Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review

Background

Shoulder pain is a common clinical problem, and numerous tests are used to diagnose structural pathology.

Objectives

To systematically review the reliability of physical examination procedures used in the clinical examination of patients with shoulder pain.

Data sources

MEDLINE, PEDro, AMED, PsychInfo, Cochrane Library (2009) and CINAHL were searched from the earliest record on the database to June 2009.

Study eligibility criteria

Reliability studies that included any patients with shoulder pain were analysed for their quality and reliability results.

Study appraisal and synthesis methods

Pre-established criteria were used to judge the quality of the studies (high quality >60% methods score) and satisfactory levels of reliability (kappa or intraclass correlation coefficient ≥0.85, sensitivity analysis 0.70). A qualitative synthesis was performed based on levels of evidence.

Results

Thirty-six studies were included with a mean methods score of 57%. Seventeen studies were deemed to be of high quality; high-quality studies were less likely to meet the pre-agreed level of reliability. The majority of studies indicated poor reliability for all procedures investigated.

Limitations

Overall, the evidence regarding reliability was contradictory.

Conclusions and implications

There is no consistent evidence that any examination procedure used in shoulder assessments has acceptable levels of reliability. Alternate methods of classification which are reliable should be used to classify patients with shoulder problems.     

Indexing of randomised controlled trials of physiotherapy interventions: a comparison of AMED, CENTRAL, CINAHL, EMBASE, Hooked on Evidence, PEDro, PsycINFO and PubMed

Objective

To compare the comprehensiveness of indexing the reports of randomised controlled trials of physiotherapy interventions by eight bibliographic databases (AMED, CENTRAL, CINAHL, EMBASE, Hooked on Evidence, PEDro, PsycINFO and PubMed).

Design

Audit of bibliographic databases.

Methods

Two hundred and eighty-one reports of randomised controlled trials of physiotherapy interventions were identified by screening the reference lists of 30 relevant systematic reviews published in four consecutive issues of the Cochrane Database of Systematic Reviews (Issue 3, 2007 to Issue 2, 2008). AMED, CENTRAL, CINAHL, EMBASE, Hooked on Evidence, PEDro, PsycINFO and PubMed were used to search for the trial reports. The number of trial reports indexed in each database was calculated.

Results

PEDro indexed 99% of the trial reports, CENTRAL indexed 98%, PubMed indexed 91%, EMBASE indexed 82%, CINAHL indexed 61%, Hooked on Evidence indexed 40%, AMED indexed 36% and PsycINFO indexed 17%. Most trial reports (92%) were indexed on four or more of the databases. One trial report was indexed on a single database (PEDro).

Conclusions

Of the eight bibliographic databases examined, PEDro and CENTRAL provide the most comprehensive indexing of reports of randomised trials of physiotherapy interventions.     

Motivating patients with shoulder and back pain to self-care: can a videotape of exercise support physiotherapy?

Objectives

The National Health Service is developing an ethos of self-care. Patients are being encouraged to become proficient in helping themselves. This has long been a philosophy of the physiotherapy profession, where self-care between consultations has been an integral part of the treatment process through encouraging the uptake of self-care skills training. This study explored how patients with shoulder and back pain perceived videotaped exercises and instructions to support their routine physiotherapy, and how the videotape was used.

Design

A videotape, developed by physiotherapists for patients with musculoskeletal problems, of exercises to view at home was given to patients by their physiotherapists to support their routine physiotherapy consultations. A qualitative methodology was used to examine how patients responded to being given a videotape of exercises and instructions between consultations. Data were collected through semi-structured interviews.

Setting

The study was based in 26 general practices that had access to practice-based physiotherapists in two primary care trusts in the north-west of England.

Participants

Thirty-three patients with shoulder and back pain who received a videotape of exercises and advice were interviewed.

Results

Three themes emerged from the data: finding space for exercise; remembering and doing exercises; and supporting the physiotherapy-patient relationship. Patients discussed aspects of motivation, and described how a videotape of exercises might support or inhibit the performance of exercises prescribed by physiotherapists. Patients identified a range of different ways in which they derived support from the videotape.

Conclusions

The videotape supported patients with a variety of different needs as it enhanced their ability to complete exercises correctly. Videotapes (or DVDs) are useful for patients and could be adopted as a tool to support treatment.     

Activation of lumbar paraspinal and abdominal muscles during therapeutic exercises in chronic low back pain patients

Arokoski JP, Valta T, Kankaanpää M, Airaksinen O. Activation of lumbar paraspinal and abdominal muscles during therapeutic exercises in chronic low back pain patients. Arch Phys Med Rehabil 2004;85:823-32.

Objectives

To assess the activities of paraspinal and abdominal muscles during therapeutic exercises for the treatment of patients with nonspecific chronic low back pain (CLBP), and to study the effects of active physical rehabilitation on these activities.

Design

A cross-sectional study comparing muscle activities during 18 stabilization exercises, and a prospective follow-up of patients with CLBP during rehabilitation.

Setting

Rehabilitation clinic in university hospital in Finland.

Participants

Nine volunteers (5 men, 4 women) aged 27 to 58 years.

Intervention

Three months of active outpatient rehabilitation (4 to 6 times in a rehabilitation clinic, supplemented with self-motivated exercise at home) supervised by a physiotherapist.

Main outcome measures

Surface electromyography was recorded bilaterally from L5 level paraspinal, rectus abdominis, and obliquus externus abdominis muscles. The recorded signal was averaged and normalized to the maximal electromyographic amplitude obtained during the maximal voluntary contraction. The measurements were taken before and after the exercise treatment period.

Results

CLBP patients showed variable trunk muscle activity patterns during the different therapeutic exercises, similar to those that we reported earlier in healthy subjects. The maximal trunk isometric extension (pre, 147.3±75.9Nm; post, 170.1±72.3Nm) and flexion (pre, 72.0±37.9Nm; post, 93.5±42.5Nm) torques did not show a significant changes during the exercise period. However, trunk rotation-flexion torque (pre, 52.9±26.5Nm; post, 82.4±65.8Nm) increased significantly (35.8%) after the exercise period (P<.05). The corresponding maximal electromyographic amplitudes of back and abdominal muscles remained unchanged. Disability, as assessed by visual analog scale and Oswestry Disability Index, did not change.

Conclusions

The CLBP patients performed therapeutic exercises with similar abdominal and back extensor muscle activities in the same way as the healthy subjects in our earlier studies. In this study, active physical rehabilitation had no effect on the abdominal and back muscle activities or on pain and functional disability indices.     

Pain in persons with postpolio syndrome: frequency, intensity, and impact

Stoelb BL, Carter GT, Abresch RT, Purekal S, McDonald CM, Jensen MP. Pain in persons with postpolio syndrome: frequency, intensity, and impact.

Objective

To describe the frequency, intensity, and impact of pain in persons with postpoliomyelitis syndrome (PPS).

Design

Retrospective, cross-sectional survey.

Setting

Community-based survey.

Participants

Convenience sample of people with PPS.

Interventions

Not applicable.

Main Outcome Measures

Overall intensity and duration of pain, pain sites, pain interference, pain treatments, and relief provided by pain treatments.

Results

A total of 91% (n=57) of the study participants (N=63) reported pain. The most frequently reported pain sites were the shoulders, lower back, legs, and hips. Participants reported pain intensity to be the greatest in the knees, legs, wrists, lower back, and head. Pain interfered most with sleep and with activities requiring a high level of musculoskeletal involvement. Respondents also reported pain problems that were more severe than those of the general population and than those of a sample of people with multiple sclerosis. Many treatments had been tried previously for pain, but continued use of treatments was reported by relatively few participants at the time of the survey.

Conclusions

The findings indicate that pain is a persistent and common problem in persons with PPS, highlighting the need for effective and accessible pain treatments for this population.     

Shoe orthotics for the treatment of chronic low back pain: a randomized controlled pilot study

Objectives

The purpose of this pilot study was to investigate the feasibility of a randomized clinical trial of shoe orthotics for chronic low back pain.

Methods

The study recruited 50 patients with chronic low back pain through media advertising in a midwestern suburban area. Medical history and a low back examination were completed at a chiropractic clinic. Subjects were randomized to either a treatment group receiving custom-made shoe orthotics or a wait-list control group. After 6 weeks, the wait-list control group also received custom-made orthotics. This study measured change in perceived pain levels (Visual Analog Scale) and functional health status (Oswestry Disability Index) in patients with chronic low back pain at the end of 6 weeks of orthotic treatment compared with no treatment and at the end of 12 weeks of orthotic treatment.

Results

This study showed changes in back pain and disability with the use of shoe orthotics for 6 weeks compared with a wait-list control group. It appears that improvement was maintained through the 12-week visit, but the subjects did not continue to improve during this time.

Conclusions

This pilot study showed that the measurement of shoe orthotics to reduce low back pain and discomfort after 6 weeks of use is feasible. A larger clinical trial is needed to verify these results.     

Outcome following a physiotherapist-led intervention for chronic low back pain: the important role of cognitive processes

Objectives

To examine whether patients with chronic low back pain exhibit changes in cognitive factors following Interactive Behavioural Modification Therapy (IBMT), delivered by physiotherapists; and to examine the association between pre- to post-treatment changes in cognitive factors (cognitive processes) and pre- to post-treatment changes in pain, disability and depression.

Design

Observational before-after study.

Setting

Outpatient physiotherapy department.

Participants

One hundred and thirty-seven patients with chronic low back pain.

Interventions

IBMT: ‘Work Back to Life’ rehabilitation programme.

Main outcome measures

Pre- to post-treatment changes in pain, disability and a range of cognitive factors.

Results

Patients demonstrated significant favourable changes for a range of cognitive factors. Furthermore, pre- to post-treatment changes in these cognitive factors explained an additional 22%, 17% and 15% of the variance in changes in pain, disability and depression, respectively, after controlling for other important factors.

Conclusions

Changes that emerge in cognitive factors are strongly related to treatment outcome within a physiotherapy treatment context. Specifically, reductions in fear of movement and catastrophising, and increases in functional self-efficacy appear to be particularly important. Modifying these cognitive factors should be seen as a priority when treating patients with chronic low back pain.     

A prospective study of patients with chronic back pain randomised to group exercise, physiotherapy or osteopathy

Objective

To investigate the difference in outcome between patients treated with group exercise, physiotherapy or osteopathy.

Design

Prospective study of patients referred at random to one of three treatments, with follow-up 6 weeks after discharge and after 12 months.

Setting

National Health Service physiotherapy department at St Albans City Hospital, part of the West Hertfordshire Musculoskeletal Therapy Service.

Participants

Two hundred and thirty-nine patients aged 18-65 years recruited from referrals to the physiotherapy department with chronic low back pain.

Interventions

Eligible patients were randomised to group exercises led by a physiotherapist, one-to-one predominantly manipulative physiotherapy, or osteopathy.

Main outcomes

Oswestry Disability Index (ODI), EuroQol-5D, shuttle walking test and patients’ subjective responses to pain and treatment.

Results

All three treatments indicated comparable reductions in mean (95% confidence intervals) ODI at 6-week follow-up: group exercise, −4.5 (−0.9 to −8.0); physiotherapy, −4.1 (−1.4 to −6.9); and osteopathy, −5.0 (−1.6 to −8.4). Attendance rates were significantly lower among the group exercise patients. One-to-one therapies provided evidence of greater patient satisfaction.

Conclusion

The study supports the use of a variety of approaches for the treatment of chronic low back pain. Particular attention needs to be given to the problems of attracting enough participants for group sessions, as these can be difficult to schedule in ways that are convenient for different participants.     

Assessing the effect of sample size, methodological quality and statistical rigour on outcomes of randomised controlled trials on mobilisation, manipulation and massage for low back pain of at least 6 weeks duration

Objectives

To assess the effect of sample size, methodological quality and statistical rigour on outcomes of randomised controlled trials (RCTs) on manual therapy (i.e. manipulation, mobilisation and/or massage) for non-specific low back pain (LBP) of at least 6 weeks duration, and to report results from RCTs with adequate sample size, methodological quality and statistical rigour.

Data sources

MedLine, EMBASE, CINAHL, AMED, Cochrane, PEDro and the library collection of the Chartered Society of Physiotherapy.

Review methods

RCTs were identified that compared manual therapy with a control or alternative intervention in adults with non-specific LBP of at least 6 weeks duration. The sample size, methodological quality (adapted 10-point van Tulder scale) and statistical rigour were then assessed. RCTs were regarded as higher quality if they fulfilled the following three criteria: (a) >40 subjects in the manual therapy group; (b) scoring >5/10 on the Van Tulder scale; and (c) reporting statistical tests that compared the change in the intervention group with the change in the control group.

Results

Ten RCTs were included in the review but only two qualified as higher quality RCTs. Results from smaller trials and lower quality RCTs showed more variation in differences between the intervention and control groups than larger or higher quality trials. Evidence from large, high-quality RCTs with adequate statistical analyses showed that, for improvement in pain and function, a mobilisation/manipulation package is an effective intervention [compared with general practitioner (GP) care], whilst manipulation used in isolation showed no real benefits over sham manipulation or an alternative intervention. No higher quality evidence considering massage was identified.

Conclusions

Many RCTs in the area of manual therapy for LBP have shortcomings in sample size, methodological quality and/or statistical rigour, but there remains evidence from higher quality RCTs to support the use of a manual therapy package, compared with GP care, for non-specific LBP of at least 6 weeks duration.     

Cervical facet joint dysfunction: a review

Kirpalani D, Mitra R. Cervical facet joint dysfunction: a review.

Objective

To review the relevant literature on cervical facet joint dysfunction and determine findings regarding its anatomy, etiology, prevalence, clinical features, diagnosis, and treatment.

Data Sources

A computer-aided search of several databases was performed, including Medline (1966 to present), Ovid (1966 to present), and the Cochrane database (1993 to present).

Study Selection

Selected articles had the following criteria: (1) all articles analyzed cervical facet joint pain—anatomy, prevalence, etiology, diagnosis, treatment; (2) only full, published articles were studied, not abstracts; and (3) all articles were published in English.

Data Extraction

All articles were critically evaluated and included the following categories: randomized controlled trials, meta-analyses, uncontrolled clinical trials, uncontrolled comparison studies, nonquantitative systematic reviews, and literature-based reviews.

Data Synthesis

We examined 45 references that consisted of 44 journal articles and relevant sections from 1 textbook. Cervical facet joints have been well established in the literature as a common nociceptive pain generator, with an estimated prevalence that ranges from 25% to 66% of chronic axial neck pain. No studies have reported clinical examination findings that are diagnostic for cervical facet mediated pain.

Conclusions

Overall the literature provides very limited information regarding the treatment of this condition, with only radiofrequency neurotomy showing evidence of effectively reducing pain from cervical facet joint dysfunction.     

A Systematic Review of Pharmacologic Treatments of Pain After Spinal Cord Injury

Teasell RW, Mehta S, Aubut JL, Foulon B, Wolfe DL, Hsieh JTC, Townson AF, Short C, the Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of pharmacologic treatments of pain after spinal cord injury.

Objective

To conduct a systematic review of published research on the pharmacologic treatment of pain after spinal cord injury (SCI).

Data Sources

MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles published 1980 to June 2009 addressing the treatment of pain post SCI. Randomized controlled trials (RCTs) were assessed for methodologic quality using the Physiotherapy Evidence Database (PEDro) assessment scale, whereas non-RCTs were assessed by using the Downs and Black (D&B) evaluation tool. A level of evidence was assigned to each intervention by using a modified Sackett scale.

Study Selection

The review included RCTs and non-RCTs, which included prospective controlled trials, cohort, case series, case-control, pre-post studies, and post studies. Case studies were included only when there were no other studies found.

Data Extraction

Data extracted included the PEDro or D&B score, the type of study, a brief summary of intervention outcomes, the type of pain, the type of pain scale, and the study findings.

Data Synthesis

Articles selected for this particular review evaluated different interventions in the pharmacologic management of pain after SCI. Twenty-eight studies met inclusion criteria; there were 21 randomized controlled trials; of these, 19 had level 1 evidence. Treatments were divided into 5 categories: anticonvulsants, antidepressants, analgesics, cannabinoids, and antispasticity medications.

Conclusions

Most studies did not specify participants' types of pain, making it difficult to identify the type of pain being targeted by the treatment. Anticonvulsant and analgesic drugs had the highest levels of evidence and were the drugs most often studied. Gabapentin and pregabalin had strong evidence (5 level 1 RCTs) for effectiveness in treating post-SCI neuropathic pain as did intravenous analgesics (lidocaine, ketamine, and morphine), but the latter only had short-term benefits. Tricyclic antidepressants only showed benefit for neuropathic pain in depressed persons. Intrathecal baclofen reduced musculoskeletal pain associated with spasticity; however, there was conflicting evidence for the reduction in neuropathic pain. Studies assessing the effectiveness of opioids were limited and revealed only small benefits. Cannabinoids showed conflicting evidence in improving spasticity-related pain. Clonidine and morphine when given together had a significant synergistic neuropathic pain-relieving effect.     

Scapular Muscle Activity in Overhead Athletes With Symptoms of Secondary Shoulder Impingement During Closed Chain Exercises

Tucker WS, Armstrong CW, Gribble PA, Timmons MK, Yeasting RA. Scapular muscle activity in overhead athletes with symptoms of secondary shoulder impingement during closed chain exercises.

Objective

To determine the amount of muscle activation in 4 scapular muscles in overhead athletes with and without a history of secondary shoulder impingement, during 3 upper extremity closed chain exercises.

Design

One-between (group), one-within (exercise) repeated measures.

Setting

Controlled laboratory study.

Participants

Overhead athletes (n=15; mean age ± SD, 21.0±2.5y; mean height ± SD, 176.0±7.8cm; mean weight ± SD, 76.1±13.4kg) demonstrating with symptoms of shoulder impingement and overhead athletes (n=15; mean age ± SD, 20.4±3.8y; mean height ± SD, 174.1±9.7cm; mean weight ± SD, 73.3±11.7kg) with no shoulder pathologies.

Interventions

Subjects completed 5 individual trials of a standard push-up, a push-up on an unstable surface, and a revolution on a shoulder rehabilitation device while electromyography (EMG) recorded muscle activity of the serratus anterior, upper trapezius, middle trapezius, and lower trapezius.

Main Outcome Measures

The mean EMG data for the 4 muscles from the standard push-up, push-up on an unstable surface, and shoulder rehabilitation device trials were normalized as a percentage of a maximum voluntary isometric contraction for each muscle.

Results

There was a statistically significant interaction for the middle trapezius (F_2,56=3.856; P=.027). The shoulder impingement push-up on an unstable surface (33.76%±26.45%) had significantly greater activation compared with the shoulder impingement standard push-up (25.88%±13.76%), the shoulder impingement shoulder rehabilitation device (9.40%±5.86%), and the nonpathology push-up on an unstable surface (19.49%±7.73%). The shoulder impingement standard push-up had significantly greater activation compared with the shoulder impingement shoulder rehabilitation device and nonpathology standard push-up (17.99%±7.31%). The nonpathology standard push-up and nonpathology push-up on an unstable surface had significantly greater activation compared with the nonpathology shoulder rehabilitation device (7.95%±4.30%).

Conclusions

These results suggest that the muscle activation of the middle trapezius differs in overhead athletes with a history of secondary shoulder impingement compared with those who lack this history during closed chain exercise, as well as within the 3 closed chain exercises. The levels of muscle activation of the serratus anterior and upper trapezius during these closed chain exercises were similar between the 2 groups. These results support the use of closed chain exercises in the rehabilitation process of overhead athletes with secondary shoulder impingement. However, clinicians should consider the muscle(s) of interest when selecting an exercise.     

Low back pain characteristics from undergraduate student to working nurse in Australia: a cross-sectional survey

Background

Nurses are known to be a high risk group for occupational low back pain (LBP). The periods of greatest risk for developing low back pain in this population are not well defined. Recent literature suggests current preventative strategies are not consistently effective in improving low back injury statistics among health care populations.

Objectives

To identify the relative contributions of age and occupational exposure on the prevalence, duration and severity of low back pain episodes among undergraduate nursing students and recently graduated nurses.

Design

Cross-sectional survey.

Settings

Two university undergraduate nursing schools and one public teaching hospital graduate nurse training program in Western Australia.

Participants

897 undergraduate nursing students (years 1, 2 and 3) and 111 graduate nurses recruited by personal invitation during lectures.

Methods

Using a modified version of the Nordic Low Back Questionnaire, information regarding low back pain episode prevalence, impact, duration, frequency and causes was obtained.

Results

Mean age was consistent across all groups (26.7 ± 9.0 years) and had no significant effect on lifetime low back pain prevalence (p = 0.30). Very high lifetime (79%), 12 month (71%) and 7 day (31%) low back pain prevalence rates were consistent across all 3 year groups of undergraduate nursing students, but were significantly higher after 12 months of full-time employment [lifetime (95.5%), 12 month (90%) and 7 day (39%)]. Around 60% of all respondents with low back pain utilised at least one of (a) treatment, (b) medication, or (c) a reduction in activity. Nursing students and graduate nurses attributed the majority of their low back pain to bending or lifting despite recent efforts to reduce manual workplace demands (lifting) on nurses. Strategies for managing low back pain differed between nursing students and graduate nurses.

Conclusions

These results may suggest a rise in occupational exposure from student to working nurse is the primary cause of the increase in low back pain. Increased exposure may be to physical as well as psychological stressors. Given that prevalence rates are very high prior to commencing work, nursing student populations should be a target group for low back pain preventative strategies.     

Effect of isometric upper-extremity exercises on the activation of core stabilizing muscles

Tarnanen SP, Ylinen JJ, Siekkinen KM, Mälkiä EA, Kautiainen HJ, Häkkinen AH. Effect of isometric upper-extremity exercises on the activation of core stabilizing muscles.

Objective

To evaluate whether isometric exercises for the upper extremities could sufficiently activate core stabilizing muscles to increase muscle strength.

Design

Cross-sectional study.

Setting

Department of physical medicine and rehabilitation at a Finnish hospital.

Participants

Healthy adult women (N=20).

Interventions

Not applicable.

Main Outcome Measures

Peak isometric strength of the back and abdominal muscles was measured and relative loading in 5 test exercises was evaluated by surface electromyography.

Results

The rectus abdominis and obliquus externus abdominis were activated to the greatest degree in a bilateral shoulder extension exercise and the average surface electromyographic activity was 114% and 101% compared with the amplitude elicited during the maximal isometric trunk flexion exercise. Horizontal shoulder extension elicited the greatest activation of the longissimus and multifidus muscles. In this exercise, the activity levels of the left side multifidus and longissimus muscles were 84% and 69%, respectively, compared with the level of activity elicited during trunk extension.

Conclusions

Of all the exercises studied, bilaterally performed isometric shoulder extension and unilaterally performed horizontal shoulder extension elicited the greatest levels of activation of the trunk musculature. Thus, it can be assumed that these exercises elicit sufficient levels of contraction of the trunk muscles for the development of their endurance and strength characteristics in rehabilitation.     

Patient-centredness in physiotherapy from the perspective of the chronic low back pain patient

Objective

To define patient-centredness from the patient's perspective in the context of physiotherapy for chronic low back pain (CLBP).

Design

Qualitative study using semi-structured interviews to explore perceptions of various aspects of physiotherapy management of CLBP.

Setting

Physiotherapy departments in one geographical area of the UK National Health Service.

Participants

Twenty-five individuals who had received physiotherapy for CLBP within the previous 6 months.

Results

Six key themes emerged as the dimensions that the participants perceived to be important for patient-centred physiotherapy: communication; individual care; decision-making; information; the physiotherapist; and organisation of care. Communication was the most important dimension, underpinning the five other dimensions as well as being a distinct dimension of patient-centred physiotherapy.

Conclusions

Physiotherapists should have an understanding of the six dimensions of patient-centred physiotherapy for CLBP. Improving physiotherapists’ communication skills may better facilitate patient-centred physiotherapy, and therefore enhance the experience of physiotherapy for this client group.     

A study to compare the effects of massage and static touch on experimentally induced pain in healthy volunteers

Objective

To investigate the hypoalgesic effects of massage on experimental pain.

Design

A cross-over intervention study separated by a 24-hour washout period. During each experiment, participants completed five cold-induced pain tests, two before the intervention and three during the intervention. During each test, participants immersed their hand in iced water and reported the first sensation of pain and pain intensity after a further 30 seconds.

Setting

Laboratory setting.

Participants

A volunteer sample of 30 university staff and students without known pathology, recruited from noticeboard advertisements.

Interventions

Participants received massage in one experiment and static touch in the other experiment. Interventions were administered to the ipsilateral arm for 4 minutes immediately before the hand was immersed in iced water.

Main outcome measures

Time to pain threshold and the odds of a reduction in pain intensity and an increase in pain relief.

Results

A mixed model analysis was used to establish how measures varied, according to baseline, during static touch and during massage. Massage increased the pain threshold by a factor of 1.08 (95% confidence interval 0.99-1.17) compared with static touch, but this failed to reach statistical significance (P = 0.088). Massage was more likely to result in a report of low pain intensity than static touch (odds ratio 0.26, 95% confidence interval 0.10-0.71, P = 0.007). Massage was more likely to result in a state of high pain relief than static touch (odds ratio 7.7, 95% confidence interval 3.0-19.8, P < 0.001).

Conclusion

Massage produced hypoalgesic effects on experimental pain in healthy volunteers.     

A national framework for supporting improvements in the physiotherapy assessment and management of low back pain: the Scottish experience

Background

Similar to other countries worldwide, Scotland lacked a national view of whether the quality of the physiotherapy management of low back pain was compliant with national guidelines. Anecdotal evidence suggested that standards of care varied considerably despite the wide availability of clinical guidelines to clinicians.

Aim

To develop a framework that supports National Health Service (NHS) Scotland in providing consistently applied high-quality physiotherapy assessment and management of low back pain in line with guideline recommendations.

Design

Prospective, multicentred national study, data collection and improvement phase.

Setting

All NHS boards in Scotland (n = 14) plus two private provider sites.

Participants

One hundred and eighty-six individual NHS sites and two private providers of services to patients with low back pain.

Method

A national dataset was developed from evidence- and consensus-based guideline sources. All sites collected data (two 5-week periods) over 1 year (2008-2009) using a web-based database. This was interspersed by an improvement phase during which required improvements were considered and implemented. Issues were shared through a national network and national meeting.

Results

Data from 2147 patients showed improvements in the documented physiotherapy management of low back pain over the two cycles. All participants developed and implemented remedial action plans based on the results of the first cycle.

Conclusion

It is possible to implement a framework, which is led nationally but driven and owned locally, supporting physiotherapists in an active programme of locally determined improvement. However, although process and outcome are linked, the direct impact of this initiative on patient outcome is not known.     

The effects of stretching in spasticity: a systematic review

Bovend'Eerdt TJ, Newman M, Barker K, Dawes H, Minelli C, Wade DT. The effects of stretching in spasticity: a systematic review.

Objectives

To investigate the general effect of stretching on spasticity and to explore the complexity of stretching in patients with spasticity.

Data Sources

Two researchers independently performed a systematic literature search using the databases: Medline, PEDro, Cochrane library, Web of Science, CINAHL, and Allied and Complementary Medicine.

Study Selection

Studies on adults receiving a stretching technique to reduce spasticity were included.

Data Extraction

Randomized controlled trials (RCTs) were assessed on the PEDro scale for methodologic quality. Thirteen items from the CONSORT list and the Critical Appraisal Skills Program guideline were used to assess the methodologic quality of the other studies.

Data Synthesis

RCTs (n=10) and other clinical trials (n=11) were included. The methodologic quality of the RCTs was low, varying between 4 and 8 on the PEDro scale. All studies show great diversity at the levels of methodology, population, intervention, and outcome measures making a meta-analysis not feasible. Both manual and mechanical stretching methods were studied. Stretching protocols were generally inadequately described and poorly standardized. The outcome measures used often assessed impairments such as available range of motion but were unable to distinguish between neural and nonneural components of spasticity. Associated functional benefits were not usually investigated. Although there is some positive evidence supporting the immediate effects of 1 stretching session, it remains unclear how long these effects abide and its long-term consequences.

Conclusions

There is a wide diversity in studies investigating the effects of stretching on spasticity, and the available evidence on its clinical benefit is overall inconclusive. We recognize the need for consensus on a paradigm for stretching and for good-quality studies. Future research should address this issue and should investigate the clinical importance of the short- and long-term effects.     

Adverse Events Reported in Progressive Resistance Strength Training Trials in Older Adults: 2 Sides of a Coin

Liu C, Latham N. Adverse events reported in progressive resistance strength training trials in older adults: 2 sides of a coin.

Objectives

To summarize adverse events reported in randomized controlled trials that applied progressive resistance strength training in older adults and to examine factors that might be associated with these events.

Design

After systematic searches of databases, 2 reviewers independently screened and extracted adverse event-related information from identified trials.

Setting

Not applicable.

Participants

Older adults 60 years of age and above (N = 6700).

Intervention

Muscle strength training exercise that increases load gradually.

Main Outcome Measures

Adverse events and reasons for dropout. Adverse events include any undesirable outcomes that may be directly related or unrelated to the intervention.

Results

Among 121 trials identified, 53 trials provided no comments about adverse events, 25 trials reported no adverse events occurred, and 43 trials reported some types of adverse events. Most adverse events reported were musculoskeletal problems such as muscle strain or joint pain. Adverse events were reported more often in trials that recruited participants with certain health conditions, functional limitations, or sedentary lifestyle; in trials that applied high intensity; and in trials that were published after the 2001 Consolidated Standards of Reporting Trials statement had been published. Reasons reported for dropout in 58 trials might be related to adverse events. The most frequent reasons for dropout were illness or medical problems.

Conclusions

Adverse events may be underreported because there is no consensus on the definition. Reporting adverse events associated with progressive resistance strength training in older adults is informative for practitioners to translate clinical research to clinical practice by knowing both the benefits and risks. Future trials should clearly define adverse events and report them in the published article.     

The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review

Novak S, Nemeth WC. The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review.

Objectives

To determine the current evidence to support guidelines for frequency and timing of epidural steroid injections (ESIs), to help determine what sort of response should occur to repeat an injection, and to outline specific research needs in these areas.

Data Sources

A PubMed, Medline (EBSCO), and Cochrane library search (January 1971-December 2005), as well as additional references found from the initial search.

Study Selection

There were no studies that specifically addressed the objectives outlined. Eleven randomized controlled trials, 1 prospective controlled trial, and 2 prospective cohort studies were identified that included a protocol involving repeat epidural injections for radicular pain secondary to herniated nucleus pulposus or spinal stenosis. One qualitative survey was also identified. Five review articles were also included that discussed this topic.

Data Extraction

Data were extracted from clinical trials if they included the following: (1) protocols in clinical trials on ESIs that included repeat injections and the response required to trigger these injections, (2) any evidence given for establishing these protocols, and (3) similar studies that included only 1 injection. Specific mention of repeat ESIs and partial response that was mentioned in review articles was also included.

Data Synthesis

There is limited evidence to suggest guidelines for frequency and timing of ESIs or to help to define what constitutes the appropriate partial response to trigger a repeat injection. No study has specifically evaluated these objectives. Methodologically limited research suggests that repeat injections may improve outcomes, but the evidence is insufficient to make any conclusions.

Conclusions

There does not appear to be any evidence to support the current common practice of a series of injections. Recommendations for further research are made, including a possible study design.