Movement control tests of the LBP; evaluation of the difference between P with LBP and healthy controls

(Luomajoki, Kool, de Bruin, & Airaksinen, 2008)

Aims: To determine whether the number of positive tests out of six active MC tests was different in patients LBP VS healthy controls + if ≠ according to the duration of LBP.

Methods: Case control study, Non blinded, 108 P and 102 controls, consecutive Germans, LBP (excluded radiculopathy), 12 ratters. 3 trials, oral explanation + if needed demonstration. 6 Motor control tests performed (Luomajoki tests) in the same order. Statistical analysis.

Results: Comparable groups, 2,21 (P) vs 0,75 (C) positive tests. Statistical difference, large effect size. There was a significant difference between acute and chronic, as well as between subacute and chronic but not between acute and subacute patient groups. The more chronic the more +ve tests.

Limitations: Case control no search of cofounding factors? Small clinical difference. Results not shown (which test + wich – on the 6). No blinding + subjective diag.

In Practice: There may be a difference, in the number of MC tests in LBP patients and the more chronic the more positive tests. MC evaluation through Luomajoki tests may be of use in LBP patients. Although tests have not been studied for validity, and the effect of MC treatment strategies have not been proven effective.

Luomajoki, H., Kool, J., de Bruin, E. D., & Airaksinen, O. (2008). Movement control tests of the low back; evaluation of the difference between patients with low back pain and healthy controls. BMC Musculoskeletal Disorders, 9(1), 170. https://doi.org/10.1186/1471-2474-9-170

Creep and hysteresis / preconditioning : Load displacement time characteristics of the spine under PA mob

(Lee & Evans, 1992)

Aims: Among others, to evaluate the effects of cyclic and sustained PA loadings, and on loading rate on PA mobility.

Method: N = 28, 18 – 23 yo, 50/50 male/female. Assessed mobility of L3-L5 (max 150N), three cyclic loadings on L4 (150N) and sustained loading on L4 (100N in two min). Displacements measured with transducers on level above and below. Pad put under applicator to minimize discomfort. Pad preloaded.

Results: No gender difference in spinal mobility. PA mobility together varied significantly between spinal levels, L5 most mobile, then L4 and L3. Cyclic and sustained load induced progressively more displacements. For sustained, most displacement seen in the first 30 seconds (69%) creep. For cyclic two first loading cycles showed more displacement (hysteresis / preconditioning). Slow rate of loading produced more displacement. However, effects of creep and preconditioning are temporary.

Limitations: Error of the measured displacement because of soft tissue compression. We do not know the actual vertebral displacement.

Lee, R., & Evans, J. (1992). Load-displacement-time characteristics of the spine under posteroanterior mobilisation. Australian Journal of Physiotherapy, 38(2), 115–123. https://doi.org/10.1016/S0004-9514(14)60556-0

Massage for LBP

(Furlan, Giraldo, Baskwill, Irvin, & Imamura, 2015)

Aims: To assess the effects of massage therapy for people with non-specific LBP.

Methods: RCTs, LBP, Inactive (supposed to be ineffective) or active modalities. Outcomes measures = pain and functional status, < or > to 6months. Secondary outcome = overall improvement, patient satisfaction, quality of life and work-related status. Cochrane methodology. Total patients 3096.

Results: Adverse events: No other that increase in pain in 5 to 25% of patients.

-Massage vs inactive controls for acute LBP: It is unclear whether or not massage is more effective than inactive controls for pain and function at short-term follow-up.

-Massage vs inactive controls for sub-acute and chronic LBP: It is unclear whether or not massage is better than inactive controls for pain and function in the long term.

-Massage vs active controls for acute LBP: unknown.

-Massage vs active controls for sub-acute and chronic LBP: It is unclear whether or not massage is more effective than active controls for pain and function in the short-term follow-up and for pain and function in the long-term.

Low to very low quality of evidence.

Limitations: Allocation, blinding, incomplete data, selective reporting, funding not reported,

In Practice: We have very little confidence that massage is an effective treatment for LBP. For acute LBP, massage improved pain but not function when compared to inactive controls in the short-term follow-up. For sub-acute and chronic LBP, massage improved pain and function outcomes in the short-term but not in the long-term follow-up when it was compared to inactive controls. Compared with active controls, massage improved pain in the short and long- term follow-ups, but it did not improve function at any follow-up. There were only minor adverse effects with massage. The benefits of massage for patients with acute, sub-acute and chronic non-specific LBP were found mostly in the short-term follow-up period (up to six months after randomization) for pain outcomes.

Furlan, A. D., Giraldo, M., Baskwill, A., Irvin, E., & Imamura, M. (2015). Massage for low-back pain. Cochrane Database of Systematic Reviews, 2017(12). https://doi.org/10.1002/14651858.CD001929.pub3

Runners with PFP have altered biomechanics which targeted interventions can modify

(Neal, Barton, Gallie, O’Halloran, & Morrissey, 2016)

Aims: To synthesise prospective, observational and intervention studies that measure clinical and biomechanical outcomes in symptomatic running populations.

Methods: SR, 2 independent reviewers, 28 studies, PeDro scale for quality.

Results: Very limited prospective evidence indicates that increased peak hip adduction is a risk factor for PFP development in female runners; in addition to limited evidence that running retraining changes both symptoms and function via a likely kinematic mechanism of reduced peak hip adduction. This is supported by moderate evidence from cross-sectional research in mixed sex cohorts, with a correlation also identified between PFP during running and increased peak hip adduction, internal rotation and contralateral pelvic drop. Further prospective research is needed to clarify if these relationships are of a causal or associative nature. Limited evidence also indicates that proximal strengthening exercise changes both symptoms and function at short-term follow up, but currently potential biomechanical mechanisms are unclear.

Limitations: In some studies: insufficient data, methodological issues, representativeness of sample, reliability of outcome measure, only 1 HQ and 2MQ, short term 3 months only …

In Practice: Running pattern may be influencing PFP and evaluating and addressing these may help some patients (especially in female group).

Neal, B. S., Barton, C. J., Gallie, R., O’Halloran, P., & Morrissey, D. (2016). Runners with patellofemoral pain have altered biomechanics which targeted interventions can modify: A systematic review and meta-analysis. Gait and Posture, 45, 69–82. https://doi.org/10.1016/j.gaitpost.2015.11.018

No difference in quantitative MRI in PFP cartilage composition between patients with PFP and healthy controls

(Van Der Heijden et al., 2015)

Aims: To investigate differences in patellofemoral cartilage composition between patients with PFP and healthy control sub- jects using quantitative MRI

Methods: Cross-sectional case-control study, PFP group symptom duration from 2 months to 2 years, 14 to 40 yo. 64 patients and 70 controls.

Results: No significant differences were found in relaxation times of patellar and femoral cartilage between patients and control subjects within the adolescent and adult sub-groups.

Limitations: Small number, some did not do all MRI tests. Diagnostic criteria incomplete. Differences in controls needed adjustment. Selected population.

In practice: Cartilage composition seems not to differ between patients with PFP and asymptomatic controls.

Van Der Heijden, R. A., Oei, E. H. G., Bron, E. E., Van Tiel, J., Van Veldhoven, P. L. J., Klein, S., … Van Middelkoop, M. (2015). No Difference on Quantitative Magnetic Resonance Imaging in Patellofemoral Cartilage Composition between Patients with Patellofemoral Pain and Healthy Controls. American Journal of Sports Medicine, 44(5), 1172–1178. https://doi.org/10.1177/0363546516632507

Exercise for treating PFPS Review

(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

Proximal muscle rehabilitation is effective for PFP: A SR with MA.

(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

Lessons from a trial of acupuncture & massage for LBP: patient expectations & treatment effects.

(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

Assessment and management of CES

(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

A qualitative investigation of Red Flags for serious spinal pathology

(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