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Surgery is not found to be more effective for treating injuries
August 2, 2017

Many patients who have surgery go on to experience long-term complications

The rotator cuff is a network of tendons and muscles in the shoulder that keep it stable and allow it to move in a variety of directions. Due to its frequent use, the rotator cuff is also a region that is frequently injured, especially in certain athletes and older adults. It’s estimated that at least 10% of the population over the age of 60 experiences tears of the rotator cuff, which can seriously limit a patient’s ability to function normally. Treating rotator cuff tears is normally done either with surgery or with a non-surgical (conservative) approach. Physical therapy is commonly used as one of the major conservative treatments for these injuries. Although there is no clear evidence to support either of these approaches as being more effective than the other, the rates for surgery to treat rotator cuff tears has increased substantially in recent times. In addition, it’s been reported that within 1-3 years after surgery, between 20-90% of patients remain unhealed or go on to tear their rotator cuff again. Based on this, it appears that more information is needed to show whether surgery or conservative treatment is more effective for these injuries. Therefore, a powerful study called a meta-analysis was conducted, which analyzed all available research on the topic to determine which of these treatments should be used.

Six medical databases are searched for relevant studies

To conduct the meta-analysis, researchers looked through six major medical databases for studies that compared surgery to conservative treatment for rotator cuff tears. All studies that appeared relevant were assessed in detail to decide if they fit the necessary criteria. Out of the 319 studies that were identified, only three fit these criteria and were accepted for the analysis. All three were randomized-controlled trials (RCTs), which are considered the highest-quality type of individual study that can be performed. These three RCTs included data on 252 patients in total, and they were analyzed and compared to the one another with the goal of reaching a conclusion on the best possible treatment.

No important differences found between two treatments

Results showed that after one year, no significant differences were found between patients who had surgery compared to those who had conservative treatment. This was determined based on scores for two separate measurements used for overall pain and function, as patients reported similar scores regardless of which treatment they had. The findings of this meta-analysis suggest that surgery is no more effective than conservative treatment for rotator cuff tears. Due to the fact that only three studies were included in this analysis and the overall sample group of patients was small, additional studies are now needed to investigate this matter further. Before these studies are completed, a conservative treatment that includes physical therapy should be regarded as the best possible option for rotator cuff tears. This is based on the findings of this analysis and the fact that surgery is more expensive and associated with more complications than conservative treatment.

-As reported in the July ’16 issue of Disability and Rehabilitation

Laser therapy found to be moderately effective for reducing jaw pain
November 17, 2016

Physical therapy and other treatments can reduce the need for surgery

Temporomandibular disorder is a term used for a set of common diseases that affect the temporomandibular joint (TMJ). The TMJ connects the jaw to the skull and allows it to move up and down and side to side. Typical symptoms of temporomandibular disorder include TMJ pain (especially while chewing), difficulty opening the mouth, the jaw getting stuck and a clicking or popping sound. TMJ symptoms can have a negative impact on patients’ lives. Surgery is occasionally used, but conservative (non-surgical) treatments like diet changes, medications and physical therapy can all reduce the need for it. Laser therapy is a popular treatment for other conditions and may also be effective for TMJ pain, but its use remains controversial. Therefore, a powerful study called a systematic review was conducted that evaluated all literature on the topic.

Three major medical databases searched for relevant studies

To gather information, three major medical databases were searched for studies on laser therapy for TMJ pain. In order to be accepted, studies had to evaluate patients diagnosed with TMJ pain being treated with what’s called low-level laser therapy, and they had to be compared to a control group that received no treatment. This search led to six studies on 223 patients used for the systematic review. The review was followed by an even more detailed evaluation called a meta-analysis.

Lasers lead to a moderate reduction in TMJ pain for patients

The meta-analysis showed that four of the six studies in the review reported a positive effect on pain relief after laser therapy. Overall, this was taken to mean that the laser therapy led to a moderate reduction in TMJ pain, which was considered statistically significant. Unfortunately, no studies were able to confirm exactly how and why laser therapies are effective, and this means further investigation is needed. This systematic review and meta-analysis suggest that laser therapy can be an effective treatment that moderately reduces TMJ pain. It may also be possible that combining laser therapy with other components of physical therapy may lead to even better results with the hope of reducing the need for more aggressive and risky interventions like surgery in these patients.

-As reported in the August ’14 issue of JOSPT

Messages for osteoarthritis patients on importance of exercise, etc.
November 2, 2016

Patients improve more when they take matters into their own hands

Hip and knee osteoarthritis (OA) are conditions in which cartilage in the joint gradually wears away, eventually leading to long-term pain and disability. OA can negatively impact patients’ lives, and rising obesity rates and an aging population make it likely that more people will suffer from it in the future. Strategies that allow patients to self-manage their OA can significantly improve outcomes; however, there are some barriers to this approach and guidelines may not be clear enough for patients. Therefore, a study was conducted to compile a list of essential messages for patients with hip or knee OA in plain language that’s clear and easy to follow.

Team of experts and patients work together to create list of statements

A panel was formed by recruiting patients with hip or knee OA and OA experts with previous research experience. This search led to a total of 43 experts and eight patients who completed all rounds of the study. Together, this panel rated recommendations that were taken from a list of guidelines, as well as any other important statements on managing OA. When 70% or more of panel members agreed that a statement was “essential,� it was kept for the next round. This process was repeated until a final list of essential statements was made and ranked in order of importance.

Most statements related to different treatment approaches for OA

This selection process led to a list of 21 key messages about OA that were considered essential and ranked in order of importance. Of these, most (17 statements) referred to different treatment approaches for OA, and 12 of them were related to non-drug management of the condition. Some of the highest ranked recommendations included making lifestyle modifications like getting regular physical activity, losing weight, and avoiding sitting for too long. Other essential statements explained that OA is not inevitable with age, that medications should be avoided over the long-term, and that surgery should rarely be needed to treat hip or knee OA. This clear list of statements should be given to any patients with hip or knee OA and its use may lead to better self-management and improved overall outcomes for them.

-As reported in the November ’14 issue of Arthritis Care & Research

Exercise and PT lead to improvements for patients with neck disorder
October 27, 2016

Specific type of rehabilitation program has not yet been evaluated

Cervical radiculopathy (CR) is a neck disorder in which damaged nerves in the neck (cervical spine) lead to pain and other symptoms in the shoulders, neck, arms or hands. In most cases, CR results from a reduction in the size of the intervertebral foramen (IVF), which is an opening between two vertebrae. Spinal issues that influence IVF size include herniated discs, disc degeneration and arthritis.. A variety of treatment options are available for CR, including exercise, physical therapy and posture education, but evidence on their effectiveness is minimal. One possible approach is to focus on exercises that maximize the size of the IVF, which may lead to improvements; however, this type of rehabilitation program has never been evaluated. Therefore, a powerful study called a randomized-controlled trial (RCT) was conducted to determine what treatments are effective and if focusing on the IVF leads to any differences.

Participants randomly divided into two groups for four-week program

Patients with CR were recruited, and after inclusion criteria were applied to the 71 respondents, 36 were accepted and used for the RCT. These patients were then randomly assigned to either the comparison group or the experimental group. The rehabilitation program for the comparison group took place during eight sessions over four weeks. It consisted of stability and mobility exercises, manual (hands-on) therapy from a physical therapist to the neck and mid-back, and a home-exercise program. The experimental group received the same rehabilitation program, but two modifications were made with the intention of increasing the size of the IVF. Patients were assessed for pain, disability and range of motion (ROM) before the program, immediately afterwards, and four weeks later.

Both programs lead to improvements, but no extra benefits seen in experimental group

Four weeks after each program, both groups achieved highly favorable results in pain, disability, ROM and patient-reported improvement. Unfortunately, no significant differences were found between the two groups, which suggests that the focus on increasing IVF size did not lead to any additional benefits. Nonetheless, this RCT shows that an exercise and manual therapy program can lead to various benefits for patients with CR in the short-term. It may therefore be a safe and effective approach for treating patients with this bothersome disorder.

-As reported in the January ’15 issue of JOSPT

Physical Therapists Join Fight to Combat Rising Opioid Epidemic
October 19, 2016

Physical Therapists Join Fight to Combat Rising Opioid Epidemic

America is in the midst of an opioid epidemic. Consider that in 2012 alone, health care providers wrote 259 million prescriptions for opioid pain medication, enough for every American adult to have their own bottle of pills.

Opioids, responsibly dosed, are an appropriate part of medical treatment in some situations. But they carry significant risks, including depression, withdrawal symptoms, overdose, and addiction. The statistics are scary:

As many as 1 in 4 people who receive prescription opioids long-term for noncancer pain struggle with addiction;
Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids;
People who are addicted to prescription opioids are 40 times more likely to become addicted to heroin; and
78 people die every day from an opioid-related overdose.

To address this national health crisis, the Centers for Disease Control and Prevention (CDC) issued guidelines in March 2016 urging providers to reduce opioid prescribing in favor of safe, nondrug alternatives such as physical therapy for chronic pain conditions, including low back pain, hip and knee osteoarthritis, and fibromyalgia. In August 2016, the Surgeon General sent a letter to every physician in the country asking for their help to solve the problem.

Meanwhile, the American Physical Therapy Association (APTA) launched a national public awareness campaign to educate consumers about the risks of opioids and the safe alternative of physical therapy for pain management.

A safe way to manage and treat pain

Physical therapists treat pain and improve function through movement and exercise without the risky side effects of opioids. A physical therapist’s individualized, hands-on approach engages the patient, making her or him an active participant in her or his own recovery.

Patients should choose physical therapist treatment instead of opioids when…

The risks of opioids outweigh the rewards. CDC experts say that opioids should not be considered as first-line or routine therapy for chronic pain. Even when opioids are prescribed, the CDC recommends that patients receive “the lowest effective dosage,” and opioids “should be combined” with nonopioid therapies, such as physical therapy.

Pain or function problems are related to low back pain, hip or knee osteoarthritis, or fibromyalgia. The CDC cites “high-quality evidence” supporting exercise as part of a physical therapist treatment plan for these chronic pain conditions.

Pain lasts at least 90 days. At this point, pain is considered “chronic,” and the risks for continued opioid use increase. The CDC says that “clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.”

APTA’s #ChoosePT initiative is raising awareness about the dangers of prescription opioids and the safe, nondrug alternative for pain management provided by physical therapists. Visit http://MoveForwardPT.com for information to help you decide if physical therapist treatment is right for you.

Exercise leads to many improvements for patients with shoulder pain
October 2, 2016

Approximately half of shoulder pain patients are treated by a physical therapist

Shoulder pain is very common, with some reports claiming that as many as 26% of adults currently have it to some degree. About half of all patients with shoulder pain are referred to a physical therapist and treated with exercise therapy and massage. Despite the fact that both of these treatments are commonly used, there are no high-quality studies that have evaluated if adding massage to exercise leads to additional improvements. Based on this, a powerful study called a randomized-controlled trial (RCT) was conducted that investigated the addition of massage to an exercise program for shoulder pain.

80 patients randomly assigned to one of two groups

Patients with shoulder pain were recruited and assessed for inclusion. Eighty were accepted and randomly assigned to either the exercise-only or exercise and massage group. Patients in the exercise-only group were led through an exercise program by a physical therapist with seven treatment sessions over five weeks. The physical therapist demonstrated the exercises and provided feedback, and patients were instructed to continue their exercises at home afterwards. Patients in the massage and exercise group underwent the same exercise program, plus 10-15 minutes of soft tissue massage from the physical therapist over seven sessions. All patients were assessed for pain, disability, and range of motion (ROM) before the intervention, one week afterwards, and 12 weeks afterwards.

Exercise alone may be sufficient for should pain treatment

Results showed that both groups improved in pain and disability to a level that would be considered worthwhile by patients. There was no difference between groups for disability or ROM, but the exercise-only group experienced a slightly greater improvement in pain compared to the exercise and massage group. This suggests that the massage did not lead to any additional benefits for patients compared to exercise alone. Massage therapy is an important component of physical therapy and has been found to be effective in treating many other conditions, and is considered more effective than no treatment for shoulder pain; however, when combined with exercise, it appears massage does not add to overall benefits. For this reason, and also because exercise is a more active intervention, exercise therapy should be regarded as the treatment-of-choice for patients with shoulder pain.

-As reported in the May ’15 issue of the Physical Therapy

Patients with lasting LBP often have weak muscles around hip
September 22, 2016

Variety of exercise interventions typically recommended for these patients

Low back pain (LBP) has recently become the largest cause of disability throughout the world. There are many ways in which LBP can be treated, but current guidelines show strong evidence to support exercise as one of the best treatments available. Despite the fact that exercise therapy is known to be effective, it’s still not clear exactly which types of exercises are best for people with chronic (long-lasting) LBP. Treatment decisions for these patients are based on the physical therapist’s evaluation and usually tend to include strengthening the abdominal and lower back muscles, but one alternative is to focus on the muscles surrounding the hips, too. It’s possible that weakness of these muscles may be common in LBP patients and may therefore need to be addressed, but it’s not clear how many of these patients experience this. Therefore, a study was conducted to assess the prevalence of hip muscle weakness and tenderness of the hip and lower back in patients with chronic LBP.

Large group of LBP patients matched with healthy subjects

A group of 151 patients with chronic LBP were invited and agreed to participate. They were then matched with 75 healthy control subjects, who did not have a history of more than three months of LBP. All participants were then examined for muscle strength of numerous muscles in and around the hip, including the gluteus medius (outside of hip), gluteus maximus (largest of hip muscles) and the tensor fasciae latae (TFL, located in thigh and related to gluteus maximus). Tenderness, or the reproduction of patients’ pain, was also measured.

Gluteus medius weakness common in many LBP patients

Results showed that patients with chronic LBP displayed a few signs of hip muscle dysfunction, including gluteus medius weakness and tenderness of both gluteal muscles. Upon further analysis, it was found that the gluteus medius muscle weakness actually contributed to patients’ chronic LBP. Based on these findings, it’s possible that physical therapy programs that focus on strengthening these weak muscles can lead to greater benefits with better overall outcomes. Therefore, physical therapists should be sure to consider gluteus medius strength and address it when it’s weak to improve their interventions and reduce pain more efficiently for these patients.

-As reported in the May ’15 issue of the European Spine Journal

Patients with painful conditions have poorer physical fitness
September 15, 2016

Increasing physical activity levels can help reduce symptoms

The health benefits of regular physical activity and good physical fitness seem to be countless. Some of these include better respiration, increased strength and a reduced chance of developing diseases and other painful conditions. Data from hospitals shows that some patients with certain conditions are less physically active than healthy people. But for patients with various musculoskeletal conditions-which consists of nearly any type of pain or disability in bones, muscles or joints-who are receiving physical therapy, it’s not known if the same is true. Therefore, a study was performed to compare the levels of physical activity and physical fitness between patients with various long-term musculoskeletal conditions receiving physical therapy and a random selection of other people.

Participants assessed with a questionnaire and two tests

Individuals with various musculoskeletal disorders who were receiving physical therapy were recruited. A broad sample of volunteers with different backgrounds was also asked to participate as a control group. This search led to 167 patients and 313 control subjects. Patient characteristics such as age, work-related status, height and weight were recorded for all participants. Then patients filled out a questionnaire with questions about their physical activity habits and were given two tests to assess physical fitness. One test had participants walk as far as possible on a 49-foot track in six minutes, and the other had them rise and sit from a chair as many times as possible within 30 seconds.

Vigorous physical activity and physical fitness levels are significantly lower in patients

Results from the questionnaire showed that the patient group got about the same amount of moderate physical activity compared to controls, but significantly less vigorous physical activity. Vigorous physical activity includes jogging, tennis, basketball and soccer. Patients with musculoskeletal conditions also walked a significantly shorter distance and performed significantly fewer repetitions on the sit-to-stand test than controls, showing a lower level of physical fitness. While these results are somewhat expected, they should be seen as a call to action for physical therapists to give proper advice to their patients. Regular vigorous physical activity and good physical fitness are essential to making improvements, and physical therapists should therefore encourage these habits in patients to help them work towards these goals.

-As reported in the December ’14 issue of Physiotherapy

Rehab leads to better overall outcomes than surgery for athletes
August 31, 2016

Long-lasting injury is common in soccer, Australian rules football and ice hockey

Athletic groin pain (AGP) is general term used to describe any chronic (long-lasting) injury to the groin area, which is at the junction of the torso and leg, in physically active individuals. AGP has become more prevalent in recent years, and it’s especially common in athletes who play soccer, Australian rules football, and ice hockey. AGP can be treated either with a variety of surgical procedures or with rehabilitation, which usually includes physical therapy and exercise training. To date, the effectiveness of these two treatments for AGP has not been compared, so a powerful study pairing called a systematic review and meta-analysis was conducted.

Return to play rates and times of two treatments are compared

Four major medical databases were searched for studies on athletes who had either surgery or rehabilitation for AGP that were returning to sports, and each study had to contain information on their return to play rates-how many players actually return-and return to play times. This search identified 561 articles to be assessed, and 57 fit the criteria and were used for the review. These studies contained data on 3,332 patients, who were 99% male, and their primary outcome measures were return to play rates and time after the interventions.

Rehabilitation leads to significantly quicker return to play times,
with little difference between rates

Results showed that recovery times in the rehabilitation group were half of those in the surgical group, at a statistically significantly 12.6 weeks faster. In addition, little difference was found in return-to-play rates between surgery and rehabilitation, which suggests that both led to approximately the same number of athletes returning to sport. A close similarity was also found in return-to-play rates when surgery was compared with physical therapy. Unfortunately, the quality of the evidence used in this study was not very high; however, the findings still make a solid case that rehabilitation is a more effective treatment for AGP. Considering the fact that surgery is more expensive and can lead to additional complications, it appears that rehabilitation should be the treatment-of-choice in most cases of AGP that will lead to the best outcomes while more research is conducted on this topic.

-As reported in the June ’15 issue of the British Journal of Sports Medicine

Training program effective for reducing the rate of ankle sprains
August 18, 2016

Other measures to prevent sprains come with certain downsides

Ankle sprains are the most common sports-related injury, and they are particularly prevalent in sports that require a lot of jumping, pivoting and/or changing direction. Athletes who sprain their ankles typically experience pain, disability and dysfunction, and they are also more prone to reinjure the same ankle again. For this reason, certain measures like taping and bracing may be used to reduce the risk for ankle sprains and have been found to be effective; however, there are some disadvantages to each of them. Preventative exercise programs may avoid these disadvantages while still protecting the ankle, so long as patients comply. Proprioceptive training is one type of program that’s been found to prevent ankle sprains, but it’s only been studied in combination with other exercise components. Therefore, a powerful study pairing called a systematic review and meta-analysis was conducted to determine if proprioceptive training alone could reduce the incidence or recurrence of ankle sprains in athletes.

Seven relevant studies utilized for review

Five medical databases were searched for relevant studies on proprioceptive training to prevent ankle sprains. Proprioceptive training includes a series of exercises intended to teach the body to control the position of a deficient or injured joint. From this, 345 studies were identified and seven were accepted and included in the meta-analysis.

Proprioceptive training has a preventative effect on ankle sprains

Results showed that when considering all athletes of various sports, regardless of their ankle injury history status, proprioceptive training was found to have a preventative effect on ankle sprains. From this, it was calculated that approximately 17 athletes, or 13 participants with a history of ankle sprain would need to undergo this training in order to prevent one future ankle sprain. The preventative benefits of proprioceptive training were found to be substantial for athletes with a history of ankle sprain, but the evidence is not as strong for athletes without this history, and more research is needed on this topic. Despite this, it appears that proprioceptive training can serve an important role in reducing ankle sprains for active individuals; however, its use in those with no history of ankle sprain will have less of an impact than in those with a history.

-As reported in the May ’15 issue of the Journal of Science and Medicine in Sport