- Your Bridge to Health -

Hands-on movement by PT have a positive effect on tennis elbow
October 9, 2018

Lateral epicondylitis, often referred to as tennis elbow, is a painful condition that results from overuse. It occurs when the tendons that connect the muscles of the forearm to the outside of the elbow become damaged and inflamed, which leads to pain or a burning sensation in this region. Tennis elbow is-unsurprisingly-most common in tennis players, but can also affect other athletes and anyone who repeatedly performs movements that involve the elbow. Most patients with tennis elbow are treated conservatively (non-surgically) at first with various interventions that are often part of a treatment plan designed by a physical therapist. Although many of these interventions have been studied, most reviews focus on several of them being used at once, which makes it difficult to determine the effectiveness of each one individually. For example, the effectiveness of joint mobilization-a technique in which the therapist moves the elbow in a number of specific ways-has not yet been evaluated in a comprehensive manner. Therefore, a powerful pair of studies called a systematic review and meta-analysis was conducted to determine if joint mobilizations are effective for improving pain, grip strength and disability for patients with tennis elbow.

Three medical databases are searched for relevant studies

Researchers performed a search of three major medical databases for studies that investigated the use of any type of joint mobilizations being used to treat adult patients with tennis elbow. A total of 257 articles were originally identified and assessed to determine if they were eligible, of these 20 met the necessary criteria and were accepted into the study. Once these studies were identified, researchers analyzed their findings and compared them to one another with the goal of finding trends about joint mobilizations. The quality of each study was also assessed so that a consensus could be made as to how reliable their findings were.

High-quality evidence shows that two types of joint mobilization are beneficial

Overall, results were supportive of the effectiveness of joint mobilizations for tennis elbow. In particular, high-quality evidence was found that showed two types of joint mobilization-mobilization with movement (MWM) and Mill’s manipulation-were more beneficial than comparison groups for improving pain in the short term and intermediate term. There was also strong evidence that MWM is more beneficial than no treatment at improving grip strength in the short term. MWM consists of a technique in which the therapist glides the forearm while securing the shoulder with the other hand, during which the patient simultaneously performs a pain-free gripping action. In Mill’s manipulation, the therapist performs a maneuver that quickly stretches out the painful tissue from tennis elbow with a thrust mechanism. Based on these findings, researchers felt confident recommending either MWM or Mill’s manipulation for a moderate-sized positive effect on pain and grip strength. Patients with symptoms that suggest tennis elbow may therefore want to consider seeing a physical therapist for their condition, since they can provide these types of mobilizations and other techniques that will help them improve in the fastest and safest manner possible.

-As reported in the April ’18 issue of the Journal of Hand Therapy

Balance training improves sports performance & may reduce injury risk
September 25, 2018

Good balance comes with several important benefits

Balance is defined as the process of maintaining the body’s center of gravity vertically over the base of support, and it relies on rapid, continuous feedback from a number of structures throughout the body. Having good postural balance is important for many reasons, as it reduces the risk for falls and resulting injuries, and also helps to optimize movements in athletic performance. This is why balance exercises are very frequently included in training programs for athletes in various sports, fall prevention programs for the elderly, and rehabilitation programs designed by physical therapists. The benefits of balance training have been identified in many studies, but the exact type of training that is most efficient still remains unclear. For this reason, researchers decided to conduct a powerful study called a systematic review. In this review, all available literature on the topic was collected and analyzed to acquire a better understanding of the effects of balance training and what type, frequency, intensity and duration are best.

A total of 50 studies are accepted into the review

Investigators performed a search of two medical databases for studies that evaluated the effectiveness of a balance-training program for either improving sports performance or preventing injuries. This search led to 2,395 studies being screened, and 50 of these fit the necessary criteria and were accepted into the review. Once collected, the findings of these studies were analyzed and compared to one another, and their quality was assessed to determine their level of reliability.

Most studies show that balance training is effective for its intended goals

Overall, results were supportive of balance training in both applications. For the first focus of the review on athletic performance, the sports most commonly studied were soccer, basketball, and handball. The majority of these studies found significant differences between the groups that participated in balance training compared to those who did not, meaning that the training was effective for improving sports performance in these athletes. Similar findings were identified for the second focus of the review as well, as balance training was also found to reduce the incidence of sports injuries among athletes of various sports, including basketball, soccer, volleyball and football. These are all high-risk sports in which an injury can lead to long-term disability if severe enough, which highlights why prevention is so important. Finally, researchers discovered that the optimal balance-training program should last for about eight weeks and consist of two 45-minute training sessions per week. Based on these findings, it appears that balance training can serve a crucial role in sports by both enhancing performance and reducing the risk for injuries. Athletes who are looking to elevate their abilities while keeping their injury risk at a minimal are therefore encouraged to contact their local physical therapist to initiate a balance-training program. These programs are designed specifically for their sport, abilities, and goals, and participation will help them to optimize and extend their careers in the safest possible manner.

– As reported in the August ’17 issue of the Journal of Human Kinetics

Review finds that exercise is one of the best ways to prevent falls
September 18, 2018

The incidence of falls is expected to continue rising

Falls are one of the biggest problems that older adults face. Data has shown that approximately 36% of adults over the age of 65 will experience a fall every year, and each one of these accidents can have serious implications. Not only can a fall result in a serious injury or death, but older individuals that do fall go on to have more anxiety and depression, and a reduced quality of life as a result. The world’s population is also aging, which means that the incidence of falls is expected to continue rising with it. This shows why it’s so important to identify methods that will help prevent falls among older persons. Many prevention methods are available and a great deal of research has been conducted on this subject, but a comprehensive review that ranks all of these methods is yet to be performed. With this in mind, a team of researchers conducted a powerful pair of studies called a systematic review and meta-analysis to determine which interventions were most effective for preventing falls in older adults.

Four medical databases searched for relevant studies

The team of researchers performed a search of four major medical databases for studies that evaluated the effectiveness of fall-prevention programs for the elderly. This led to 1,210 articles being screened and 283 randomized-controlled trials (RCTs) being accepted. RCTs are high-quality individual studies that are considered the gold standard for determining how well a treatment or intervention works. Once collected, the data from each of these RCTs were analyzed and compared to one another to detect trends and develop conclusions on the most beneficial fall-prevention programs. Researchers also assessed the quality of studies, which helped them gauge how reliable their results were.

Exercise consistently found to reduce the risk for falling

A total of 54 RCTs with 39 different interventions focused on the risk of falls that caused injury, and the findings from these studies showed that some of the most effective interventions for reducing this risk included exercise, vision assessment, and environmental assessment and modification. Another 158 RCTs with 77 interventions focused on the number of fallers, and once again, exercise was amongst the most effective strategies for reducing this figure. Other positive interventions included orthotic devices, dietary modifications and calcium and vitamin D supplementation. Most of the included RCTs had a low risk of bias, which means their quality was high and their findings could be consistently relied upon. Taken together, these results strongly suggest that exercise is one of the best possible methods for reducing the risk for falling and the number of falls in the elderly population. Other interventions like dietary and home-based modifications, vision assessments, orthotics and supplements also appear to be helpful and may be recommended in addition to exercise. Older adults who may be at risk for falling are therefore encouraged to visit a physical therapist for an exercise treatment program. These programs are based on patients’ needs and abilities, and when followed, can help reduce the risk of falls and keep seniors safer.

– As reported in the November ’17 issue of JAMA

Two exercises programs are effective in reducing falls in older men
September 13, 2018

Prevention strategies are needed to address a major danger in the elderly community

As individuals grow older, several changes occur that are considered risk factors for falling. These include decreases in balance, control of posture, muscle strength and changes in walking performance. For this reason, prevention strategies are needed to address these risk factors and lower the risk for falls in the elderly community. There are many exercise programs that are used to accomplish this, and the majority of them are based on aerobic training, which is effective for reducing fall risk factors. More recent guidelines suggest that other elements should also be included to increase the impact of these exercise programs, such as resistance exercises, which are used to increase strength. Despite the evidence available on aerobic and resistance exercises, its not completely clear if combining the two of them is any more effective than each one of them individually. For this reason, a powerful study called a randomized-controlled trial (RCT) was conducted, which is considered the gold standard used to determine the effectiveness of a treatment.

55 older men complete the 32-week study

Men between the ages of 65-79 who were medically approved for exercise were recruited for the study and screened to determine if they were eligible to participate. A total of 55 individuals fit the necessary criteria and completed the study. These participants were randomly assigned to one of three groups: the aerobic exercise group, the combined exercise group or the control group. Both exercise programs consisted of three sessions each week for 32 weeks and were planned for moderate-to-vigorous intensity. The aerobic exercise group trained twice per week in a land environment and once per week in an aquatic environment. All sessions consisted of a 10-minute warm-up, 30 minutes of brisk walking, 10 minutes of strengthening exercises and a 5-minute cooldown. The combined exercise program was the same as the aerobic exercise program, but one of the weekly land sessions was replaced by a resistance exercise session. The main part of this session consisted of a circuit of seven resistance-based strengthening exercises, which increased in intensity for the first 24 weeks and then decreased afterward until the end. The control group had no exercise intervention and was instructed to pursue their habitual daily life activities. All participants were evaluated using a number of tests before the study and then at weeks 1, 8, 16, 24 and 32.

Both exercise programs are effective, but combining them is even more beneficial

Results showed that both aerobic and resistance exercises on their own were more effective than no exercise for reducing risk factors for falls such as balance, posture control, mobility and leg strength; however, combining these two types of exercise interventions was actually even more effective for reducing these falls risk factors. In particular, the combined exercise program was found to be more effective for increasing agility, two types of balance, and leg strength and power. Although this RCT did not evaluate the actual risk for falls or fear of falling, these results do suggest that following this type of combined exercise program can result in an added protection for falls in the elderly community. Based on these findings, it appears that either an aerobic or resistance exercise program can be effective for reducing the risk of falls in older men, but combining both of them is even more effective and may serve an important role in addressing this significant danger.

-As reported in the April 17 issue of Clinical Rehabilitation

Bracing & balance training reduce the risk for ankle sprains
September 11, 2018

Ankle sprains are generally regarded as some of the most common injuries seen in sports, if not the most common. Approximately 23,000-25,000 ankle sprains occur in the U.S. every day, which results in $2 billion worth of healthcare costs annually. These injuries are most frequently seen in sports that require quick direction changes, cutting movements and rapid acceleration and deceleration, which is why about 41% of them occur in basketball. Ankle sprains are also common in football and soccer, and the higher the level of activity, the stronger the chance of spraining the ankle. After a first ankle sprain, between 35-73% of patients report ongoing symptoms, and the risk of having another sprain is about 70%. This is why effective interventions are needed to reduce the risk for initial and repeated ankle sprains, and two ideas proposed for this goal are bracing and balance training. Unfortunately, studies evaluating these interventions are lacking, which led researchers to conduct a systematic review and meta-analysis. This powerful pair of studies collects all the available data on the topic with the goal of determining if bracing or balance training are truly effective for preventing ankle sprains.

Four medical databases searched for relevant studies

To collect data, investigators performed a search using four major medical databases for studies that evaluated the use of either balance training or ankle bracing to prevent ankle sprains. Balance training was defined as any type of program that involved exercises designed to improve balance, which were performed on a variety of surfaces and with eyes open or closed. Ankle bracing was defined as any type of device worn on the ankle joint, while taping was not included. This search led to 71 studies being reviewed, and eight of these fit the necessary criteria and were accepted into the review. The included studies contained data on 7,195 athletes that ranged from high school to professional sports leagues, with an average age of 20 years. The findings of these studies were then compared to one another, and their quality was assessed to gauge reliability.

Evidence of moderate quality supports the use of both interventions

On the whole, results from the studies reviewed showed that balance training and bracing were both effective for reducing the risk and incidence of ankle sprains. Two of the three studies that evaluated bracing found that patients who wore these braces had a significantly lower incidence of ankle sprains and a 64% reduced risk for having a sprain compared to patients not wearing a brace. Of the six studies that evaluated balance training, five found a significant decrease in the incidence of ankle sprains in patients who participated versus those who did not, and these patients also had a 46% reduced risk for an ankle sprain. Overall, the quality of the included studies was moderate, with all studies scoring a 5 or higher on a 10-point scale, and one study scoring an 8. Taken together, these findings suggest that both balance training and bracing can reduce the risk for ankle sprains in athletes. More research is now needed to determine if either intervention alone or a combination of the two is most effective. In the meantime, athletes are encouraged to become proactive and see a physical therapist for a balance training program or additional advice on how to keep their ankle sprain risk as low as possible, especially if they have a history of ankle sprain.

– As reported in the June ’18 issue of the International Journal of Sports Physical Therapy

Exercise program is the most effective in reducing falls
September 4, 2018

Controversy and uncertainty exist despite extensive research

Up to 35% of older adults fall each year, and falls are the main cause of injury, injury-related disability, and death in this population. In addition to the physical and economic repercussions, falls can also have a psychological impact, as older adults who fall often develop a fear of falling and become less physically active as a result. Several systematic and meta-analyses have therefore established several approaches for reducing falls and healthcare costs, but some controversy and uncertainty still exist. For this reason, a “state of the art” review was conducted that summarized the best available evidence on how to assess and address risk factors for falls in community-dwelling older adults.

High-quality studies prioritized over others

Three medical databases were searched for pertinent studies, and researchers only selected studies that focused on risk factors, assessment, and management strategies or interventions to reduce falls in older adults. Systematic reviews, meta-analyses, randomized-controlled trials and works that were cross-referenced most often were prioritized, and the most clinically relevant information from each was summarized.

Exercise is essential for all older patients, especially those at risk

Researchers found that the first step in reducing fall risk is to identify at-risk patients. This is accomplished by having patients check in with their healthcare provider yearly to report any falls or difficulties with gait and balance and to have a comprehensive screening assessment. The assessment should evaluate gait, balance, frailty, disability, comorbid conditions, and current medications, functional abilities, and fear of falls. If the patient is found to be at high risk for falls and is ready and willing to participate in a program, they should be offered a multifactorial, tailored exercise program, which was found to be most effective for reducing falls and resulting healthcare costs. Physical therapists specialize in creating these types of programs and can guide patients through them. For patients not at a high risk, regular exercise is still recommended in order to maintain adequate fitness and keep fall risk low, and community-based exercise programs, Tai chi, and independent physical activity are all recommended. Healthcare professionals and caretakers should be aware of these evidence-supported recommendations and comply with them in order to reduce falls in the elderly community.

-As reported in the April ’16 issue of the British Medical Journal

Knee arthritis patient outcomes affected by significant hip weakness
August 28, 2018

Understanding the role of hip strength can help improve treatments

Osteoarthritis (OA) is a condition in which cartilage that normally protects a joint gradually wears down over the course of time, which leads to pain and other symptoms when the bones begin rubbing against one another. OA can develop in any joint, but is most common in the knee because it’s a joint that bears a great deal of weight. Knee OA is associated with high levels of pain and reduced function, and when the condition gets too bad, individuals often go on to have surgery to replace the knee joint. This shows why it’s so important to establish effective treatments for knee OA patients that will help them avoid surgery, but experts have pointed out that much more work needs to be done on the topic. One area of interest is the role of hip strength, as some have suggested that knee OA patients may have weak muscles surrounding their hips, and treatments can therefore target this weakness. With this in mind, a team of researchers performed a powerful pair of studies called a systematic review and meta-analysis to determine if patients with knee OA have deficits in their hip strength compared to healthy individuals.

Five medical databases searched for relevant studies

Investigators performed a search of five major medical databases for studies that evaluated the relationship between knee OA and the strength of patients’ hip muscles. They identified 102 studies that were screened in more detail, and five of these were accepted into the review, which contained data on 237 participants. The findings from each of these studies were then compared to one another, and their quality was assessed to determine how reliable they were.

The weak hip muscles identified can be targeted in physical therapy programs

Overall, the quality of the studies reviewed was variable, but there was enough information to show that the hip muscles of knee OA patients were generally weaker than those in healthy individuals. In terms of isometric hip strength—the strength used if you were to push against an immovable object—there was moderate-quality evidence that knee OA patients have weaker hip abduction strength when compared with controls. (Abduction is moving the hip and the leg away from the center of the body.) When considering isokinetic hip strength—the strength that occurs when a muscle contracts and shortens at a constant speed—there was also moderate quality evidence that knee OA patients have weaker abduction/adduction and transverse internal/external rotation hip strength. Unfortunately, there were no studies that specifically evaluated hip strength as a risk factor for the development of knee OA. Nonetheless, this systematic review and meta-analysis show that patients with knee OA have deficits in their hip strength when compared to healthy individuals. Although more research is still needed on the topic, this could mean that improving hip muscle strength could lead to reduced pain levels and better hip function. Individuals with knee OA should therefore consider seeing a physical therapist for a comprehensive treatment program that will include hip-strengthening exercises to increase the chances of a successful outcome that does not involve surgery.

-As reported in the August ’16 issue of JOSPT

Patients treated with rehabilitation are less likely to use narcotics
August 24, 2018

The incidence of knee-related conditions has been increasing

Knee pain and knee osteoarthritis, sometimes referred to collectively as non-traumatic knee pain (NTKP), is very common in individuals aged 65 and older. Statistics have shown that the incidence of these conditions in older adults has increased by 65% over the past 20 years, with rates doubling in women and tripling in men. In addition, the rates for knee surgery have also increased over this period of time, which adds to the cost of managing these individuals. Several guidelines recommend rehabilitation such as exercise therapy to address pain and disability in patients with NTKP, which may also reduce the chances of these individuals using other dangerous treatment like opioids or needing to have surgery. Unfortunately, there is limited information on how many NTKP patients undergo rehabilitation, and it’s possible that not nearly enough are doing so. For this reason, a study was conducted to determine how many of these patients were receiving rehabilitation for their condition and examine how it affects their outcomes.

Data collected on extremely large group of patients

To conduct the study, researchers collected data on Medicare claims between 2009-2010. They looked for information on the utilization and cost of treatment for individuals over the age of 65 being treated for NTKP, which included 52,504 patient records. With this data, they examined which patients received rehabilitation services like physical therapy, how early this treatment started, what other treatments were delivered and how their outcomes differed depending on what treatment they received.

Only small percentage of patients are treated with rehabilitation services

Of the 52,504 NTKP patients examined, only 11% received any type of rehabilitation services for their condition at any time. Of the patients who were rehabilitated with physical therapy and other treatments, 52% began treatment within 15 days of their diagnosis, 27% started treatment within 16-120 days and 21% started treatment more than 120 days after being diagnosed. Further analysis showed that the participants who had early rehabilitation were 33% less likely to take narcotics like opioids, 50% less likely to receive invasive procedures like injections and 42% less likely to have surgery in the future than individuals who did not receive rehabilitation. Patients who didn’t receive rehabilitation until later, on the other hand, actually had higher odds of receiving these other types of interventions than those who did not receive any rehabilitation. These findings show that patients who are treated with physical therapy soon after being diagnosed with NTKP have better chances of improving without the use of dangerous narcotics or surgery, but only a small percentage are actually receiving this kind of treatment. It’s therefore important that doctors acknowledge the benefits of early rehabilitation for NTKP patients and refer them to physical therapy accordingly.

-As reported in the June ’17 issue of Physical Therapy

Improvements from PT for knee pain maintained by patients for 3 years
August 21, 2018

Long-term effects of treatment are questionable and have not been studied well

Patellofemoral pain syndrome (PFPS)-sometimes referred to as runner’s knee-is a painful condition that’s particularly common in physically active individuals. Patients with PFPS typically experience a dull ache behind or around the kneecap that gets worse with running or going up or down stairs. The initial treatment for PFPS is usually conservative (non-surgical) and may consist of a physical therapy program with various exercises that target the quadriceps muscles in the front of the thigh. While many studies have shown that this type of treatment is effective in the short term, long-term results are not as clearly understood. One reason for this is a lack of long-term studies that evaluate the potential benefits of conservative treatment. With this in mind, researchers conducted a follow-up study to investigate if improvements from a one-month physical therapy program in patients with PFPS were maintained three years later.

Participants are assessed at five different time points over three years

In the original study, 41 patients who had PFPS for at least one month were randomly assigned to one of four treatment programs: 1) quadriceps strengthening, 2) quadriceps stretching, 3) taping beneath the kneecap and 4) control, which did not receive any treatment. The total length of the intervention was one month, with the first week including specific exercises based on the groups participants were assigned to, and the second week consisting of a combination treatment of quadriceps strengthening, quadriceps stretching and kneecap taping. In the final two weeks, treatments were individualized to each patient and focused on aligning posture, correcting faulty movement patterns, improving knee and hip strength, stretching tight muscles and restoring flexibility. Patients were also given a home-exercise program with similar exercises to perform during these four weeks, and after completing this intervention, they were told to perform one quadriceps stretching and one quadriceps strengthening exercise daily for the next three years. All participants were assessed in seven categories at five different time points: before the intervention began, and then after one week, after two weeks, at the end of the intervention and three years later.

Majority of patients maintain their initial improvements and stick with exercise programs

Of the 41 original patients, 37 were available for the follow-up three years later. Overall, the measurements taken at this time were very similar to those taken at the completion of the intervention, which shows that patients maintained most of their improvements. In particular, all patients reported an improvement in knee pain scores when performing various physical activities, and 73% of them experienced no pain during the testing protocol. In addition, 28 of 34 patients (82%) were able to resume the sport that they had to stop because of PFPS, while three patients never played a sport in the first place. It was also found that 33 patients (89%) were continuing to do some of the exercises prescribed after completing the intervention, which probably helped improve their outcomes. The one measurement in which scores did decline was quadriceps strength, but this may simply be due to the fact that patients gained significant strength during the intervention. Nonetheless, these scores were still higher than those at the start of the study. These findings very clearly show that a physical therapy program for patients with PFPS leads to various improvements immediately after the intervention, and that these benefits appear to last for up to three years. Patients dealing with knee pain that may be related to PFPS are therefore encouraged to seek out treatment from physical therapist and to stick with their home-exercise program for the best chances of a successful long-term outcome.

-As reported in the May ’16 issue of the Clinical Journal of Sports Medicine

Course of exercise yields similar results as surgery for knee injury
August 16, 2018

Physical therapy may be utilized either instead of or after surgery

The meniscus is a crescent-shaped piece of cartilage between the thighbone (femur) and the shinbone (tibia), and its job is to stabilize the knee and absorb shock. Damage to the meniscus, which is called a meniscal lesion, can occur from an injury or due to gradual changes over time, which come with age. Patients with meniscal lesions who have knee pain and difficulty performing daily activities may be given different treatment recommendations depending on what type of doctor they see. Some patients are told to follow a wait-and-see policy, in which they rest for a period of time and see if their condition improves. Physical therapy may be utilized during this time. For patients with extreme pain and for those that do not improve, surgery may be recommended instead to repair the damage in the knee. In many cases, patients are referred to a course of physical therapy after surgery to help them rehabilitate. Treatment typically consists of a series of exercises to reduce pain and inflammation and help restore their normal range of motion. Although this is an approach that’s commonly recommended, it is not clear how effective exercise therapy is for these patients. Therefore, a powerful pair of studies called a systematic review and meta-analysis was conducted. The systematic review gathered all relevant research on exercise therapy and surgery for meniscal lesions, and the meta-analysis reviewed these all in detail to determine which approach is best for patients.

Nine medical databases searched for appropriate studies

To collect data for the review, researchers searched through nine major medical databases for studies on exercise therapy and surgery for meniscal lesions. Only randomized-controlled trials and controlled clinical trials—two types of powerful studies—that fit a set of criteria were accepted. This led to a total of 12 studies with data on 594 patients being accepted for the systematic review and meta-analysis. All studies were then analyzed and assessed for strength of evidence and risk of bias.

Exercise therapy found to have certain advantages over surgery

Overall, exercise therapy and surgery were found to lead to similar outcomes in knee pain, function, and performance for patients with meniscal lesions. Exercise therapy, however, was more effective for improving muscle strength than surgery after a short period of time. In addition, exercise therapy was found to be more effective than no treatment at all for muscle strength and performance in the short term. In the long term after surgery, exercise therapy was also more effective than no treatment on patients’ ability to function normally. Taken together, this suggests that patients who have surgery for meniscal lesions can benefit from exercise therapy after the procedure is performed. More research is needed to investigate this topic in greater detail, but it appears that exercise therapy can be considered an alternative option to surgery for treating meniscal lesions, and it may lead to similar overall results.

-As reported in the April ’16 issue of the Journal of Science in Medicine in Sport