Prospective, observational cohort study.
Fifteen participants (7 male, 8 female) with a mean age of 55 years old were recruited from a convenience sample of consecutive patients evaluated for knee osteoarthritis (OA) at the Physical Therapy Clinic, Brooke Army Medical Center, San Antonio, Texas. With regards to severity, ten patients had bilateral symptoms, all 15 patients had radiographic signs of knee OA, and 10 had visible boney enlargement of the knee joint. Additionally, four of the included patients were active duty military personnel.
1. Knee pain for most days of the prior month: AND Crepitus with active motion and Morning stiffness in knee 38 years
2. Knee pain for most days of the prior month: AND Crepitus with active motion and Morning stiffness in knee > 30 minutes and Bony enlargement
3. Knee pain for most days of the prior month: AND No crepitus and Bony enlargement
Additional inclusion criteria include being eligible for care in a military medical treatment facility, minimum age 38 years old, and the ability to read, write, and speak sufficient English to complete the outcome tools.
Exclusion Criteria: Only periarticular pain or pain referred from another region (no joint pain), injections to the knee within the last 30 days, history of knee joint replacement surgery on involved limb, evidence of other systemic rheumatic condition (lupus, rheumatoid arthritis, psoriasis, or gout), and balance deficits from other non-musculoskeletal conditions (neurologic impairments, diabetic neuropathy, cerebellar disorders, or Parkinson disease)
Outcome Measures: The Western Ontario and McMaster Universities arthritis index (WOMAC), Global Rating of Change (GROC), Functional Squat Test (FST) evaluated with numerical pain rating scale (NPRS) and range of motion (ROM), and the Step-Up Test (SUT). Additionally, tolerance to treatment was determined by asking the participants a series of questions regarding whether their symptoms had gotten significantly worse at five different time points since their last visit. Time points included were immediately following treatment, several hours following treatment, that evening prior to bed, the following morning, and from the following morning until the follow-up (approximately 72 hours later).
Evaluation: The initial evaluation included a detailed history, review of systems, and physical examination. The history included questions regarding the duration, severity, location, and distribution of symptoms. The physical examination included functional tests, palpation of bony landmarks, ROM measurement, muscle length tests, and manual assessment of the joints and soft tissues of the lower extremity.
Interventions: Each patient was treated two times per week for four weeks and received both manual therapy and perturbation interventions. Visits included joint and soft-tissue mobilization, which was supplemented with stretching, ROM, and strengthening exercises. Additionally, each patient was provided with a home exercise program targeting their specific functional limitations. The manual therapy techniques were tailored to the impairments of each individual patient, however these interventions included varying grades of knee flexion, knee extension, and patella mobilizations. With regards to perturbation training, each patient was progressed based upon clinical reasoning and as tolerated by the individual patient. Each program generally started with more emphasis on manual therapy interventions and towards the end of the program, the focus switched to perturbation exercises.
WOMAC: The mean WOMAC score demonstrated a statistically significant improvement from baseline to 6 months with a 46% improvement, which was well above the minimal clinically important difference (MCID) of 12%. Additionally, the total WOMAC score was significantly improved at the end of the 4 week intervention period and remained improved at the 6 month follow-up. Finally, the only WOMAC sub-scale that did not remain improved at the 6 month follow-up was the ‘Stiffness’ sub-scale.
GROC: At the one month follow-up, 87% of patients reached the 3 point change in GROC to identify a clinically important change. Changes decreased over time with 80% of patients still maintaining this threshold of change at 3 months and only 60% at the final 6 month follow-up. Additionally, and probably more importantly, 47% of patients met the threshold for ‘dramatic change’ (GROC > 6) at all time points.
FST: Following the 4 week intervention period, statistically significant improvements in NPRS and ROM during the FST were documented. An average decrease from 5 to 3 on the NPRS and an improvement from 29° to 35° with regards to ROM.
SUT: The Step-Up Test values also significantly improved at the 4 week evaluation with a mean improvement of 4-5 steps during the 15 second test. This translated to an average increase from 9 to 14 steps completed during the test.
Due to the prospective cohort design of this study, no comparison group was included, thus no cause and effect relationship can be identified. Additionally, some of the improvements seen in this study could be attributed to other medical treatment many of the patients received. By 6 months five patients had received knee joint injections of either corticosteroid or viscosupplementation and two of those same patients received arthroscopic surgery. Of these patients receiving either injection or arthroscopic surgery, none reported improvement in symptoms immediately following the aforementioned procedures. Pain medication was used by 12 patients initially (10 patients daily; 2 patients as needed), including non-steroidal anti-inflammatory drugs and/or acetaminophen. However, it should be pointed out that at each of the follow-up points, fewer patients were taking medications than at baseline.
While no cause and effect relationship can be determined, this study does demonstrate theoretical effectiveness of a combined manual therapy and perturbation training approach to the treatment of knee osteoarthritis. This approach was associated with significant improvements in pain, function, and balance measures. There were several limitations evident within the study, however the potential positive impact of the interventions provided add to the current literature supporting perturbation and manual therapy techniques for patients suffering from knee osteoarthritis.
Rhon D, et al. Manual physical therapy and perturbation exercises in knee osteoarthritis. Journal of Manual & Manipulative Therapy. 2013; 21(4): 220–228.
The AAOMPT Student Special Interest Group is recruiting students to help run the booth at the upcoming Combined Sections Meeting in Las Vegas, Nevada from February 4-6th. While at the booth you will have the opportunity to help advocate for the American Academy of Orthopaedic Manual Physical Therapists and the value that we bring to the physical therapy profession. You will also have to chance to help run our raffle where we are giving away 3 yearly subscriptions to MedBridge Education‘s online continuing education resource.
Thanks in advance for your help in promoting this great organization!
John Snyder, SPT, CSCS
Vice President AAOMPT Student SIG
Over the past year, I have been writing articles for MedBridge Education’s Blog and recently, I have agreed to an Affiliate Partnership with this great continuing education company. In doing so, my readers and followers have the opportunity to purchase a discounted yearly subscription (saving $225) to MedBridge’s extensive online course library, which features instructors such as Chad Cook, Louie Puentedura, Terry Malone, Lenny Macrina, Kyle Kiesel, Phil Plisky and much more. I have already taken several courses and I 100% believe the money spent will be well worth it for any physical therapist or DPT student.
Thanks and enjoy!
John Snyder, SPT, CSCS
The following is another article written for the online, video-based physical therapy continuing education company MedBridge Education…
Among one of the most common musculoskeletal complaints, neck pain has been estimated to effect between 22% and 77% of individuals in their lifetime according to the Neck Pain Clinical Practice Guidelines published by Childs et al. While this pain is typically self-limiting and resolves with time, Bovim et al found that 30% of patients reporting neck pain will ultimately develop chronic symptoms of greater than 6 months in duration. In addition to this study, researchers also found that between 37% (Cote et al) and 44% (Hurwitz et al) of those who experience neck pain will report lingering symptoms for at least 12 months. Unfortunately, even after successful treatment, there has been a reported recurrence rate of 50-85% within the first 1-5 years following resolution of symptoms (Halderman et al). Neck pain is multi-factorial in nature with patients reporting varying symptoms depending on pathology, psychosocial influences/fear-avoidance, and age. Because of the varying clinical presentations of this particular group of patients, an individualized treatment plan developed based on their specific impairments/symptoms should be implemented.
The primary goal of classification is to determine the treatment approach most likely to yield the best clinical outcome for an individual patient and secondarily to determine the patient’s appropriateness for physical therapy. Taking after the treatment-based classification system proposed by Delitto et al for low back pain, Childs et al developed a similar system for disorders of the cervical spine. The first step in this classification scheme is determining the patient’s appropriateness for physical therapy. In general, this stage encompasses screening for ‘red flags’ (cervical myelopathy, cancer, ligamentous instability, fracture, and vascular compromise) as well as non-musculoskeletal causes of neck pain (i.e. cardiac event). This preliminary stage of the process is integral in ruling out significant pathology that needs further radiological imaging and/or surgical intervention prior to beginning a course of physical therapy. During this stage, two specific clinical prediction rules (CPR) can be utilized in order to improve your ability to make the best clinical judgment in this important preliminary stage in the examination process (Cervical Myelopathy and Fracture). After successfully clearing your patient from the presence of serious pathology, the patient’s psychosocial profile should be screened for the presence of any ‘yellow flags’ that may alter your treatment approach (catastrophizing, high fear-avoidance beliefs, ect.). These patients may benefit from a graded exercise, graduated exposure, and/or a pain science education approach in conjunction with the treatment-based classification system groupings.
The final stage of this classification scheme involves determining the correct treatment category for the patient based on their clinical presentation. The classification system for neck pain can be broken into 5 distinct categories (Mobility, Centralization, Exercise & Conditioning, Pain Control, and Headache). The Mobility group receives cervical and/or thoracic manipulative and mobilization interventions in conjunction with cervical exercises (active range of motion, deep cervical flexors, ect.). Identifying these patients can be improved by implementing the CPR for cervical manipulation and the CPR for thoracic manipulation in addition to your clinical expertise and the criteria proposed by Childs et al. Those in the centralization group should receive interventions to create centralization of their symptoms either through the use of their specific directional preference via repeated movements or through the use of manual/mechanical cervical traction. Furthermore, the identification of individuals who will specifically benefit from cervical traction can be aided through the use of the CPR developed by Raney et al. Patients who will benefit from general conditioning and exercise typically display lower pain/disability scores and have a longer duration of symptoms and benefit from targeted strengthening and endurance interventions to improve muscular imbalances and/or deficits. The pain control grouping consists of non-aggravating manual techniques, therapeutic modalities, and activity modification. However, the patient should be progressed to a more active classification category as soon as tolerated. Finally, the headache group is treated with manual therapy techniques directed at the cervical and thoracic spine (manipulation, sub-occipital release, ect.) in addition to upper extremity strengthening. As stated in Chad Cook, PT, PhD, MBA, FAAOMPT’s course, “Manual Therapy for the Cervical Spine: An Evidence-Based Approach”, the process of classification is ongoing, and it is assumed that a patient’s presentation will change with time and treatment. Due to this continual change in presentation, ongoing reassessment is required in order to determine the most appropriate sub-group and subsequent intervention at any point in time during the patient’s course of treatment.
While this is a relatively new classification system, there is some evidence available supporting its effectiveness. In 2007, Fritz et al performed a preliminary investigation into the utility of this particular treatment approach. Baseline patient characteristics and evaluations were performed on 274 patients and subjects were split into two groups (those matched to their classification group and those unmatched). Overall, 113 patients received matched interventions and 161 patients received unmatched interventions. Patients receiving matched interventions showed greater changes in both Neck Disability Index (NDI) scores and pain rating scores compared to their unmatched counterparts. Additionally, 72.5% of patients in the matched group achieved the minimal detectible change in NDI, whereas those in the unmatched group only achieved this feat in 53.8% of patients. Along with this outcome data, the authors found a kappa value of 0.95 for classification determination and 0.96 for the treatment matching decision, both of which are in very strong agreement. In conjunction with this randomized controlled trial, Heintz and Hegedus published a case report of a patient presenting with mechanical neck pain who was successfully treated with the aforementioned treatment-based classification system. Over this patient’s 6-week treatment (38 days), pain was reduced from 4-10/10 to 0/10 with only a complaint of stiffness at end-range and their NDI score decreased from 52% (severe disability) to 6% (no disability). Obviously, this is only one patient, but it does add evidence to the effectiveness of this particular treatment approach. While the research regarding this treatment approach is in its infancy, the current evidence available provides preliminary support to its effectiveness in treating patients presenting with mechanical neck pain.
1. “Metacognition, Critical Thinking, and Science Based Practice” by Kyle Ridgeway, DPT (PTThinkTank.com)
2. “Let’s Talk Spinal Manipulation (Thrust, Grade 5, or Whatever Else You Wanna Call It)…” by Joseph Brence, DPT, FAAOMPT (ForwardThinkingPT.com)
3. “MRI Findings in Low Back Pain” by Mark Gibson (MarkGibsonPhysio.com)
4. “Clinical Prediction Rules: The Good, The Bad, and The Ugly” by Matthew Barton, SPT, CSCS, HFS (AAOMPTsSIG.wordpress.com)
5. “Becoming a Self-Sustaining Physical Therapist: From Spoon-Fed to Hunter-Gatherer” by Kenneth Taylor, SPT (AAOMPTsSIG.wordpress.com)
6. “Agree or Disagree the Less Wrong Way” by Kyle Ridgeway, DPT (PTThinkTank.com)
7. “What is a Lateral Shift & Why Does It Matter?” by Trent Nessler, DPT (ACLPrevention.com)
8. “Here’s to a Nonoperative 2014” by John Childs, PhD, DPT, FAAOMPT (EvidenceInMotion.com)
9. “Busting the Myth that Manipulation is at End-Range” by Harrison Vaughn, DPT (InTouchPT.wordpress.com)
10. “Does evidence support using the Functional Movement Screen?” by Chris Beardsley (StrengthandConditioningResearch.com)
1. Beattie PF, et al. The Within-Session Change in Low Back Pain Intensity Following Spinal Manipulative Therapy is Related to Differences in Diffusion of Water in the Intervertebral Discs of the Upper Lumbar Spine and L5-S1. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44 (1): 19–29.
2. Di Stasi SL, et al. Neuromuscular Training to Target Deficits Associated With Second Anterior Cruciate Ligament Injury. Journal of Orthopaedic & Sports Physical Therapy. 2013; 43 (11): 777–792, A1–11.
3. Frank B, et al. Trunk and Hip Biomechanics Influence Anterior Cruciate Loading Mechanisms in Physically Active Participants. American Journal of Sports Medicine. 2013; 41 (11): 2676–2683.
4. Hartigan EH, et al. Kinesiophobia After Anterior Cruciate Ligament Rupture and Reconstruction: Noncopers Versus Potential Copers. Journal of Orthopaedic & Sports Physical Therapy. 2013; 43 (11): 821–832.
5. Herrington L, et al. Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: a clinical commentary. Physical Therapy in Sport. 2013; 14 (4): 188–198.
6. Lind M, et al. Free Rehabilitation Is Safe After Isolated Meniscus Repair: A Prospective Randomized Trial Comparing Free with Restricted Rehabilitation Regimens. American Journal of Sports Medicine. 2013; 41 (12): 2753–2758.
7. Rabin A, et al. A Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to Experience Short-Term Success Following Lumbar Stabilization Exercises: A Randomized Controlled Validation Study. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44 (1): 6–18, B1–13.
8. Rhon D, et al. Manual physical therapy and perturbation exercises in knee osteoarthritis. Journal of Manual & Manipulative Therapy. 2013; 21 (4): 220–228.
9. Sihvonen R, et al. Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. New England Journal of Medicine. 2013; 369 (26): 2515–2524.
10. Thomas LC, et al. Effect of Selected Manual Therapy Interventions for Mechanical Neck Pain on Vertebral and Internal Carotid Arterial Blood Flow and Cerebral Inflow. Physical Therapy. 2013; 93 (11): 1563–1574.
Madison Square Garden can seat 20,000 people for a concert. This blog was viewed about 65,000 times in 2013. If it were a concert at Madison Square Garden, it would take about 3 sold-out performances for that many people to see it. Additionally, views came from over 130 different countries with the majority coming from the United States, Canada, and the UK. Thanks to all my viewers and those who referred their audience to my blog! Your continued support is what allows me the ability to contribute the content on this site.
Thanks again and have a happy New Year!
In the next installment of my Research Review series for MedBridge Education, we will discuss a recent study that appeared in Physical Therapy Journal conducted by Thomas et al. The authors investigated the changes in vertebral and internal carotid blood flow during selective positions that are commonly associated with manual therapy techniques were assumed. This study provides additional evidence toward understanding the role of neck position on blood inflow to the brain.
Experimental, observational magnetic resonance imaging (MRI) study.
Twenty participants (10 male, 10 female) with a mean age of 33.1 years were recruited into the study. All participants had normal anatomy of their craniocervical arterial circulation, however three participants (15%) had dominance of one vertebral artery.
Inclusion Criteria: Healthy subjects, between the ages of 18 and 65 years old, no reported mechanical neck pain or headache.
Exclusion Criteria: Diagnosed inflammatory joint disease, any history of serious cervical spine trauma (i.e. fractures), any congenital disorder recognized as being associated with hypermobility or instability of the upper cervical spine, diagnosed vertebrobasilar artery insufficiency (VBI), claustrophobia or discomfort in confined spaces (standard contraindication for MRI), and any contraindication identified by the local health authority MRI safety screening questionnaire.
Experimental Conditions: While the MRI was being performed, the patients’ cervical spine was positioned in 9 distinctly different positions that simulate positions used in manual therapy techniques. These positions included: neutral position, left rotation, right rotation, left rotation with distraction, right rotation with distraction, left rotation localized to C1–C2, right rotation localized to C1–C2, distraction, and post-test neutral.
Outcome Measures: Blood flow in craniocervical arteries was measured with MRI using a phase-contrast flow quantification sequence. The arterial plane of section was selected to intersect the top of the atlas loop of the vertebral arteries at the level of the C1 vertebra, with imaging extending to just below the atlas loop. Average blood flow volume measured in milliliters per second was used as the primary test variable and was analyzed in neutral and each of the neck positions for each artery. The average blood flow volume in each artery then was compared between the neutral position and each of the experimental neck positions. Additionally, total blood supply to the brain was determined from the sum of average flow volume (mL/s) in both vertebral and both internal carotid arteries. A meaningful difference between the neutral position and any of the experimental conditions was determined to be > 10%.
Average inflow to the brain in neutral was 6.98 mL/s and was not significantly changed by any of the test positions. According to the data collected, the lowest total blood inflow level was recorded during left rotation (6.52 mL/a). There was no significant difference in flow in any of the 4 arteries in any position from neutral, despite large individual variations. Although mean values of average flow volume were not significant for any position, there were certain individuals with marked flow changes in some positions. Flow generally decreased slightly for both the end-range rotation and distraction positions but increased in the other positions in comparison to neutral. Flow changes were all less than 10%, which is considered to be the normal variation for cerebral inflow.
Secondary to restraints of the MRI and positioning of patients, full end-range rotation may not have been achieved. Additionally, some of the hand positions had to be altered from typical manual therapy techniques due to the constraints of the MRI set-up. None of the tested positions also included the thrust manipulation commonly used concurrently during a manual therapy procedure. Most notably, the results of this study should be cautioned as no subjects were included that presented with neck pain and/or headache symptoms.
Cervical manipulation is a polarizing topic amongst physical therapists and healthcare professionals as a whole. Many believe the risks are not worth the clinical benefits it provides to individuals suffering from mechanical neck pain. This study investigated blood flow to the brain during positions commonly associated with manipulative techniques and found only marginal changes in blood flow with multiple positions. What this study is not able to do (and wasn’t designed to do) is confirm the utility of positional tests for identifying those with blood flow restrictions or confirm that cervical thrust procedures do not involve blood flow changes (the subjects were healthy and there was no thrust used in this study). This sophisticated study adds nicely to the literature but clinicians still face the conundrum of identifying who may and my not be at risk during a thrust manipulation. Prior to intervening with cervical manipulative techniques, clinicians are urged to follow a thorough evaluation framework similar to that proposed by Flynn et al and the International Federation of Orthopaedic Manipulative Physical Therapists. Cervical manipulation should be implemented with caution and following a thorough subjective and physical examination when indicated by individual patient presentation.
Thomas LC, Rivett DA, Bateman G, Stanwell P, Levi CR. Effect of Selected Manual Therapy Interventions for Mechanical Neck Pain on Vertebral and Internal Carotid Arterial Blood Flow and Cerebral Inflow. Physical Therapy. 2013; 93(11): 1563–1574.
The following is another article written for the online, video-based physical therapy continuing education company MedBridge Education…
Following any type of surgery, significant weakness of the primary and secondary musculature is common. For example, quadriceps weakness has been documented during the immediate post-operative phase following surgery (Snyder-Mackler et al), as well as years following rehabilitation (Rosenberg et al). Additionally, patients who undergo Total Knee Arthroplasty (TKA) exhibit similar findings. According to Mizner et al and Stevens et al, quadriceps strength drops 50-60% of pre-operative levels one month following TKA, despite the initiation of rehabilitation within 48 hours of surgery. Following this trend, Rokito et al found external rotation deficits following rotator cuff repair of 79% and 90% at six months and one year, respectively. Considering the severity and chronicity of these strength deficits, more effective interventions are warranted to restore strength and improve long-term outcomes. One particular modality that has been shown to improve these deficits is neuromuscular electrical stimulation (NMES).
Kim et al recently published a systematic review investigating the utility of NMES following ACL reconstruction to improve quadriceps function and strength. In this review, which involved 8 randomized controlled trials (RCTs), it was demonstrated that NMES in conjunction with exercise, compared to exercise alone or in combination with electromyographic bio-feedback, results in greater quadriceps strength recovery. As discussed in a previous article, return to sport is the ultimate goal for most patients and quadriceps femoris strength is of the utmost importance. Schmitt et al conducted a cross-sectional study to determine the impact of quadriceps weakness on return to sport functional testing. Those patients who presented with a quadriceps index (quadriceps strength involved/uninvolved) of < 85% performed inferiorly when compared to those with a quadriceps index of > 90%. Additionally, quadriceps weakness predicted performance on single-leg hop testing regardless of graft type, presence of meniscus injury, knee pain, and knee symptoms. Similarly, Fitzgerald et al not only measured increased quadriceps strength, but also length of time until progression to agility/plyometric training. This randomized controlled trial found that those in the NMES group met the criteria for progression in a greater proportion than those in the control group. At 16 weeks, 85.7% (18/21) of patients receiving NMES achieved progression to agility training, whereas only 68% (15/22) of those in the control group achieved similar results.
In addition to ACL rehabilitation, those undergoing total knee arthroplasty enjoyed similar benefits. Stevens-Lapsley et al conducted a prospective, longitudinal, randomized controlled trial investigating the effects of NMES on patients following TKA. Patients were randomized into a group receiving standardized rehabilitation or to a group receiving the same rehabilitation in addition to NMES, which was initiated 48 hours following surgery. In both the short-term (3.5 weeks) and long-term (52 weeks), patients in the NMES group demonstrated superior quadriceps strength, hamstring strength, and functional performance (Timed “Up & Go” Test, the Stair-Climbing Test, and the Six-Minute Walk Test). Additionally, Walls et al investigated the pre-operative utility of this modality. Those individuals who received NMES achieved significant increases in quadriceps strength from weeks 6-12, whereas the control group did not achieve the same feat. Lastly, in a case report published by Petterson et al, a cyclist presenting 12 months following bilateral TKA displayed significant impairments with regards to quadriceps strength and volitional muscular contraction. Following six weeks of NMES and volitional therapeutic exercise, this patient achieved a 25% improvement in left quadriceps femoris maximal volitional force output and his central activation ratio (CAR) also improved from 0.83 to 0.97 as quantified by the burst superimposition technique. Furthermore, strength gains continued after the end of treatment as his quadriceps strength index was 94% of his right leg at 12 months following treatment.
While the majority of research pertaining to the efficacy of NMES has been done in the lower extremity, this is not the only region where its benefits can be found. As previously stated, muscular deficits frequently accompany patients following rotator cuff repair. To this end, Reinold et al investigated the ability of NMES to affect maximum voluntary contraction of the infraspinatus muscle. In comparison to trials without NMES, peak force production was significantly greater with an average force of 3.75 kg in comparison to just 3.08 kg. This increase was present regardless of patient age, size of the tear, intensity of the current, or the number of days following surgery. While this preliminary study does not give credence to the effect during a full course of rehabilitation, it does speak to the ability of NMES to increase the ability of this musculature to contract safely and more efficiently following surgery. Further research will define the effectiveness of this intervention following rotator cuff pathology, however this study lends hopeful possibilities.
Neuromuscular electrical stimulation should play an integral role in your practice regardless of setting. Patients presenting with strength deficits and impairments will benefit from NMES when combined with volitional exercise. Meryl Gersh, PT, PhD goes into great detail with regards to electrode placement, optimal dosage, and indication criteria in her course “Applying Electrical Stimulation in Your Physical Therapy Practice”. Increasing your patients’ volitional muscular contraction is of the utmost importance when it comes to fostering improved long term outcomes and NMES in conjunction with their current program should yield enhanced results.
Over at ACL Prevention, Trent Nessler, DPT has posted several fantastic posts centered around using movement analysis in the treatment of orthopedic conditions (“Does Movement Assessment Really Tell You Anything?“, “Does Injury Prevention = Improved Performance?“, “Does endurance play a role in lower kinetic chain injury prevention?“).
Evidence-Based Practice has been an important topic leading up to and following the AAOMPT Annual Conference in Cincinnati, Ohio. Selena Horner at Evidence in Motion and Harrison Vaughn at In Touch PT both give their opinion on the current state of this theoretical model (“AAOMPT and Evidence Based Practice” and “Evidence-Based Practice: Survey Results“).
Mike Reinold has continued to provide excellent content at his website starting with his views on Glenohumeral Internal Rotation Deficit (GIRD). As he points out, GIRD is not as simple as previously assumed and, at times, these deficits are not detrimental to the athlete or his/her performance. The take away from this article is simple, “assess, don’t assume”.
Finally, over at Ortho Chat, my fellow classmate TJ Moore posted several fantastic interviews with some of the leaders in our field. The first of which is a discussion with Keelan Enseki regarding the treatment of Sports Hernia. Shortly following, Chad Cook joined him to discuss the current state of Randomized Controlled Trials in the physical therapy literature. And finally, Tom Tisdale discussed the current best practice with regards to treatment, diagnosis, and prevention of Ulnar Collateral Ligament Pathology. Definitely worth checking out.
1. Engquist M, et al. Surgery Versus Nonsurgical Treatment of Cervical Radiculopathy: A Prospective, Randomized Study Comparing Surgery Plus Physiotherapy With Physiotherapy Alone With a 2-Year Follow-up. Spine. 2013; 38(20): 1715–1722.
2. Ericsson YB, et al. Lower extremity performance following ACL rehabilitation in the KANON-trial: impact of reconstruction and predictive value at 2 and 5 years. British Journal of Sports Medicine. 2013; 47(15): 980-985.
3. Farrokhi S, et al. A Biomechanical Perspective on Physical Therapy Management of Knee Osteoarthritis. Journal of Orthopaedic & Sports Physical Therapy. 2013; 43(9): 600–619.
4. Gagnier JJ, et al. Interventions Designed to Prevent Anterior Cruciate Ligament Injuries in Adolescents and Adults: A Systematic Review and Meta-analysis. American Journal of Sports Medicine. 2013;41(8):1952–1962.
5. Kuhn JE, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. Journal of Shoulder & Elbow Surgery. 2013; 22(10): 1371-1379.
6. Manske RC, et al. Current Concepts in Shoulder Examination of the Overhead Athlete. International Journal of Sports Physical Therapy. 2013; 8(5): 554–578.
7. Martin RL, et al. Ankle Stability and Movement Coordination Impairments: Ankle Ligament Sprains. Journal of Orthopaedic & Sports Physical Therapy. 2013; 43(9): A1–A40.
8. Peters J, et al. Proximal Exercises are Effective in Treating Patellofemoral Pain Syndrome: A Systematic Review. International Journal of Sports Physical Therapy. 2013; 8(5): 689–700.
9. Rio E, Moseley L, Purdam C, et al. The Pain of Tendinopathy: Physiological or Pathophysiological? Sports Med. 2013.
10. Shaarani SR, et al. Effect of Prehabilitation on the Outcome of Anterior Cruciate Ligament Reconstruction. American Journal of Sports Medicine. 2013; 41(9): 2117–2127.
Research Review: Effect of Prehabilitation on the Outcome of Anterior Cruciate Ligament Reconstruction
In my first in a series of ‘Research Review’ articles for MedBridge Education, I will review a recent study that appeared in The American Journal of Sports Medicine. Shaarani et al investigated the utility of a Prehabilitation program for patients scheduled to undergo anterior cruciate ligament reconstruction (ACLR). Considering the variable rate of return to sport following ACLR (43-93%), urgency exists for improving rehabilitation following ACL injury.
Randomized Controlled Trial (RCT).
20 patients with a rupture of the ACL were recruited from 2 orthopedic centers between December 2010 and December 2011. Following randomization, 11 patients were assigned to the intervention group while 9 were placed in the control group. No significant differences existed between groups for age, height, weight, body mass index, and Tegner activity level before/after injury.
Inclusion Criteria: Males between the ages of 18 and 45 years old with an isolated ACL tear. All patients had a positive anterior drawer, Lachman, and pivot-shift test.
Exclusion Criteria: Associated fractures, meniscal repair, collateral ligament injury requiring repair/reconstruction, comorbidities that would be contraindicated from high physical exertion, and living outside the Greater Dublin area for practical reasons related to exercise supervision and exercise gym usage.
Outcome Measures: Single-leg hop test, peak torque of the quadriceps and hamstring, muscle cross-sectional area (CSA), Modified Cincinnati Knee Rating System (mCKRS), and Tegner activity level.
Randomization: From a pool of 437 patients, 56 were eligible following inclusion/exclusion criteria. There were, however, 14 non-responders and 19 subjects who refused to participate. Randomization was determined following outpatient consultation. Opaque envelopes were used to randomly assign individuals to their group.
Interventions: The Prehabilitation Group (PG) was enrolled in a 6-week exercise program, which consisted of supervised resistance and balance training. This program was comprised of 4 exercise sessions per week, which included 2 supervised gym sessions and 2 supervised home sessions. The primary focus was lower limb strengthening with a quadriceps emphasis, as well as proprioceptive training. Each exercise consisted of 3 sets of 12 repetitions and the weights were increased weekly by 10-15%. During the last gym session, the weights were reduced to the previous week’s value to prevent preoperative fatigue and to favor the muscular response to endurance and gaining mass. In contrast, the Control Group (CG) was not given a pre-operative exercise program; however these patients were not discouraged from exercise or taking part in normal activity of daily living before surgery. Postoperatively, both groups received standardized physical therapy sessions, which included increasing range of motion (ROM) and weight-bearing while improving symmetry and gait pattern.
Immediately following the 6-week Prehabilitation program, the intervention group showed several significant improvements prior to surgery. These benefits included the following: significantly improved single-leg hop testing; increased quadriceps and vastus medialis CSA, and improved mCKRS. At 12 weeks post-operative, the rate of decline in the single leg hop test was less and the mCKRS was significantly improved in the exercise group compared with the CG, however no changes existed between groups in CSA. Of particular importance was that on average patients in the PG returned to sport in 34.2 weeks versus 42.5 weeks in the CG though this did not reach statistical significance (P=0.055).
The most important limitations of this study were the small sample size (n = 20) and lack of a long-term follow-up in comparison to the typical rehabilitation length. It is therefore difficult to extrapolate these short-term benefits to long-term outcomes. Additionally, single-leg hop and peak quadriceps torque testing were observed by an individual who was not blinded to the treatment groups. Finally, in terms of the study design itself, utilizing a sham exercise program would have eliminated the potential attention bias.
This pilot study supports implementing a prehabilitation program following ACL injury in preparation for surgical intervention. As previously stated, the percentage of patients who are able to return to sport following ACLR is broad and relatively unimpressive. The benefits of prehabilitation demonstrated during this initial investigation could have a profound impact on return to sport following ACLR. The improvement in single-leg hop testing is particularly encouraging, as it has been documented to be a problematic area with regards to athletes following ACLR. Both Myers et al and Xergia et al found significant asymmetries in single-leg hop testing between individuals who had undergone ACLR and uninjured control subjects. Following rehabilitation, athletes need to have the proprioceptive ability and confidence to perform single-leg stopping, cutting, and jumping activities without hesitation. Coinciding with these measures, this study did show a shorter timeframe for return to sport in athletes who completed a course of prehabilitation. Despite not reaching statistical significance, an average decrease of over 8 weeks is clinically meaningful to any sports medicine practitioner, athlete, or coach.
Shaarani SR, O’Hare C, Quinn A, Moyna N, Moran R, O’Byrne JM. Effect of Prehabilitation on the Outcome of Anterior Cruciate Ligament Reconstruction. American Journal of Sports Medicine. 2013; 41(9): 2117–2127.