Background
The CORKA trial (ISRCTN 13517704) was commissioned to investigate rehabilitation outcomes inn patients assessed as being at risk of poor outcome after knee arthroplasty (KA). The trial used a screening tool based on an analysis of factors associated with a poor outcome after knee arthroplasty to guide patient selection for the trial. The tool was not as sensitive as hoped and further work is required to develop factors based on individual level to predict patients requiring supervised rehabilitation as recommended in UK NICE guideline NG157
Purpose
To use simple physical performance tests, pre KA, to predict functional health outcomes, post KA, to try to identify patients at greater risk of poor outcomes and provide information on patients likely to benefit from targeted rehabilitation post KA.
Methods
Secondary analysis of data collected for the Community-based Rehabilitation after Knee Arthroplasty (CORKA) RCT. Physical assessments were measured at baseline and included the figure of 8 walk test, 30-second chair stand test (CST), single leg stance on the operated leg (SLS), and the Physical Activity Scale for the Elderly (PASE). The Late-Life Function and Disability Instrument (LLFDI) was used to assess community-dwelling older adult’s function. The LLFDI function score was measured at six months, one year and two years post–baseline assessment. Linear regression analysis was used to predict the LLFDI score from the physical assessments while adjusting for age, sex, BMI, and site of recruitment.
Results
A total of 621 participants (men n= 250, women n= 371) were recruited for this study with a mean age 70.4 ± 8.1 years, and BMI of 31.5 ± 4.7. Participants were recruited from 8 different NHS sites across the UK. SLS and PASE significantly predicted LLFDI function at six months (SLS B=0.14, 95%CI 0.06-0.22, PASE B=0.018, 95%CI 0.05-0.03) and two years (SLS B=0.21, 95%CI 0.11-0.31, PASE B=0.022, 95%CI 0.004-0.038) with the CST and SLS significantly predicting LLFDI function at one year (SLS B=0.18, 95%CI 0.09-0.27, CST B=0.36, 95%CI 0.04-0.68).
Conclusion
Single leg stance on the operated leg and the Physical Activity Scale for the Elderly consistently predicted LLFDI function from six months to two years after KA surgery. Further research should investigate how dynamic and static balance along with objective measures of physical activity may predict which patients are at risk of poor health outcomes following KA surgery.
Implication
If balance and general physical activity can provide a more accurate method to predict which patients are at risk of low health outcomes post KA surgery then pre-habilitation programmes could be used along with targeted post-op rehabilitation programmes to provide better health outcomes for those at greater risk.
Background: Exercise is considered the cornerstone of effective management for lateral elbow tendinopathy. While exercise is known to induce an analgesic response in healthy populations, this response is less clear in pain populations, such as chronic lateral elbow tendinopathy (LET). Manual therapy is also known to induce an analgesic response. For example, Mobilisation-with-Movement (MWM) has been shown to increase pressure pain thresholds (PPT) and pain-free grip strength in people with LET. People with chronic LET have also demonstrated altered pain processing, including widespread mechanical hyperalgesia, cold hyperalgesia and increased pain facilitation as measured through temporal summation. The effects of exercise, both alone and in combination with manual therapy, on sensory outcomes is unknown. Furthermore, the association of pain processing characteristics and changes in pain and function following exercise (with and without manual therapy) is unknown.
Purpose: The primary aim of this study was to examine the effects of exercise alone and in combination with manual therapy on sensory characteristics, pain and function in individuals with LET. The secondary aim was to evaluate the association of pain processing characteristics and changes in pain and function following exercise, with and without manual therapy. Design: Within-subject, single-blinded, randomised study.
Methods: Twenty-four participants (age 49.7 ±8.2 years, duration elbow pain 15 ±25 months) with a clinical diagnosis of LET underwent three experimental conditions in random order: Control, Exercise (6 x 10-seconds isometric gripping to pain threshold) and Exercise with concurrent Mobilisation-with-Movement (Exercise+MWM). A blinded assessor measured PPT and temporal summation (over the elbow, and tibialis anterior), and resting pain intensity (11-point scale) before, immediately after and 10-minutes after each condition. Grip force was recorded during the Exercise conditions. Repeated-measures ANOVAs were used to compare between conditions and over time (p < 0.05). Conditioned pain modulation (CPM), temporal summation, Patient-Rated Tennis Elbow Evaluation, Tampa Scale of Kinesiophobia and Hospital Anxiety and Depression Scale were measured at baseline. Results: Resting elbow pain significantly increased following the Exercise-only condition (0.8, 95%CI 0.4 to 1.1) compared to other conditions. Exercise+MWM significantly increased average grip force compared to Exercise alone (mean difference 42 N, 95%CI 10 to 74). PPT at the elbow (p = 0.001) and tibialis anterior (p = 0.016) significantly improved following Exercise+MWM compared to Exercise alone. There was a significant correlation between the net CPM effect and the net effect of adding manual therapy to Exercise on PPT (p < 0.01). Conclusion: There was no evidence of exercise-induced analgesia in people with LET. Adding manual therapy to exercise produced an analgesic response and a greater exercise output compared to exercise alone. Descending inhibitory control of nociceptive stimuli (as measured by conditioned pain modulation) may be associated with the analgesic effects of adding manual therapy to exercise.
Implications:
• Combining manual therapy with exercise provides an analgesic response
• Combining manual therapy with exercise increases exercise output, which is known to be important for stimulating a biological response within the tendon
• Exercise alone increases resting pain levels, potentially negatively impacting adherence to an exercise program.
Background: Clinical guidelines recommend exercise as a core treatment for hip and knee osteoarthritis (OA). Other non-pharmacological therapies are commonly delivered as adjuncts to exercise. A Cochrane systematic review published by the author team found no clinically meaningful effect of various adjunctive therapies used with land-based exercise therapy, compared to the placebo equivalent and exercise, or exercise only for hip or knee OA.
Purpose: This subgroup analysis reports the results on the effects of adjunctive manual therapies used in combination with land-based exercise therapy for hip or knee OA.
Methods: A systematic review and meta-analysis was performed. Searches were completed across six databases up to June 2021. Studies included randomised controlled trials (RCTs) or quasi-RCTs of people with hip or knee OA comparing adjunctive therapies alongside land‐based exercise therapy (experimental group) versus 1) placebo adjunctive therapies alongside land‐based exercise therapy, or 2) land‐based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant‐reported global assessment and adverse events. We evaluated short‐term (< 6 months), medium‐term (6-12 months) and long‐term (≥ 12 months) effects. Risk of bias was assessed using the Cochrane Risk of Bias tool v1. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). Statistical heterogeneity was assessed using the I2 statistic. Findings from analysis of the manual therapies subgroup is reported using pooled Standardised Mean Differences (SMD). Effect sizes were categorised as small (0.2-0.5), medium (0.5-0.8) and large (> 0.8).
Results: Of the 62 trials included in the review, seven investigated manual therapies, including joint mobilisations and massage, combined with exercise against exercise only. None compared against placebo manual therapy and exercise. Six trials included people with knee OA and two included hip OA. The number of treatments delivered varied between 8 and 15, delivered over 6-12 weeks. Two trials delivered manual therapy over 11 months, with inclusion of booster sessions (at months 5, 8 and 12). Medium-term effects were evaluated in five trials, and three assessed long-term effects. Adverse events were reported in one trial. There was no short-term difference in pain severity (SMD 0.01 [-0.30, 0.31], n= 608, I2 = 68%), physical function (SMD -0.13 [-0.45, 0.20], n=669, I2 = 75%), or patient global assessment (Risk Ratio (RR) 1.19 [0.97, 1.46], n=235, I2 = 0%). Based on one trial (n= 101), there was a significant improvement in pain (SMD 0.55 [0.15, 0.94]) in favour of exercise only (vs manual therapy and exercise), but not in function (SMD 0.33 [-0.07, 0.72]. There was also no long-term difference in pain (SMD -0.27 [-0.72, 0.18], n=286, I2=68%), or physical function (SMD -0.07 [-0.49, 0.36], n=286, I2=65%). Certainty of evidence using GRADE was rated as low for all comparisons.
Conclusions/Implications: Current evidence does not support manual therapies used adjunctively with exercise therapy for short-term, medium-term or long-term improvement in pain, function or patient global assessment for hip or knee OA compared to exercise therapy only. Caution should be applied in interpreting results due to low-certainty evidence.
Background
Persistent shoulder pain is a common problem and people with this condition are often referred for orthopaedic specialist management in tertiary care. Protracted waiting times for a consultation occur frequently within these services, yet surgical conversion rates remain relatively low. Developing models of care that can distinguish between prospective surgical candidates and people who may benefit from an alternative care pathway could improve service efficiency, optimise healthcare expenditure, and enhance patient outcomes. Altered sensory processing may be present in this patient group and influence treatment outcomes, however the current evidence regarding this is limited. Furthermore, the sociodemographic, clinical, general health and lifestyle, and psychological characteristics of this group are yet to be comprehensively explored. Investigation of these characteristics could provide insight into factors that may impact the experience and trajectory of shoulder pain in this population.
Purpose
The primary objective of this study was to compare sensory processing measures in people attending tertiary care for shoulder pain with control participants. A secondary objective was to compare the groups’ sociodemographic, clinical, general health and lifestyle, and psychological characteristics.
Methods
Participants with shoulder pain ≥ 3 months attending a tertiary orthopaedic clinic (n = 119) and community participants without shoulder pain (n = 44) underwent a standardised quantitative sensory testing protocol, measuring pressure pain threshold (PPT), temporal summation (TS), and conditioned pain modulation (CPM). Sociodemographic, clinical, general health and lifestyle, and psychological characteristics were assessed via a participant interview, self-report questionnaires, and a physical assessment. All measures were conducted in a single session.
Results
Participants with shoulder pain demonstrated significantly lower PPTs at all sites (i.e., local, and widespread mechanical hyperalgesia) and significantly decreased CPM effect during the cold pressor test (i.e., descending inhibition of nociception) than the control participants. There was no significant difference between groups for TS. Participants with shoulder pain displayed decreased general health and function, less healthy lifestyles, and poorer psychological health compared with the control group.
Conclusion
Features of impaired sensory processing were evident in people attending a tertiary care orthopaedic clinic for management of shoulder pain compared with a control group. The impact of sensory function on treatment outcomes in similar patient cohorts requires investigation.
Implications
Pain mechanisms in people with persistent shoulder pain appear more complex than being an isolated musculoskeletal (i.e., nociceptive) complaint. The value of a multidisciplinary approach to care should be considered, with a view to improving an individual’s physical and psychological wellbeing in addition to any relevant biomechanical or medical interventions.
Background:
The shoulder is the most frequently dislocated joint, in 95% of cases the shoulder dislocates forwards. After a shoulder dislocation has occurred emergency treatment is required to reduce the dislocation and to support the arm in a sling. Rehabilitation has a key role in restoring a functional, painless shoulder. However there is limited evidence comparing different rehabilitation methods after the initial support in a sling. Current guideline recommendations internationally range from advice only to advice and an additional programme of supervised physiotherapy.
The choice of rehabilitation offered following a shoulder dislocation has large resource implications for the person and health care provider. Consequently, if a single advice session were all that is required, it would lessen the burden on patients and the healthcare resources required.
Purpose:
We aimed to compare the clinical effectiveness of a single session of advice with a single session of advice and a programme of physiotherapy.
Methods:
We completed a pragmatic, superiority, multi-centre randomised controlled trial, funded by the National Institute for Health and Care Research (NIHR; 16/167/56). Trauma research teams at 41 UK NHS Trust sites screened adults with a first-time traumatic anterior shoulder dislocation confirmed radiologically, being managed non-operatively.
Four hundred and eighty two participants were eligible and consented from 40 UK NHS sites between 14th November 2018 and 14th March 2022. All participants received an initial single session of advice to aid self-management. This lasted for up to one hour and included education on the injury, common complications and how to prevent them, pain relief and suggested exercises. Following this single session of advice all participants were randomly allocated (stratified by participant age, hand dominance and recruiting site) to this advice session alone or additional physiotherapy over a four month period.
The primary outcome was the Oxford Shoulder Instability Score, measured six months after treatment allocation. Secondary outcomes included the QuickDASH, EQ-5D-5L and complications.
Results:
There was no statistically significant difference between advice compared to advice and a programme of physiotherapy at the primary six-month time point, for the primary intention to treat adjusted analysis (favours physiotherapy: 1.5; 95% CI -0.3 to 3.5) or at earlier three month and six week time points.
Conclusion:
Until ARTISAN there was no strong evidence to guide rehabilitation management following an initial two-weeks support in a sling. We now know an additional programme of physiotherapy is not superior to advice alone.
Implications:
An individually tailored programme of physiotherapy is not superior to advice, however, people who are not experiencing recovery as expected could self-refer for a supervised programme of physiotherapy after the initial self-management period. This will provide a balance between best use of health care resources, empowering patients and reducing unnecessary appointments for those who can self-manage.
Background: Joint motion assessment informs diagnosis, interventions, and assessment. Hip range of motion (HROM) measures are included in Clinical Practice Guidelines for hip management. To optimize patient outcomes, we need to bridge between research, education, and clinical expertise to deliver refined and precise patient management. Purpose: Present hiption as the natural plane of motion of the hip that allows for maximal hip flexion and greatest ease of movement. 1) identify if hiption is clinically measurable and reproducible, 2) compare normative values for HROM as measured in cardinal planes vs. hiption plane, and 3) determine if HROM in hiption as reliable as cardinal HROM in both experienced and novice raters. Secondary aims: assess functional squat between planes and assess potential impact of hypermobility. Methods: Exploratory cohort model, supine HROM flexion (F), external rotation (ER), internal rotation (IR) in cardinal and hiption planes. Hiption determined as plane of maximal hip flexion with least resistance and greatest comfort. Hip IR/ER at 90 degrees hip flexion both planes. Beighton scale completed for joint laxity. Maximal squat depth in cardinal, hiption plane and self-selected position. Data analyzed with paired t-test for HROM between planes, and squat depths. ICC for inter-tester reliability, and correlation analysis for HROM and Beighton scale. Results: 121 subjects, ages 20-65 (28.4, +/- 8.0) (female 61%, male 38%, non-binary 1%). Hip ROM 121 subjects (mean values degrees): Cardinal: F left 126.0 (8.08), R 126.9 (7.42), IR L 32.7 (9.33), R 29.9 (9.42), ER L 46.3 (11.49), R 48.4 (11.39). Hiption: F L 132.2 (8.09), R 132.9 (7.52), IR L 33.7 (10.46), R 31.2 (9.79), ER L 48.5 (11.31), R 50.4 (10.63). Adjusted hiption ROM based upon a transverse plane determination of hiption: IR L 52.3 (10.59), R 49.4 (9.91), ER L 29.5 (10.59), R 32.3 (9.59). Paired t-tests between planes, positive for all (p < .000): F L (t= -18.7; CI -6.9, -5.5), R (t= -16.1; CI -6.6, -5.2), IR L (t= -24.1; CI -21.1, -17.9), R (t= -26.2; CI -20.9, -17.9), ER L (t= 23.1; CI 15.3, 18.2), R (t= 21.9; CI 14.7, 17.6). Reliability: HROM cardinal - good; F L (ICC .83), R (ICC .76), IR L (ICC .79), R (ICC .74), ER L (ICC .80), R (ICC .78). Hiption – moderate to good; F L (ICC .83), R (ICC .81), IR L (ICC .86), R (ICC .77), ER L (ICC .83), R (ICC .79). Adjusted IR L (ICC .66), R (ICC .49), ER L (ICC .66), R (ICC .50). Mean squat (cm/SD) cardinal 105.8 (9.8), self-selected 98.9 (8.8), hiption plane 97.5 (11.0). Difference significant cardinal/self-selected (p < 0.000) (95% CI= 5.0, 8.7), and cardinal/hiption (p < 0.000) (95% CI= 5.5, 11.1). Self-selected/hiption not significant (p= 0.167) (95% CI= -0.6, -3.5). Discussion: HROM in hiption greater for flexion, internal rotation; not external rotation. Findings all significant. Reliability good for hiption vs cardinal plane except adjusted IR and ER (moderate). Squat deeper in hiption. Future research should assess impact of hiption on manual interventions, exercise prescription, and rehabilitation for hip/pelvic impairments.
BACKGROUND: Plantar fasciitis (PF) is characterized as the inflammation and possible degeneration of the plantar fascia, often presenting as pain and stiffness in the morning and with weight bearing activities. With non-surgical treatment, about 80% of patients improve within 12 months, however, some individuals go on to have a failed healing response and develop chronic heel pain. Extracorporeal shockwave therapy (ECSWT) has been identified as a minimally invasive, effective treatment for the treatment of chronic PF but less is known when this is used in combination with manual therapy and/or exercise.
PURPOSE: The purpose of this study was to examine the effects of ECSWT alone, ECSWT in combination with joint mobilizations to the talocrural, subtalar, and first metatarsophalangeal joints, and ECSWT in combination with exercise on heel pain and lower extremity function in individuals with chronic PF.
METHODS: Participants (n=108) with chronic heel pain secondary to PF were randomly assigned to one of the three treatment groups. Participants were asked to: i.) rate their heel pain at rest, after activity, and ii.) improvement using the visual analog scale (VAS) and function using the Lower Extremity Functional Scale (LEFS) before and 12-weeks following treatment. Two one-way ANOVAs were conducted to examine baseline and post-intervention pain and functional outcome measures between the three treatment groups to determine differences in the change scores. A dependent samples t-test also examined significant differences from pre- to post-intervention within each treatment group for the outcome measures.
RESULTS: There was a statistically significant difference between groups for heel pain at rest with a small effect size, F(2,102)=4.902, p=.009, ŋ2=.088. Bonferonni post-hoc comparisons revealed that heel pain after activity was lower in the ECSWT and joint mobilizations group (-19.46 on the VAS, p=.016) and in the ECSWT group alone (-17.39 on the VAS, p=.036) compared to the ECSWT and exercise group. There were no statistically significant differences between the ECSWT and joint mobilizations and ECSWT group on heel pain after activity. No other significant differences were found between each of the treatment groups comparing change scores from pre- to post-scores for the other outcome measures (p>.05). Significant differences post-treatment were found, however, in the VAS scores for heel pain at rest and overall improvement in heel pain and in LEFS scores. The ECSWT and joint mobilization group demonstrated the greatest reduction in heel pain at rest and after activity, reported the greatest overall improvement, and improved function compared to the ECSWT alone or ECSWT and exercise groups.
CONCLUSION: ECSWT alone and in combination appears to improve heel pain and function but when combined with joint mobilizations of the talocrural, subtalar, and first metatarsophalangeal joints, greater improvements post treatment and in overall heel pain at rest and after activity and in lower extremity function are present. The beneficial findings of ECSWT as a consideration for treatment is consistent with previous research but combining ECSWT with joint mobilizations may result in greater benefits in pain and function.
Background: Manual therapy (MT) is an effective intervention for treatment of people with knee osteoarthritis (OA). Dose is a well-recognised aspect of any treatment approach and is known to affect clinical outcomes. Treatment frequency is an aspect of MT dose that has not been thoroughly investigated. Existing studies show large variability and lack of rationale to support selection of treatment frequency. Variation in provision of treatment makes it difficult to directly compare results from different studies, or for physiotherapists to translate findings into clinical practice. Therefore, there is a clear need for research to investigate the optimal frequency of MT for people with knee OA.
Study Aim: The primary aim is to investigate whether frequency of treatment with MT for people with knee OA affects clinical outcomes at 6-month follow-up. A secondary aim is whether MT is superior to a best practice exercise and advice intervention.
Method: We conducted a fully powered, 3-arm, randomised controlled trial (RCT), comparing participants receiving six MT treatments at a frequency of once per week (MT1), those receiving six treatments at a frequency of twice per week (MT2), and a control group (UC) who did not receive MT. All groups received a standardized best-practice package of care incorporating an individually tailored exercise programme, advice, and education.
We analysed clinical outcomes using linear mixed models across the trial period with the primary outcome being functional outcome at 6-months (KOOS). Secondary outcomes included pain, quality of life (QOL), and physical performance measures (PPMs).
Results: We recruited 154 participants with mild to moderate knee OA with only 4 withdrawals (2.6%). At 6-months there was no between group difference for MT1 and MT2. The primary outcome (KOOS function) was 2.24 lower in MT2 (95%CI -7.89, 3.40) p=0.432. This result was repeated for all secondary outcomes except MT2 were quicker on the timed up-and-go, 1.41 secs (95%CI 0.28, 2.53) p=0.015 and the 40-metre fast paced walk, 3.35 (95%CI 0.06, 6.64) p=0.046. For the secondary analyses the MT groups combined were superior to UC for KOOS function, 5.68 (95%CI 0.57, 10.79) p= 0.03, and three of the four PPM. Graphical trends suggest that MT2 improved faster, but MT1 continued to improve and sustained this improvement at 6-months.
Conclusions: Adding MT to UC gives a superior functional outcome at 6-months, but the frequency of treatment does not impact this substantially.
Implications: Clinicians and patients with knee OA can reach a shared decision on how often to attend for treatment with MT.