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

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

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

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

Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee

Deyle, Henderson, Matekel, Ryder et al

Background: Few investigations include both subjective and objective measurements of the effectiveness of treatments for osteoarthritis of the knee. Beneficial interventions may decrease the disability associated with osteoarthritis and the need for more invasive treatments.

Objective: To evaluate the effectiveness of physical therapy for osteoarthritis of the knee, applied by experienced physical therapists with formal training in manual therapy.

Design: Randomized, controlled clinical trial.

Setting: Outpatient physical therapy department of a large military medical center.

Patients: 83 patients with osteoarthritis of the knee who were randomly assigned to receive treatment (n = 42; 15 men and 27 women [mean age, 60 ± 11 years]) or placebo (n = 41; 19 men and 22 women [mean age, 62 ± 10 years]).

Intervention: The treatment group received manual therapy, applied to the knee as well as to the lumbar spine, hip, and ankle as required, and performed a standardized knee exercise program in the clinic and at home. The placebo group had subtherapeutic ultrasound to the knee at an intensity of 0.1 W/cm² with a 10% pulsed mode. Both groups were treated at the clinic twice weekly for 4 weeks.

Measurements: Distance walked in 6 minutes and sum of the function, pain, and stiffness subscores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A tester who was blinded to group assignment made group comparisons at the initial visit (before initiation of treatment), 4 weeks, 8 weeks, and 1 year.

Results: Clinically and statistically significant improvements in 6-minute walk distance and WOMAC score at 4 weeks and 8 weeks were seen in the treatment group but not the placebo group. By 8 weeks, average 6-minute walk distances had improved by 13.1% and WOMAC scores had improved by 55.8% over baseline values in the treatment group (P < 0.05). After controlling for potential confounding variables, the average distance walked in 6 minutes at 8 weeks among patients in the treatment group was 170 m (95% CI, 71 to 270 m) more than that in the placebo group and the average WOMAC scores were 599 mm higher (95% CI, 197 to 1002 mm). At 1 year, patients in the treatment group had clinically and statistically significant gains over baseline WOMAC scores and walking distance; 20% of patients in the placebo group and 5% of patients in the treatment group had undergone knee arthroplasty.

Conclusions: A combination of manual physical therapy and supervised exercise yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.

Annals of Internal Medicine, 1 Feb 2000, Vol 132 Issue 3, 173-181

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

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis

Ottawa Methods Group: Brosseau, Wells, Tugwell, Egan et al

BACKGROUND AND PURPOSE: Osteoarthritis (OA) affects a large and growing proportion of the population. The purpose of this project was to create guidelines for the use of therapeutic exercises and manual therapy in the management of adult patients (>18 years of age) with a diagnosis of OA. All stages of the disease were included in the analysis, and studies of patients who had recent surgery or other rheumatologic, musculoskeletal, or spinal problems or of subjects without known pathology or impairments were excluded.

METHODS: The Ottawa Methods Group used Cochrane Collaboration methods to find and synthesize evidence from comparative controlled trials and then asked stakeholder groups to nominate representatives to serve on a panel of experts. The Ottawa Panel agreed on criteria for grading the strength of the recommendations and their supporting evidence. Of the 609 potential articles on therapeutic exercises for OA that were identified, 113 were considered potentially relevant, and 26 randomized controlled trials and controlled clinical trials were ultimately used.

RESULTS: Sixteen positive recommendations of clinical benefit were developed for therapeutic exercises, especially strengthening exercises and general physical activity, particularly for the management of pain and improvement of functional status. Manual therapy combined with exercises also is recommended in the management of patients with OA.

DISCUSSION AND CONCLUSION: The Ottawa Panel recommends the use of therapeutic exercises alone, or combined with manual therapy, for managing patients with OA. There were a total of 16 positive recommendations: 13 grade A and 3 grade C+. The Ottawa Panel recommends the use of therapeutic exercises because of the strong evidence (grades A, B, and C+) in the literature.

Physical Therapy, Vol. 85, No. 9, September 2005, pp. 907-971

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Filed under: Exercise therapy, Manual therapy, Osteoarthritis, Treatment guidelines

The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: Executive Summary

Haldeman, S; Carroll, L; Cassidy, J D; Schubert, J; Nygren, Å

This Task Force consisted of a 5-member Executive Committee, a 13-member Scientific Secretariat, a 17-member Advisory Committee, and 18 research associates and graduate students. Committee members originated from 9 countries and represented 19 clinical and scientific disciplines or specialties. The Task Force was affiliated with 8 collaborating universities and research institutes in 4 countries, and 11 professional organizations agreed to become nonfinancial sponsors.

Key Findings From the Task Force

Epidemiology of Neck Pain

* Most people can expect to experience some neck pain in their lifetimes, although for the majority, neck pain will not seriously interfere with normal activities.

* Depending on the case definitions used, the 12-month prevalence of neck pain ranged from 12.1% to 71.5% in the general population, and from 27.1% to 47.8% in workers. However, neck pain with associated disability was less common: 12-month prevalence estimates ranged from 1.7% to 11.5% in the general population.

* Each year, between 11% and 14.1% of workers reported being limited in their activities because of neck pain. Neck pain was common in all occupational categories, and the results of the Ontario cohort study suggest that worker’s compensation data significantly underestimate the burden of neck pain in workers.

* The number of persons seeking health care in emergency rooms for traffic-related Whiplash-associated disorders (WAD) has been increasing over the past 3 decades.

Risk Factors for Neck Pain

* Analysis of risk factors for neck pain suggest that this disorder has a multifactorial etiology. Nonmodifiable risk factors for neck pain included age, gender, and genetics. There is no evidence that common degenerative changes in the cervical spine are a risk factor for neck pain.

* Modifiable risk/protective factors for neck pain include smoking, exposure to environmental tobacco, and physical activity participation. In the workplace high quantitative job demands, low social support at work, sedentary work position, repetitive work, and precision work increased the risk of neck pain. However, there is a lack of evidence that workplace interventions were effective in reducing the incidence of neck pain in workers.

* Eliminating insurance payments for pain and suffering, and improving benefits disability costs were both associated with a lower incidence of whiplash claims and faster recovery from symptoms. Devices aimed at limiting head extension during rear-end collisions were found to have a preventive effect.

Course and Prognosis

* Most people with neck pain do not experience a complete resolution of symptoms. Between 50% and 85% of those who experience neck pain at some initial point will report neck pain again 1 to 5 years later. These numbers appear to be similar in the general population, in workers and after motor vehicle crashes.

* The prognosis for neck pain also appears to be multifactorial. Younger age was associated with a better prognosis, whereas poor health and prior neck pain episodes were associated with a poorer prognosis. Poorer prognosis was also associated with poor psychological health, worrying, and becoming angry or frustrated in response to neck pain. Greater optimism, a coping style that involved self-assurance, and having less need to socialize, were all associated with better prognosis.

* Specific workplace or physical job demands were not linked with recovery from neck pain. Workers who engaged in general exercise and sporting activities were more likely to experience improvement in neck pain. Postinjury psychological distress and passive types of coping were prognostic of poorer recovery in WAD. There is evidence that compensation and legal factors are also prognostic for poorer recovery from WAD.

Assessment of Neck Pain

* The assessment for fracture in the emergency room and the diagnosis of neck pain with radiculopathy are of value, but there is little evidence that diagnostic procedures for neck pain without severe trauma or radicular symptoms have validity and utility.

* Screening protocols to alert low-risk patients with blunt trauma to the neck have high predictive values in detecting cervical spine fracture. Computerized tomography scan has better validity and utility in cervical trauma for high-risk or multi-injured patients. The clinical physical examination is more predictive at excluding a structural lesion or neurologic compression than at diagnosing any specific etiologic condition in patients with neck pain. All other assessment tools such as electrophysiology, imaging, injections, discography, functional tests, and bloods test lack validity and utility.

* Reliable and valid self-assessment questionnaires given to neck pain patients can provide useful information for management and prognosis.

* The finding of degenerative changes on imaging has not been shown to be associated with neck pain.

Treatments for Neck Pain (Noninvasive and Invasive)

* A number of nonsurgical treatments appeared to be more beneficial than usual care, sham, or alternative interventions but none of the active treatments were clearly superior to any other in the short or long term. Educational videos, mobilization, manual therapy, exercises, low-level laser therapy, and perhaps acupuncture appeared to have some benefit. For both WAD and other neck pain without radicular symptoms, interventions that focused on regaining function and returning to work as soon as possible were relatively more effective than interventions that did not have such a focus.

* There is evidence for short-term symptomatic improvement of radicular symptoms with epidural or selective root injections with corticosteroids, but these treatments did not appear to decrease the rate of open surgery.

* Evidence is lacking to support intra-articular steroid injections or radiofrequency neurotomy. It is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared with nonoperative measures. However, relatively rapid and substantial relief of pain and impairment in the short term (6-12 weeks after surgery) after surgical treatment appears to have been reliably achieved.

* Early results from trials of cervical disc arthroplasty appear to show 1- to 2-year outcomes for radicular symptoms that are similar to outcomes for anterior fusion surgery. There is no evidence to support the use of cervical disc arthroplasty in patients with neck pain who do not have primary radicular pain.

Decision Analysis Study Findings

* Quality of life years (QALYs) associated with standard NSAIDs, Cox-2 NSAIDs, exercise, manipulation, and mobilization were compared in a decision-analytic model. None of the active treatments was found to be clearly superior to any other in the short or long term when estimates of the course of neck pain, adverse event risks, treatment effectiveness and risk, and patient-preferences for health outcomes were considered.

A New Conceptual Model for Neck Pain

The Neck Pain Task Force proposes a new conceptual model for the course and care of neck pain. The model is centered on persons with neck pain or who are at risk for neck pain. The model describes neck pain as an episodic occurrence over a lifetime with variable recovery between episodes. It outlines the options available to deal with neck pain; the factors that determine available options, choices, and consequences; and the short- and long-term impacts of neck pain.

A New Classification System for Neck Pain

For the subset of individuals who seek clinical care, the Neck Pain Task Force recommends a 4-grade classification system of neck pain severity that is intended to help in the interpretation of scientific evidence. The new system will also help people with neck pain, researchers, clinicians, and policy makers in framing their questions and decisions:

* Grade I neck pain: No signs or symptoms suggestive of major structural pathology and no or minor interference with activities of daily living; will likely respond to minimal intervention such as reassurance and pain control; does not require intensive investigations or ongoing treatment.

* Grade II neck pain: No signs or symptoms of major structural pathology, but major interference with activities of daily living; requires pain relief and early activation/intervention aimed at preventing long-term disability.

* Grade III neck pain: No signs or symptoms of major structural pathology, but presence of neurologic signs such as decreased deep tendon reflexes, weakness, and/or sensory deficits; might require investigation and, occasionally more invasive treatments.

* Grade IV neck pain: Signs or symptoms of major structural pathology, such as fracture, myelopathy, neoplasm, or systemic disease; requires prompt investigation and treatment.

When choosing treatments to relieve grades I and II neck pain, patients and their clinicians should consider the potential side effects and personal preferences regarding treatment options.

Spine:Volume 33(4S) Supplement15 February 2008pp S5-S7

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Filed under: Cervical, Exercise therapy, Manual therapy, Patient education, Spine, Whiplash Injuries , The Bone and Joint Decade 2000-2010 Task Force on Neck Pain

Sacroiliac joint fusion and the implications for manual therapy diagnosis and treatment.

Dar G, Khamis S, Peleg S, Masharawi Y, Steinberg N, Peled N, Latimer B, Hershkovitz I

The present paper examines gender differences and changes in prevalence of ankylosed sacroiliac joint (SIJ) with age. SIJs of 287 patients, aged 22-93 years, were examined for fusion, using 3-D CT images. Presence, side and location of the fusion along the joint borders were recorded. Fusion of the SIJ was found to be gender and age dependent; present in 27.7% of all males in contrast to only 3.0% in females. The phenomenon increased with age in the male population from 5.8% in the 20-39 age cohorts to 46.7% in the 80+ cohort.

As mobilization and/or manipulation of a dysfunctional SIJ are common procedures used by manual therapists, the effect that aging has on SIJ mobility requires therapists to alter or change their method with advancing age.

Manual Therapy, 2008, 13(2), 155-8

Link to Abstract

Filed under: Manual therapy, sacrum