Author: clementphysio

(Van der Heijden, Lankhorst, Van Linschoten, Bierma-Zeinstra, & Van Middelkoop, 2015)

Aim: To assess the effects (benefits and harms) of exercise therapy aimed at reducing knee pain and improving knee function for people with patellofemoral pain syndrome.

Methods: Cochrane Review of RCT and quasi RCT about exercise for PFP, 2 indep reviewers, outcomes : pain during activity (short-term: ≤ 3 months); usual pain (short-term); pain during activity (long-term: > 3 months); usual pain (long-term); functional ability (short-term); functional ability (long-term); and recovery (long-term). 31 heterogeneous trials including 1690 participants with PFP are included.

Results: Ex vs control: Pooled data from five studies (375 participants) for pain during activity (short-term) favoured exercise therapy. The CI included (MCID) of 1.3 indicating the possibility of a clinically important reduction in pain. The same finding applied for usual pain, pain during activity (long-term) and usual pain (long-term). Pooled data from seven studies (483 participants) for functional ability (short-term) also favoured exercise therapy. Clinically important improvement in function long term 12 months.

Hip + knee : Pooled data from three studies (104 participants) for pain during activity (short-term) favoured hip and knee exercise the CI included a clinically important effect. The same applied for usual pain (short- term). One study (49 participants) found a clinically important reduction in pain during activity (long-term) for hip and knee exercise. Although tending to favour hip and knee exercises, the evidence for functional ability (short-term and long-term) and recovery (one study) did not show that either approach was superior.

Limitations: heterogeneity.

In Practice: This review has found very low quality but consistent evidence that exercise therapy for PFPS may result in clinically important reduction in pain and improvement in functional ability, as well as enhancing long-term recovery. However, there is insufficient evidence to determine the best form of exercise therapy and it is unknown whether this result would apply to all people with PFPS. There is some very low quality evidence that hip plus knee exercises may be more effective in reducing pain than knee exercise alone.

Van der Heijden, R., Lankhorst, N., Van Linschoten, R., Bierma-Zeinstra, S., & Van Middelkoop, M. (2015). Exercise for treating patellofemoral pain syndrome (Review). Cochrane Database of Systematic Reviews, (1), 199. https://doi.org/10.1002/14651858.CD010387.pub2.www.cochranelibrary.com

(Lack, Barton, Sohan, Crossley, & Morrissey, 2015)

Aims: This review (1) evaluates the efficacy of proximal musculature rehabilitation for patients with PFP; (2) compares the efficacy of various rehabilitation protocols; and (3) identifies potential biomechanical mechanisms of effect in order to optimise outcomes from proximal rehabilitation in this problematic patient group.

Methods: SR, 2 independent reviewers, PEDro scale and a PFP inclusion/exclusion criteria checklist. 12 studies included.

Results: Strong evidence indicates proximal combined with quadriceps rehabilitation is significantly better at reducing pain than quadriceps rehabilitation alone. Moderate evidence indicates proximal rehabilitation is better at improving pain compared to quadriceps rehabilitation alone. In the medium term, strong and moderate evidence indicates proximal and proximal combined with quadriceps rehabilitation, respectively, is more effective at reducing pain then quadriceps rehabilitation alone. In the longer term, limited evidence indicates proximal combined with quadriceps rehabilitation is more effective at reducing pain than quadriceps rehabilitation alone. Greater improvements in function were also reported for proximal, and proximal combined with quadriceps rehabilitation compared with quadriceps rehabilitation alone in the short (strong evidence), medium (strong to moderate evidence) and longer (limited evidence) term.

Unknown which protocol is the most efficacious to reduce pain, in the medium and long term. In terms of function, low quality evidence.

Limitations: Variability in study design, type of protocol (OKC or CKC), and differing outcome measures limited further data pooling. Data reporting lacks in included studies.

In Practice: These findings support the implementation of proximal muscle rehabilitation programmes for the management of PFP in clinical practice. Strength, strength-endurance and neuromuscular activity of proximal musculature are effective in the management of PFP and should be incorporated in clinical practice. As none is superior it can allow clinicians to be guided by patient response, preference or available equipment, without negatively impacting on patient care.

Lack, S., Barton, C., Sohan, O., Crossley, K., & Morrissey, D. (2015). Proximal muscle rehabilitation is effective for patellofemoral pain: A systematic review with metaanalysis. British Journal of Sports Medicine, 49(21), 1365–1376. https://doi.org/10.1136/bjsports-2015-094723

(Kalauokalani, Cherkin, Sherman, Koepsell, & Deyo, 2001)

Aims: To evaluate the association of a patient’s expectation for benefit from a specific treatment with improved functional outcome.

Methods: Secondary analysis from a RCT comparing massage, acupuncture, and self-care material (control group) used for patients with chronic LBP. 135 patients, 10 treatments within 10 weeks. The participants were asked to rate how helpful they believed each treatment would be for their current back problems on a (0-10) scale. They also were asked to describe their expectations for improvement of their back pain without regard to treatment using a 7-point Likert scale. Measures of expectation for treatment benefit (each high / low) / relative expectation (which ttt has higher expectation) / average expectation for treatment benefit (general benefit) and / general expectation regarding prognosis (optimism about improvement) were analysed.

Results: No ≠ in proportion of patients who improved in each group. More improved Roland scores were found among participants with higher expectations for benefit from their assigned treatment than among those with lower expectations. The improvement in Roland disability scores from baseline to follow-up assessment also was significantly greater in the higher expectations group than in the lower expectation group. Among the participants with higher relative expectations for massage estimates of 10-week Roland scores were better (lower) if the participants had received massage than if they had received acupuncture. Thus, regardless of the treatment received, the effect of the treatment depended on the magnitude of relative expectations. Neither average expectations for treatment benefit nor general expectations regarding prognosis had a significant association with the 10-week functional outcome as measured by the Roland score.

Limitations: Confounding variable / small sample / only between 2 passive treatments / …

In Practice: ● Patient expectation for benefit from a specific treatment correlates significantly with improved clinical outcome ● The relative odds of improvement are five times greater among those with high expectations for treatment benefit compared with those with low expectations for benefit after adjusting for sociodemographic, health status, and physical factors. ● General optimism regarding prognosis does not appear to have an important influence on out- comes. ● These findings may have implications for both physicians and patients regarding treatment choice, particularly when no treatment is clearly superior and when the relative safety and costs of each treatment are similar. ● These findings may also indicate a role of assessing patient expectations in the interpretation and design of clinical trials.

Kalauokalani, D., Cherkin, D. C., Sherman, K. J., Koepsell, T. D., & Deyo, R. A. (2001). Lessons from a trial of acupuncture and massage for low back pain: Patient expectations and treatment effects. Spine, 26(13), 1418–1424. https://doi.org/10.1097/00007632-200107010-00005

(Greenhalgh, Finucane, Mercer, & Selfe, 2018)

Aim: The purpose of this paper is to highlight the many challenges faced by clinicians in recognising and managing CES and offer guidance on the evidence-based management of these patients.

Methods: Masterclass

Results: The early symptoms of CES are often subtle and vague.

1. Bilateral neurogenic sciatica – Pain associated with the back and/ or unilateral/bilateral leg symptoms may be present.

2. Reduced perineal sensation – Sensation loss in the perineum and saddle region

3. Altered bladder function leading to painless urinary retention – Bladder dysfunction can range from increased urinary frequency, difficulty in micturition, change in urine stream, urinary incontinence and urinary retention.

4. Loss of anal tone – loss or reduced anal tone – Bowel dysfunction may include faecal incontinence, inability to control bowel motions and/or in- ability to feel when the bowel is full with consequent overflow.

5. Loss of sexual function

Importance of chronology and evolution. Improving of pain does not necessarily mean the condition is improving. Many cofounders: Medication, PMH, Spinal surgery history. Full neuro needed. Documenting what is done with time. If suspicion backup with CES card.

Limitations: Author’s review of literature.

In practice: Importance of questioning, objective exam, masqueraders, documenting.

Greenhalgh, S., Finucane, L., Mercer, C., & Selfe, J. (2018). Assessment and management of cauda equina syndrome. Musculoskeletal Science and Practice, 37(June), 69–74. https://doi.org/10.1016/j.msksp.2018.06.002

(Greenhalgh & Selfe, 2009)

Aims: To explore the experiential knowledge of experienced palliative care clinicians in the field of serious spinal pathology.

Methods: Qualitative study: Nominal group technique + focus group.

Results:

Limitations: Qualitative study, experts’ experience, only in one service in UK. Recall bias.

In Practice: Band-like trunk pain, vague non-specific lower limb symptoms and decreased mobility are worthy of further investigation, but front-line musculoskeletal clinicians may find it useful to consider these items within the subjective history at an early stage in the patient’s journey. These three items could inform the clinical reasoning process, raise the index of suspicion and help to steer the patient’s ongoing medical management.

Greenhalgh, S., & Selfe, J. (2009). A qualitative investigation of Red Flags for serious spinal pathology. Physiotherapy, 95(3), 224–227. https://doi.org/10.1016/j.physio.2009.04.006

(Finucane, Greenhalgh, & Selfe, 2017)

Aim: Discuss red flags.

Methods: Author’s insight

Limitations: Low level evidence, author’s opinion.

In practice: Patients with a past history of cancer that has an affinity to bone such as lung, prostate and breast cancer, who present with new symptoms that persist should be thoroughly evaluated with a high suspicion of MBD. A safety netting process of closely observing patients at risk over time is reasonable and an important consideration in effectively managing these potentially serious cases. Using knowledge of a patient’s risk of developing MBD and current red flags may help to raise a clinician’s index of suspicion and result in timely investigation and management of the patient.

Finucane, L., Greenhalgh, S., & Selfe, J. (2017, July 10). Which red flags aid the early detection of metastatic bone disease in back pain? Physiotherapy Practice and Research. https://doi.org/10.3233/PPR-170095

(Finucane, 2013)

Aims: This case reports highlights the importance of early diagnosis of metastatic disease, and identifies symptoms that may help to raise the index of suspicion for the clinician.

Methods: Case report

Results: Patient presentation :

Band like pain / Abdominal pain / Numbness non dermatomal / Vague leg pain / Night waking pain / Intermittent pain / Agg by walking sitting standing, eased by supine lying / Tramadol relieved / no CES symptoms. History of breast K, weight loss 3 kg in 3 months, failed conservative treatment. Previous episodes of LBP but not same sy / no resting pain / limited spinal extension and flexion reproducing LBP but no other / SLR=50° bilaterally and reproduced back pain. Femoral nerve tension test was negative and sensation, power and reflex testing was normal. Babinski and clonus tests were negative

Limitations: Low level of evidence

In Practice: Red Flags = History of cancer, failed conservative treatment, weight loss, night pain, multi-segment pain, band-like pain and odd-funny feelings in legs. Cancers that produce metastasis BLP (LBP) Breast Lung Prostate. Pain can be intermittent and respond to NSAIDs then progress to become worse and unremitting. The pain can radiate into the abdomen or chest and is often described as sharp, shooting deep and band-like. Pain symptoms can be aggravated by lying supine and there is often night pain. The patient may complain of bilateral leg pain. Funny, strange, odd vague feelings in leg can exist.

Finucane, L. (2013). Metastatic disease masquerading as mechanical low back pain; atypical symptoms which may raise suspicion. Manual Therapy, 18(6), 624–627. https://doi.org/10.1016/j.math.2013.02.009

(Flynn, Childs, & Fritz, 2006)

Aim: To assess whether audible pop during manips are related to/affects outcome.

Methods: 70 participants primary complaint of LBP. 13 physios 5 sessions 4 weeks. Outcome measures: NPRS, Oswestry and Lx F° with inclinometer at baseline, 1 week and 4 weeks. In the two first sessions they received HVLA-manips. Manips to the symptomatic side, if no pop/cavitation heard, 4 attempts max: two on each side. + ROM exercises. 3-4 x10 rep/daily on the days they did not attend physio. Pain during PA + Stiffness subjective “scale”.

Results: 84 % of the patients had a pop, 16 % had no pop. No sign diff in ODDS ratio between poppers and no-poppers in pain, disability and lumbar ROM at any of the times points (baseline, 1 week, 4 weeks).

Limitations: More than one manip if no pop thus difference in treatment dose / Only one type of manipulation tested. / Other interventions may influence results (Cofounding factors)

In Practice: Perceived audible pop may not relate to improved outcomes from HVT manip for P with non-radicular LBP at immediate or long-term follow-up.

Flynn, T. W., Childs, J. D., & Fritz, J. M. (2006). The audible pop from high-velocity thrust manipulation and outcome in individuals with low back pain. In Journal of Manipulative and Physiological Therapeutics (Vol. 29, pp. 40–45). https://doi.org/10.1016/j.jmpt.2005.11.005

(Weppler & Magnusson, 2010)

Aims: Understand literature regarding stretching effects.

Methods: Author’s review

Results: “Muscle’s extensibility” concept is conflicting, discrepancies in the use of term “length or extensibility”, and measures of those parameters. Mechanical theories seem not supported by literature. The most probable theory is currently an increase in sensation / tolerance by the person through the stretching. All studies are short term 3 to 8 weeks; no studies above. One study may contradict findings but uses a high dose regimen: 20 min stretching program for one muscle group in one limb, 5 days a week over 6 weeks, may shift torque/angle curve to the right with effects not completely reversed after 30 days. Still question about the relevance of the stretching, the impact of “short / tight” muscles on function, what is optimal extensibility? etc …

Limitations: Author’s point of view, low level of evidence, not standardized review.

In Practice: Insight on what are we trying to achieve when stretching? Why, how etc. We can improve person’s sensation at least in short term, one session brings immediate results, 3 to 8 weeks too. Maybe not helpful to increase muscle length.

Weppler, C. H., & Magnusson, S. P. (2010). Increasing Muscle Extensibility: A Matter of Increasing Length or Modifying Sensation? Physical Therapy, 90(3), 438–449. https://doi.org/10.2522/ptj.20090012