Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial.

Cleland JA, Abbott JH, Kidd MO, Stockwell S, Cheney S, Gerrard DF, Flynn TW.

OBJECTIVE:

To compare the effectiveness of 2 different conservative management approaches in the treatment of plantar heel pain.

BACKGROUND:

There is insufficient evidence to establish the optimal physical therapy management strategies for patients with heel pain, and little evidence of long-term effects.

METHODS:

Patients with a primary report of plantar heel pain underwent a standard evaluation and completed a number of patient self-report questionnaires, including the Lower Extremity Functional Scale (LEFS), the Foot and Ankle Ability Measure (FAAM), and the Numeric Pain Rating Scale (NPRS). Patients were randomly assigned to be treated with either an electrophysical agents and exercise (EPAX) or a manual physical therapy and exercise (MTEX) approach. Outcomes of interest were captured at baseline and at 4-week and 6-month follow-ups. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance (ANOVA). The hypothesis of interest was the 2-way interaction (group by time).

RESULTS:

Sixty subjects (mean [SD] age, 48.4 [8.7] years) satisfied the eligibility criteria, agreed to participate, and were randomized into the EPAX (n = 30) or MTEX group (n = 30). The overall group-by-time interaction for the ANOVA was statistically significant for the LEFS (P = .002), FAAM (P = .005), and pain (P = .043). Between-group differences favored the MTEX group at both 4-week (difference in LEFS, 13.5; 95% CI: 6.3, 20.8) and 6-month (9.9; 95% CI: 1.2, 18.6) follow-ups.

CONCLUSION:

The results of this study provide evidence that MTEX is a superior management approach over an EPAX approach in the management of individuals with plantar heel pain at both the short- and long-term follow-ups. Future studies should examine the contribution of the different components of the exercise and manual physical therapy programs.

Journal of  Orthopedic Sports Physical Therapy. 2009 Aug;39(8):573-85. – abstract

Power point presentation of the main outcome charts- here

Filed under: Exercise therapy, Foot and ankle, Manual therapy , iontophoresis, manipulation, mobilization, plantar fasciitis, plantar fasciosis

Massage for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Back Review Group

Furlan, AD; Imamura, M; Dryden, T; Irvin, E

Abstract

Study Design. Systematic Review.

Objectives. To assess the effects of massage therapy for nonspecific low back pain.

Summary of Background Data. Low back pain is one of the most common and costly musculoskeletal problems in modern society. Proponents of massage therapy claim it can minimize pain and disability, and speed return to normal function.

Methods. We searched MEDLINE, EMBASE, CINAHL from their beginning to May 2008. We also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 3), HealthSTAR and Dissertation abstracts up to 2006. There were no language restrictions. References in the included studies and in reviews of the literature were screened. The studies had to be randomized or quasi-randomized trials investigating the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific low back pain. Two review authors selected the studies, assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group, and extracted the data using standardized forms. Both qualitative and meta-analyses were performed.

Results. Thirteen randomized trials were included. Eight had a high risk and 5 had a low risk of bias. One study was published in German and the rest in English. Massage was compared to an inert therapy (sham treatment) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups. In 8 studies, massage was compared to other active treatments. They showed that massage was similar to exercises, and massage was superior to joint mobilization, relaxation therapy, physical therapy, acupuncture, and self-care education. One study showed that reflexology on the feet had no effect on pain and functioning. The beneficial effects of massage in patients with chronic low back pain lasted at least 1 year after the end of the treatment. Two studies compared 2 different techniques of massage. One concluded that acupuncture massage produces better results than classic (Swedish) massage and another concluded that Thai massage produces similar results to classic (Swedish) massage.

Conclusion. Massage might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this need confirmation. More studies are needed to confirm these conclusions, to assess the impact of massage on return-to-work, and to determine cost-effectiveness of massage as an intervention for low back pain.

Spine: 15 July 2009 – Volume 34 – Issue 16 – pp 1669-1684 - abstract

doi: 10.1097/BRS.0b013e3181ad7bd6

Full text available in  through MTABC member only website (link) under the research tab and then library.

Filed under: Exercise therapy, Lumbar spine, Massage, Patient education, Topic review , Low back, Lumbar spine, massage therapy, nonspecific low back pain, pain, Systematic review

Randomized Trial of Therapeutic Massage for Chronic Neck Pain

Sherman, Karen J. PhD, MPH; Cherkin, Daniel C. PhD; Hawkes, Rene J. BS;

Abstract

Objectives: Little is known about the effectiveness of therapeutic massage, one of the most popular complementary medical treatments for neck pain. A randomized controlled trial was conducted to evaluate whether therapeutic massage is more beneficial than a self-care book for patients with chronic neck pain.

Methods: Sixty-four such patients were randomized to receive up to 10 massages over 10 weeks or a self-care book. Follow-up telephone interviews after 4, 10, and 26 weeks assessed outcomes including dysfunction and symptoms. Log-binomial regression was used to assess whether there were differences in the percentages of participants with clinically meaningful improvements in dysfunction and symptoms (ie, >5-point improvement on the Neck Disability Index; >30% improvement from baseline on the symptom bothersomeness scale) at each time point.

Results: At 10 weeks, more participants randomized to massage experienced clinically significant improvement on the Neck Disability Index [39% vs. 14% of book group; relative risk (RR)=2.7; 95% confidence interval (CI), 0.99-7.5] and on the symptom bothersomeness scale (55% vs. 25% of book group; RR=2.2; 95% CI, 1.04-4.2). After 26 weeks, massage group members tended to be more likely to report improved function (RR=1.8; 95% CI, 0.97-3.5), but not symptom bothersomeness (RR=1.1; 95% CI, 0.6-2.0). Mean differences between groups were strongest at 4 weeks and not evident by 26 weeks. No serious adverse experiences were reported.

Conclusions: This study suggests that massage is safe and may have clinical benefits for treating chronic neck pain at least in the short term. A larger trial is warranted to confirm these results.

The Clinical Journal of Pain:

March/April 2009 – Volume 25 – Issue 3 – pp 233-238 – abstract

doi: 10.1097/AJP.0b013e31818b7912

Filed under: Cervical, Conservative therapies, Massage, Spine

Complementary and Alternative Medicine in Back Pain Utilization Report

Santaguida PL, Gross A, Busse J, Gagnier J, Walker K, Bhandari M, Raina P.

Objectives: This systematic review was undertaken to evaluate which complementary and alternative medicine (CAM) therapies are being used for persons with back pain in the United States.

Data Sources: MEDLINE^®, EMBASE^®, CINAHL^® and Cochrane Central^® and a variety of CAM specific databases were searched from 1990 to November 2007. A grey literature search was also undertaken, particularly for clinical practice guidelines (CPG) related to CAM.

Review Methods: Standard systematic review methodology was employed. Eligibility criteria included English studies of adults with back pain, and a predefined list of CAM therapies.

Results: A total of 103 publications were evaluated; of these 29 did not present CAM therapy use stratified for back pain. There were a total of 65 utilization studies, 43 of which were American. Four publications evaluated the concurrent use of four or more CAM therapies and these suggest that chiropractic/manipulation is the most frequently used modality followed by massage and acupuncture. A limited number of publications evaluated utilization rates within multiple regions of the back and show that CAM was used least for treating the thoracic spine and most for the low back. However, rates of use of massage were similar for neck and lower back regions. Concurrent use of different CAM or conventional therapies was not well reported.

From 11 eligible CPG, only one (for electro-acupuncture) provided recommendations for frequency of use for low back pain of all acuity levels.

Eighteen cost publications were reviewed and all but one publication (cost-effectiveness) were cost identification studies. There is limited information on the impact of insurance coverage on costs and utilization specific to back pain.

Conclusions: There are few studies evaluating the relative utilization of various CAM therapies for back pain. For those studies evaluating utilization of individual CAM therapies, the specific characteristics of the therapy, the providers, and the clinical presentation of the back pain patients were not adequately detailed; nor was the overlap with other CAM or conventional treatments.

Evidence Report/Technology Assessment No. 177 – full text

Filed under: Alternative therapies, Manual therapy, Massage, Spine

Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline

R Chou,L Hoyt Huffman

Background: Many nonpharmacologic therapies are available for treatment of low back pain.

Purpose: To assess benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain).

Data Sources: English-language studies were identified through searches of MEDLINE (through November 2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4). These electronic searches were supplemented by hand searching of reference lists and additional citations suggested by experts.

Study Selection: Systematic reviews and randomized trials of 1 or more of the preceding therapies for acute or chronic low back pain (with or without leg pain) that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction.

Data Extraction: We abstracted information about study design, population characteristics, interventions, outcomes, and adverse events. To grade methodological quality, we used the Oxman criteria for systematic reviews and the Cochrane Back Review Group criteria for individual trials.

Data Synthesis: We found good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks’ duration) low back pain. Benefits over placebo, sham therapy, or no treatment averaged 10 to 20 points on a 100-point visual analogue pain scale, 2 to 4 points on the Roland–Morris Disability Questionnaire, or a standardized mean difference of 0.5 to 0.8. We found fair evidence that acupuncture, massage, yoga (Viniyoga), and functional restoration are also effective for chronic low back pain. For acute low back pain (<4 weeks’ duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat (good evidence for moderate benefits) and spinal manipulation (fair evidence for small to moderate benefits). Although serious harms seemed to be rare, data on harms were poorly reported. No trials addressed optimal sequencing of therapies, and methods for tailoring therapy to individual patients are still in early stages of development. Evidence is insufficient to evaluate the efficacy of therapies for sciatica.

Limitations: Our primary source of data was systematic reviews. We included non–English-language trials onl

Annals of Internal Medicine. 2007;147:492-504. – full text

Filed under: Conservative therapies, Lumbar spine, Spine, Treatment guidelines

Acetabular Labral Tears

CL Lewis, SA Sahrmann

Anterior hip or groin pain is a common complaint for which people are referred for physical therapy, with the hip region being involved in approximately 5% to 9% of injuries in high school athletes. Although anterior hip pain is known to result from a number of musculoskeletal and systemic pathologies, a tear of the acetabular labrum is a recent addition to the list that is of particular interest to physical therapists. This mechanically induced pathology is thought to result from excessive forces at the hip joint and has been proposed as part of a continuum of hip joint disease that may result in articular cartilage degeneration. Although the number of recent articles in the orthopedic literature identifying acetabular labral tears as a source of hip pain is increasing, labral tears often evade detection, resulting in a long duration of symptoms, greater than 2 years on average, before diagnosis. Studies have shown that 22% of athletes with groin pain and 55% of patients with mechanical hip pain of unknown etiology  were found to have a labral tear upon further evaluation. In order to provide the most appropriate intervention for patients with anterior hip or groin pain, physical therapists should be knowledgeable about all of the possible sources and causes of this pain, including a tear of the acetabular labrum and the possible factors contributing to these tears. Therefore, the purpose of this article is to review the anatomy and function of the acetabular labrum and present current concepts on the etiology, clinical characteristics, diagnosis, and treatment of labral tears.

PHysical Therapy, Vol. 86, No. 1, January 2006, pp. 110-121 – full text

Filed under: Assessment, Conservative therapies, Hip

Management of Symptomatic Lumbar Degenerative Disk Disease

L Madigan, AR Vaccaro, LR Spector, R Alden Milam

Symptomatic lumbar degenerative disk disease, or discogenic back pain, is difficult to treat. Patients often report transverse low back pain that radiates into the sacroiliac joints. Radicularor claudicatory symptoms are generally absent unless there is concomitant nerve compression. Physical examination findings are often unremarkable. Radiographic examination may revealdisk space narrowing, end-plate sclerosis, or vacuum phenomenon in the disk; magnetic resonance imaging is useful for revealing hydration of the disk, annular bulging, or lumbar spine end-plate (Modic) changes in the adjacent vertebral bodies. The use of diskography as a confirmatory study remains controversial. Recent prospective, randomized trials and meta-analyses of the literature have helped expand what is known about degenerative disk disease. In most patients with low back pain, symptoms resolve without surgical intervention; physical therapy and nonsteroidal anti-inflammatory drugs are the cornerstones of nonsurgical treatment. Intradiskal electrothermal treatment has not been shown to be effective, and arthrodesis remains controversial for the treatment of discogenic back pain. Nucleus replacement and motion-sparing technology are too new to have demonstrated long-term data regarding their efficacy.

Approximately 70% to 85% of adults will be affected by low back pain (LBP) at some point during their lifetimes.1,2 Numerous anatomic sites can be responsible for the pain, and accurate diagnosis is often difficult. Degenerative disk disease (DDD), internal disk disruption, lumbar disk herniation, and facet joint arthritis, as well as intra-abdominal pathology, are allpotential causes of LBP. Patients with DDD or discogenic back pain can present with aconstellation of symptoms that range from benign LBP to excruciating back pain with lower extremity symptoms. Risk factors for LBP, such as jobs requiring heavy lifting, use of a jackhammer or machine tools, or the operation of motor vehicles, have been identified in the literature.3 Continued degeneration of the affected disk can lead to secondary problems such as degenerative spondylolisthesis, lumbar stenosis, and facet arthrosis.

Journal of the American Academy of Orthopaedic Surgeons, 2009;17:102-111 – abstract

Filed under: Conservative therapies, Lumbar spine, Surgery, Topic review

A systematic literature review of nonsurgical treatment in adult scoliosis.

Everett CR, Patel RK.

STUDY DESIGN.: A formal systematic review of the literature for conservative treatment of adult deformity was performed.                                                                                              OBJECTIVE.: To evaluate evidence for the efficacy and effectiveness of proposed conservative treatment options in adult deformity. SUMMARY OF BACKGROUND DATA.: Adult deformity is a major demographic health issue in the geriatric population in both the United States and the world communities. Surgeons are often very conservative in the treatment of adult scoliosis because of the complication rates associated with the surgeries and the marginal bone quality endemic to this population. A prerequisite to surgical intervention is usually failure of all appropriate conservative care. There is currently a lack of consensus on the most efficacious conservative treatments for adult deformity.                                                    METHODS.: A systematic review of clinical studies; using the key terms of adult or degenerative and scoliosis combined with any of the following: bracing, casting, physical therapy, chiropractic, and injections for treatment. The database inclusions were PubMed, OVID, and CINAHL. Articles were excluded if the primary patient populations were adolescents or the treatment options performed were primarily surgical. The methodology of the studies was graded and the evidence was classified into 1 of 5 levels based on study types. Based on this, a treatment recommendation was determined.                                            RESULTS.: There is indeterminate, Level III/IV evidence on the effectiveness of any conservative care option. Specifically, there is Level IV evidence on the role of physical therapy, chiropractic care, and bracing. There is Level III evidence for injections in the conservative treatment of adult deformity. There is insufficient research for a treatment recommendation beyond Level 2c very weak evidence, but the available literature is supportive of further clinical research in conservative care as a treatment in adult deformity.                                                                                                                                CONCLUSION.: Conservative care in general may be a helpful option in the care of adult deformity, but evidence for this is lacking. Unfortunately, no treatment option within conservative care has support within the literature as a preferred solution. Basic clinical research at any level would be helpful to further clarify the options.

Spine. 2007 Sep 1;32(19 Suppl):S130-4.- abstract

Full text available in  through MTABC member only website (link) under the research tab and then library.

DOI: 10.1097/BRS.0b013e318134ea88

Filed under: Conservative therapies, Scoliosis, Spine, Uncategorized

Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee: A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus a Home Exercise Program

Deyle, Allison, Matekel, Ryder et al

Background and Purpose. Manual therapy and exercise have not previously been compared with a home exercise program for patients with osteo-arthritis (OA) of the knee. The purpose of this study was to compare outcomes between a home-based physical therapy program and a clinically based physical therapy program.

Subjects. One hundred thirty-four subjects with OA of the knee were randomly assigned to a clinic treatment group (n=66; 61% female, 39% male; mean age [±SD]=64±10 years) or a home exercise group (n=68, 71% female, 29% male; mean age [±SD]=62±9 years).

Methods. Subjects in the clinic treatment group received supervised exercise, individualized manual therapy, and a home exercise program over a 4-week period. Subjects in the home exercise group received the same home exercise program initially, reinforced at a clinic visit 2 weeks later. Measured outcomes were the distance walked in 6 minutes and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Results. Both groups showed clinically and statistically significant improvements in 6-minute walk distances and WOMAC scores at 4 weeks; improvements were still evident in both groups at 8 weeks. By 4 weeks, WOMAC scores had improved by 52% in the clinic treatment group and by 26% in the home exercise group. Average 6-minute walk distances had improved about 10% in both groups. At 1 year, both groups were substantially and about equally improved over baseline measurements. Subjects in the clinic treatment group were less likely to be taking medications for their arthritis and were more satisfied with the overall outcome of their rehabilitative treatment compared with subjects in the home exercise group.

Discussion and Conclusion. Although both groups improved by 1 month, subjects in the clinic treatment group achieved about twice as much improvement in WOMAC scores than subjects who performed similar unsupervised exercises at home. Equivalent maintenance of improvements at 1 year was presumably due to both groups continuing the identical home exercise program. The results indicate that a home exercise program for patients with OA of the knee provides important benefit. Adding a small number of additional clinical visits for the application of manual therapy and supervised exercise adds greater symptomatic relief.

Physical Therapy, Vol. 85, No. 12, December 2005, pp. 1301-1317

Full text PDF

Filed under: Exercise therapy, Knee, Manual therapy, Osteoarthritis

Massage Therapy for Osteoarthritis of the Knee

Perlman, Sabina, Williams, Njike, Katz

Background Massage therapy is an attractive treatment option for osteoarthritis (OA), but its efficacy is uncertain. We conducted a randomized, controlled trial of massage therapy for OA of the knee.

Methods Sixty-eight adults with radiographically confirmed OA of the knee were assigned either to treatment (twice-weekly sessions of standard Swedish massage in weeks 1-4 and once-weekly sessions in weeks 5-8) or to control (delayed intervention). Primary outcomes were changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and functional scores and the visual analog scale of pain assessment. The sample provided 80% statistical power to detect a 20-point difference between groups in the change from baseline on the WOMAC and visual analog scale, with a 2-tailed of .05.

Results The group receiving massage therapy demonstrated significant improvements in the mean (SD) WOMAC global scores (–17.44 [23.61] mm; P<.001), pain (–18.36 [23.28]; P<.001), stiffness (–16.63 [28.82] mm; P<.001), and physical function domains (–17.27 [24.36] mm; P <.001) and in the visual analog scale of pain assessment (–19.38 [28.16] mm; P<.001), range of motion in degrees (3.57 [13.61]; P = .03), and time to walk 50 ft (15 m) in seconds (–1.77 [2.73]; P<.01). Findings were unchanged in multivariable models controlling for demographic factors.

Conclusions Massage therapy seems to be efficacious in the treatment of OA of the knee. Further study of cost effectiveness and duration of treatment effect is clearly warranted.

Archives of Internal Medicine. 2006;166:2533-2538

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Filed under: Knee, Massage, Osteoarthritis