pivot shift, Lachman, KT side to side differences, or extension or flexion deficits. However, patellofemoral pain that restricted activity was significantly higher in the open chain group (38%), compared to 15% in closed chain group nine months post-op. The closed chain group rated their therapy as good or excellent 97% of the time, compared to 80% in the open chain. Also, 72% of the closed chain group reported that they returned to sport sooner than expected, compared to 33% of the open chain group. This study supports the statement that closed chain exercises in an accelerated therapy program are safe and effective for post-op ACL reconstructions.
Reference
Bynum, E.B., Barrack, R.L, & Alexander, A.H. (1995). Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction: a prospective randomized study. American Journal of Sports Medicine, 23(4), 401-406.