Correspondence of diagnosis to initial treatment for neck pain

Objectives

A patient care model has been proposed linking patient assessment to diagnosis to treatment to outcomes. Validation of this method is required. McKenzie developed the mechanical diagnosis and therapy (MDT) process to diagnose neck pain and direct its treatment. No study known to the authors has determined the link between MDT diagnosis and treatment for neck pain. The objective of the current study was to determine inter-rater agreement on the link between MDT diagnosis and treatment for neck pain.

Setting

Outpatient physical therapy clinics.

Participants

Fifty-four clinician raters, 20 patients with neck pain.

Design

Clinicians, MDT-trained for neck pain, viewed videotaped examinations of adult patients with neck pain and rated diagnosis and initial treatment.

Main outcomes measures

Inter-rater agreement on the MDT diagnosis-treatment link and derangement-directional preference link.

Results

Inter-rater agreement on the diagnosis-treatment link of derangement-directional preference and not derangement-no directional preference of treatment was with moderate clinical and statistical significance (κ = 0.46, 95% confidence interval 0.45-0.47; P < 0.001; 86% agreement). There was moderate agreement on derangement-directional preference for the ‘derangement-extension’ link (κ = 0.40, 95% confidence interval 0.38-0.41; P < 0.001) and ‘derangement-lateral’ link (κ = 0.45, 95% confidence interval 0.44-0.46; P < 0.001), but with poor agreement for the ‘derangement-flexion’ link (κ = 0.04, 95% confidence interval 0.02-0.05; P < 0.001).

Conclusions

Clinicians trained in MDT for neck pain link diagnosis to initial treatment of patients with neck pain with moderate reliability, specifically using extension or laterally directed preference for treatment. The current study contributes towards validation of the diagnosis-treatment link of the MDT patient care model for neck pain.     

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 prospective randomised controlled trial of spinal manipulation and ultrasound in the treatment of chronic low back pain

Objectives

To assess the short- and long-term effectiveness of spinal manipulation therapy, and to identify the effect of manipulation on lumbar muscle endurance in patients with chronic low back pain (LBP).

Design

A randomised controlled trial comparing manipulation and exercise treatment with ultrasound and exercise treatment.

Setting

An outpatient physiotherapy department.

Participants

One hundred and twenty patients with chronic LBP were allocated at random into the manipulation/exercise group or the ultrasound/exercise group.

Interventions

Both groups were given a programme of exercises. In addition, one group received spinal manipulation therapy and the other group received therapeutic ultrasound.

Main outcome measures

Pain intensity, functional disability, lumbar movements and muscle endurance were measured shortly before treatment, at the end of the treatment programme and 6 months after randomisation using surface electromyography.

Results

Following treatment, the manipulation/exercise group showed a statistically significant improvement (P = 0.001) in pain intensity [mean 16.4 mm, 95% confidence interval (CI) 6.1-26.8], functional disability (mean 8%, 95% CI 2-13) and spinal mobility (flexion: mean 9.4 mm, 95% CI 5.5-13.4; extension: mean 3.4 mm, 95% CI 1.0-5.8). There was no significant difference (P = 0.068) between the two groups in the median frequency of surface electromyography (multifidus: mean 6.8 Hz, 95% CI 1.24-14.91; iliocostalis: mean 2.4 Hz, 95% CI 2.5-7.1), although a significant difference (P = 0.013) was found in the median frequency slope of surface electromyography in favour of spinal manipulation for multifidus alone (mean 0.3, 95% CI 0.1-0.5). A significant difference was also found between the two groups in favour of the manipulation/exercise group at 6-month follow-up.

Conclusions

Although improvements were recorded in both groups, patients receiving manipulation/exercise showed a greater improvement compared with those receiving ultrasound/exercise at both the end of the treatment period and at 6-month follow-up.     

Are patients who refer themselves to physiotherapy different from those referred by GPs? Results of a national trial

Objectives

To establish if there are differences in the profile of patients who refer themselves to physiotherapy compared with patients referred by or at the suggestion of their general practitioner (GP) in a range of primary care settings.

Design of study

Quasi-experimental.

Setting

Twenty-nine general practices throughout Scotland.

Participants

Three thousand and ten patients (>16 years of age) and 100 physiotherapists.

Method

Self-referral was introduced in each site. The demographic and clinical data relating to all referrals collated over a full year were compared by referral group (self-referrals, GP-suggested referrals and GP referrals).

Results

There was no relationship between gender or age group and referral group, but other differences in the profile were found. The groups differed in terms of their presenting condition and its severity (P = 0.027). Greater proportions of patients who referred at the suggestion of their GP and patients who self-referred presented with low back and neck conditions (54% versus 43%, P < 0.001). Self-referrers reported having their symptoms for less than 14 days to a greater extent than the other groups (14% versus 9% and 10%, P = 0.011). Non-preferential treatment waiting time to physiotherapy also differed, with 44% of patients who self-referred being seen within 2 weeks of referral compared with 36% of patients who referred at the suggestion of their GP (P < 0.001). Self-referrers were absent from work in lower proportions (20% versus 28% and 28%, P = 0.048) and were absent for half the mean time (2.5 days versus 6 days). They also completed their treatment in greater proportions (76% versus 69% and 72%, P = 0.002). Although all groups experienced the same mean number of physiotherapy contacts (n = 4), patients who referred at the suggestion of their GP had a proportionally lower contact rate with 65% having four or less contacts compared with 55% of patients who self-referred and 51% of patients referred by their GP (P < 0.001). There was no difference in the outcome determined by physiotherapists or patients.

Conclusions

Patients who refer to physiotherapy at the suggestion of their GP and patients who self-refer appear to have a different profile from patients who are referred by their GP.     

Bed exercises following total hip replacement: a randomised controlled trial

Objectives

To determine whether the addition of bed exercises after primary total hip replacement (THR) improves functional outcomes and quality of life, in adult patients, during the first six postoperative weeks.

Design

Single-blind randomised controlled trial.

Setting

Inpatient and outpatient orthopaedic departments at a National Health Service hospital.

Participants

Sixty primary elective THR patients.

Intervention

Patients were assigned at random to receive either a standard gait re-education programme and bed exercises, or the standard gait re-education programme without bed exercises after THR. The bed exercises consisted of active ankle dorsiflexion/plantarflexion, active knee flexion, and static quadriceps and gluteal exercises.

Main outcome measures

Iowa Level of Assistance Scale (ILOA), the Short Form-12 Health Survey (SF-12), duration of hospital admission and postoperative complications were assessed at baseline, and 3 days and 6 weeks postoperatively.

Results

There was no statistically significant difference in ILOA scores between the two groups on the third postoperative day [gait re-education and bed exercise group median 40.5, interquartile range (IQR) 17.5 to 44.5; gait re-education alone group median 38, IQR 22.0 to 44.5; P = 0.70]. Although there was a small difference between the median ILOA scores at Week 6 between the two groups (3.5, IQR 0 to 6.4 and 5.0, IQR 3.5 to 12.5; P = 0.05), this difference was not statistically or clinically significant. There was no difference between the groups in duration of hospital admission, SF-12 scores or postoperative complications at Week 6.

Conclusion

This study suggests that during the first six postoperative weeks, the addition of bed exercises to a standard gait re-education programme following THR does not significantly improve patient function or quality of life.     

The vastus medialis oblique:vastus lateralis electromyographic intensity ratio does not differ by gender in young participants without knee pathology

Objectives

To investigate whether there was a gender difference in the intensity of electromyographic (EMG) activity in vastus medialis oblique (VMO) relative to vastus lateralis (VL).

Design

A cross-sectional observational study measuring EMG activity during stepping down from a step and during straight leg raise exercises.

Setting

University campus laboratory.

Participants

Two groups of healthy participants were tested, one female (mean age 23.5 years, n = 15) and one male (mean age 23.5 years, n = 15).

Main outcome measures

Surface EMG activity (sampling rate 1000 Hz) was recorded from VMO and VL of the dominant limb during five repetitions of a step down activity and five repetitions of a straight leg raise exercise. The average intensity of the rectified and smoothed EMG activity from each activity was normalised to that elicited in a maximal quadriceps setting exercise. The ratio of normalised VMO:VL EMG intensity levels was calculated.

Results

The median difference in the VMO:VL ratio between the groups was 0.11 [approximate 95% confidence interval (CI) −0.62 to 1.00] during step down and −0.07 (approximate 95% CI −0.26 to 0.20) during straight leg raise. Using Mann Whitney U-tests, these differences were not statistically significant (P = 0.648 and 0.619, respectively).

Conclusions

This study found no gender difference in the VMO:VL EMG intensity ratio in asymptomatic participants. This suggests that the difference in incidence of patellofemoral pain syndrome between genders is not influenced by quadriceps intensity ratios, when participants are asymptomatic.     

Validation transculturelle de l’Oswestry disability index en français

Aim

The aim of this study was to interpret and validate a French version of the Oswestry disability index (ODI), using a cross-cultural validation method. The validity and reliability of the questionnaire was assessed in order to ensure the psychometric characteristics.

Method

The cross-cultural validation was carried out according to Beaton's methodology. The study was conducted with 41 patients suffering from low back pain. The correlation between the ODI and the Roland-Morris disability questionnaire (RMDQ), the medical outcome survey short form-36 (MOS SF-36) and a pain visual analogical scale (VAS) was assessed.

Results

The validity of the Oswestry questionnaire was studied using the Cronbach Alpha coefficient calculation: 0.87 (n = 36). The significant correlation between the ODI and RMDQ was 0.8 (P < 0.001, n = 41) and 0.71 (P < 0.001, n = 36) for the pain VAS. The correlation between the ODI and certain subscales (physical functioning 0.7 (P < 0.001, n = 41), physical role 0.49 et bodily pain 0.73 (P < 0.001, n = 41)) of the MOS SF-36 were equally significant. The reproducibility of the ODI was calculated using the Wilcoxon matched pairs test: there was no significant difference for eight out of ten sections or for the final score.

Conclusion

This French translation of the ODI should be considered as valid and reliable. It should be used for any future clinical studies carried out using French language patients. Complimentary studies must be completed in order to assess its sensitivity to change in the event of any modifications in the patients functional capacity.     

Effect of spectators on the performance of a physiotherapy exercise

Objective

To investigate the effect of spectators on the performance of a physiotherapy exercise.

Design

Observational study.

Setting

Research laboratory, Trinity College Dublin.

Participants

Forty adult volunteer subjects (36 females, four males). As there were only four males, these were excluded from the analysis.

Interventions

Subjects were observed and timed while performing single leg stance in two conditions 48 hours apart; once with the investigator present (investigator condition) and once with the investigator and three spectators present (spectator condition).

Main outcome measure

Duration of single leg stance in seconds.

Results

The mean duration of single leg stance, for females, under the investigator condition was 173 seconds [95% confidence interval (CI) 131 to 214], while that of the spectator condition was 168 seconds (95%CI 128 to 208). The mean difference between the two conditions was 5 seconds (95%CI −21 to 31). This was not statistically significant using a paired t-test (P = 0.686).

Conclusions

Female performance of a straightforward exercise such as single leg stance was not affected by the presence of three spectators.     

Validity of the 6-minute walk test for assessing heart rate recovery after an exercise-based cardiac rehabilitation programme

Objectives

To compare heart rate responses in the 6-minute walk test and the treadmill exercise test before and after an exercise-based cardiac rehabilitation programme.

Design

Prospective cohort study.

Setting

Hospital-based cardiac rehabilitation programme in Hong Kong.

Participants

Thirty patients (mean age 62.1 ± 8.5 years, 20 males) with stable ischaemic heart disease.

Interventions

Eight-week exercise-based cardiac rehabilitation programme involving upper and lower limb aerobic and resistance training.

Main outcome measures

Six-minute walk test and treadmill exercise test before and after the exercise programme.

Results

Comparing parameters before and after the exercise programme, the peak heart rate in the 6-minute walk test increased (median of 105 beats per minute (bpm), interquartile range 96.8-116.5 versus 110 bpm, interquartile range 100.5-124.5, P = 0.006), while heart rate recovery improved in each 30-second interval of a 2-minute recovery period. The distance covered during the 6-minute walk increased from a mean of 486.3 m (±standard deviation 113.9 m) to 552.5 m (±standard deviation 111.9 m) (P < 0.001). Rating of perceived exertion during the 6-minute walk test decreased from a median of 14 (interquartile range 13-15) to 13 (interquartile range 13-13) (P = 0.001). Heart rate recovery following treadmill exercise testing improved during the 30-second periods from 60 to 90 seconds and from 90 to 120 seconds of recovery. Metabolic equivalents increased during treadmill testing from a median of 7.0 (interquartile range 5.8-8.6) to 8.6 (interquartile range 7-8.6) (P < 0.001).

Conclusions

Both treadmill exercise and 6-minute walk tests demonstrated improvements in heart rate recovery and increases in achieved workload following exercise training. This suggests that the 6-minute walk test is a valid tool to assess heart rate recovery following such a programme.     

Pain and heart failure: Unrecognized and untreated

Background

Although evidence exists to support the presence of pain in advanced stages of heart failure (HF), the pain experience in the early phases of this progressive disease is poorly documented, and therefore, poorly understood. The current study was conducted to: 1) examine the prevalence of pain in cohort of patients with chronic HF (New York Heart Association class I-IV); and 2) determine the relationship between pain and QOL.

Methods and results

Data were obtained from 300 patients (mean age 54.2 ± 12.7 years; 72% male; 65% Caucasians; time since HF diagnosis 4.6 ± 4.8 years). Two-thirds of the patients (67%) reported some degree of pain; the prevalence of pain increased as functional class worsened (p < .009). Differences in QOL outcomes for patients experiencing pain vs. no pain were statistically significant for physical and overall QOL. Pain accounted for 20% of the variance in QOL (p < .001) even after adjusting for age, gender, and functional class.

Conclusions

Our findings suggest pain is present in a majority of patients with HF. Given the potential deleterious effects of untreated pain on QOL in patients with HF, it is important that healthcare providers assess patients for this often-unrecognized symptom.     

Do parents of children with cerebral palsy express different concerns in relation to their child's type of cerebral palsy, age and level of disability?

Objectives

To investigate the range of parents’ concerns for their children with cerebral palsy, and whether concerns varied according to type of cerebral palsy, age and level of disability.

Design

A retrospective study was undertaken analysing information from past medical records of children with cerebral palsy. Information was collected from 170 visits, including child's age, type of cerebral palsy, level of disability and the parents’ current concerns. Data were analysed using conceptual analysis to search for common themes, and quantitatively using cross-tabulation and Chi-squared tests to determine if differences existed between the concerns for different ages, diagnoses or disability levels.

Participants

Parents of children with cerebral palsy from 121 families who attended for therapy between January 2003 and December 2004.

Setting

Bobath Centre, London.

Results

Twelve specific categories of concerns were identified: activities of daily living; hand function; eating/drinking; floor mobility; sitting; standing/walking; transfers; stiffness; communication; therapy; visual perception; and behaviour. Significant differences were found to exist between the concerns of parents of children of different ages, diagnoses and levels of disability. For example, parents of children with spastic diplegia expressed more concerns about standing/walking [χ² = 41.45, degrees of freedom (df) = 3, P < 0.001], whereas concerns about sitting (χ² = 17.65, df = 3, P = 0.001), communication (χ² = 32.28, df = 3, P = 0.0001), floor mobility (χ² = 16.89, df = 3, P < 0.001) and eating/drinking (χ² = 10.06, df = 3, P = 0.018) were more common among parents of children with spastic quadriplegia and athetosis.

Conclusion

Within this sample, parents demonstrated that they have specific concerns, with clear themes emerging about parents’ concerns related to their child's diagnosis, age and level of disability.     

Primary contact physiotherapy in emergency departments can reduce length of stay for patients with peripheral musculoskeletal injuries compared with secondary contact physiotherapy: a prospective non-randomised controlled trial

Objective

To evaluate if direct physiotherapy assessment and management of patients presenting to emergency departments with musculoskeletal injuries (primary contact physiotherapy) results in reduced length of stay without any increase in adverse effects compared with secondary contact physiotherapy, where patients are seen by a physiotherapist after initial assessment by a doctor.

Design

Prospective non-randomised controlled trial.

Setting

Three metropolitan emergency departments.

Participants

Adults (n = 315) presenting to emergency departments with peripheral musculoskeletal injuries were allocated to primary or secondary contact physiotherapy; 306 participants completed the study. Patients with serious pathology, open fractures and spinal pain were excluded.

Intervention

A single episode of physiotherapy.

Main outcome measures

Primary outcome measures were patient length of stay, waiting time and treatment time. Secondary outcome measures were re-presentations to the emergency department, imaging referrals, patient satisfaction and emergency department staff acceptance.

Results

Primary contact physiotherapy resulted in a reduction in length of stay of 59.5 minutes [95% confidence interval (CI) 38.4 to 80.6] compared with secondary contact physiotherapy, with a reduced waiting time of 25.0 minutes (95%CI 12.1 to 38.0) and a reduced treatment time of 34.9 minutes (95%CI 16.2 to 53.6). There were no differences between the groups in imaging referrals or re-presentations. Patients strongly agreed (≥82%) that they were satisfied with their management, and 96% of emergency department staff agreed that primary contact physiotherapists had appropriate skills and knowledge to provide emergency care.

Conclusion

Experienced musculoskeletal physiotherapists working in emergency departments can be the first point of contact for patients with simple, semi-urgent and non-urgent peripheral musculoskeletal injuries, resulting in decreased waiting times and length of stay for patients without any adverse effects.     

Cold pack/skin interface temperature during ice treatment with various levels of compression

Objective

To compare cold pack/skin interface temperature during a 20-minute ice application with various levels of compression.

Design

Repeated measures.

Setting

Laboratory setting in an educational institution.

Participants

Forty healthy females aged between 20 and 23 years.

Interventions

An ice pack was applied to the right thigh with compression using an elastic bandage. Five different levels of compression were used: 0 (no compression), 14, 24, 34 and 44 mmHg.

Main outcome measure

Cold pack/skin interface temperature was monitored every minute during the 20-minute ice application.

Results

Ice application with compression led to significantly lower cold pack/skin interface temperatures than ice application without compression during the 20-minute application (with compression: mean 6.1 °C, 95% confidence interval 5.9-6.3 °C; without compression: mean 8.1 °C, 95% confidence interval 7.7-8.5 °C) (P < 0.05). The level of compression did not significantly affect the magnitude of the cooling temperature (14 mmHg: mean 6.4 °C, 95% confidence interval 6.0-6.8 °C; 24 mmHg and 34 mmHg: mean 6.1 °C, 95% confidence interval 5.7-6.5 °C; 44 mmHg: mean 5.9 °C, 95% confidence interval 5.5-6.3 °C) (P > 0.05). The minimum temperature reached with ice application with compression of 0, 14, 24, 34 and 44 mmHg was achieved after 9, 7, 6, 6 and 5 minutes of application, respectively (0 mmHg: mean 5.0 °C, 95% confidence interval 4.9-5.1 °C; 14 mmHg: mean 4.2 °C, 95% confidence interval 4.1-4.3 °C; 24 mmHg: mean 4.0 °C, 95% confidence interval 3.9-4.1 °C; 34 mmHg: mean 3.9 °C, 95% confidence interval 3.7-4.0 °C; 44 mmHg: mean 3.7 °C, 95% confidence interval 3.6-3.9 °C) (P < 0.05).

Conclusion

Ice application with adjunctive compression leads to a greater magnitude and rate of cooling compared with ice application without compression. The higher the level of compression, the shorter the time to the minimum recorded temperature. Further research is required to demonstrate the effect of various levels of compression applied over an ice pack in a clinical population.     

A study to determine the reliability of an ankle dorsiflexion weight-bearing device

Objectives

To investigate the inter-observer and intra-observer reliability of measurement of ankle movement during a weight-bearing dorsiflexion lunge in healthy and injured groups.

Setting

Defence Medical Rehabilitation Centre, UK.

Participants

Seventeen healthy subjects, 11 subjects with ankle injuries and three trained observers.

Design

Each observer assessed subjects on two separate test days, 7 days apart. Each measurement was repeated six times and the results were averaged. Limits of agreement and intra-class correlation coefficients were calculated to give a measure of reliability.

Main outcome measures

A measurement tool designed at the Defence Medical Rehabilitation Centre, UK.

Results

Intra-observer 95% limits of agreement ranged from ±3.30 to ±3.66 cm for the healthy group and from ±2.35 to ±3.85 cm for patients. The inter-observer limits of agreement ranged from ±1.57 to ±2.65 cm for healthy subjects and from ±0.87 to ±3.46 cm for patients.

Conclusions

Results indicate acceptable inter-observer and intra-observer reliability for use of this rehabilitation assessment tool to measure the weight-bearing dorsiflexion lunge range of ankle motion when results are averaged over six repetitions.     

A multiconvergent approach to the rehabilitation of patients with chronic fatigue syndrome: a comparative study

Objectives

This study investigated the efficacy of a rehabilitation technique for the treatment of chronic fatigue syndrome that was developed by a physiotherapist. Data collected retrospectively from a pilot study indicated that patients benefited from this multiconvergent approach, so further assessments were warranted.

Design

Treatment efficacy was assessed by comparing the primary and secondary outcome measures of patients attending multiconvergent therapy (MCT) with those of patients attending relaxation therapy and a group of non-intervention controls.

Setting

The active treatment took place at a clinic within the physiotherapy outpatient unit. Relaxation therapy and all assessments were conducted at the psychology unit.

Participants

Thirty-five participants, fitting the Centers for Disease Control and Prevention criteria for chronic fatigue syndrome, were recruited from two outpatient clinics and an existing patient panel.

Intervention

Patients were assigned to either MCT (n = 12) or relaxation therapy (n = 14). Nine participants who received general medical care were used as a comparison group.

Main outcome measures

The Karnofsky performance scale was used as the primary outcome measure of function. Secondary outcome measures assessing overall improvement in patient condition, fatigue and disability levels were also administered.

Results

A significant percentage of the patients attending the MCT sessions showed improvement in the primary outcome score used to measure the success of the treatment (MCT = 83%, relaxation = 21%, controls = 0; P < 0.001). A significant percentage of this group also reported improvement in their overall condition (MCT = 92%, relaxation = 64%, controls = 22%; P < 0.001), lower fatigue levels (MCT = 83%, relaxation = 57%, controls = 11%; P < 0.001) and lower levels of disability (MCT = 75%, relaxation = 43%, controls = 11%; P = 0.032) immediately post-therapy. In addition, these improvements were maintained at 6-month follow-up.

Conclusions

Outcomes from this small preliminary study were encouraging. The multiconvergent approach produced significant improvements for standardised primary and secondary outcome measures. Further research is required to examine the efficacy of this approach over time, and its effectiveness on a larger scale within the primary healthcare setting using additional therapists trained in the technique.     

Apport de l’arthrodistension dans la prise en charge de la capsulite rétractile primitive de l’épaule : étude comparative versus rééducation

Objectives

To describe the epidemiological and clinical features of patients with primitive adhesive capsulitis of the shoulder treated by capsular distension and then rehabilitation; to evaluate the short-, mid- and long-term efficiency of this therapeutic protocol and compare it with rehabilitation alone.

Materials and methods

This was a two-year prospective study. Sixty patients were included and divided into populations P1 (capsular distension and rehabilitation) and P2 (rehabilitation only). Assessment of the treatments’ efficacy was based on the following parameters: pain on a visual analogue scale (VAS), joint motion in several axes, a simplified Constant score (functional ability) and the SF-36 quality of life score.

Results

Thirty patients (mean age: 56) underwent capsular distension. The Constant score was judged to be poor in over half of the patients. All the quality of life parameters were modified. When compared with P2, the P1 group showed a statistically significant improvement in terms of the pain score (p = 0.005), anterior elevation (p = 0.001), lateral elevation (p = 0.005), external rotation (p = 0.006) and the Constant score (p < 0.001) one week after capsular distension. One year after capsular distension, this gain persisted in a statistically significant manner for all functional parameters and all SF-36 dimensions (p < 0.001 for PF, RP, BP, SF and RE; p = 0.01 for GH and VT and p = 0.002 for MH).

Conclusion

Our results show that capsular distension and subsequent intensive rehabilitation have a beneficial effect. This combination enables rapid, significant improvement from the first week onwards. The improvement phase lasts for one month and may hold steady for up to 12 months.     

Comparison of the analgesic efficacy of interferential therapy and transcutaneous electrical nerve stimulation

Objective

To compare the analgesic efficacy of interferential therapy (IFT) and transcutaneous electrical nerve stimulation (TENS) using an experimental cold pain model.

Design

Randomised controlled trial with repeated measures design.

Setting

University research laboratory.

Participants

Twenty healthy subjects.

Interventions

IFT and TENS applied to each subject on different days.

Main outcome measures

Cold pain threshold (time), intensity and unpleasantness (visual analogue scales).

Results

The mean cold pain threshold with a TENS intervention was higher than that with IFT. A training effect was evident as subjects’ responses become more consistent with repeated exposure to stimulation and the testing procedure. Using data from the second testing sessions, the differences in pain threshold between IFT and TENS for the two during-intervention (T3 and T4) measures were statistically significant (T3 difference in the means 5.9 seconds, 99% confidence interval 3.1 to 8.7 seconds; T4 difference in the means 6.6 seconds, 99% confidence interval 3.8 to 9.4 seconds). No significant differences were identified in pain intensity and unpleasantness ratings.

Conclusions

TENS is more effective than IFT at increasing cold pain thresholds in healthy subjects, and this effect increases with repeated exposures. Future trials should include a familiarisation session prior to testing to increase the consistency of subjects’ responses. The clinical implications of these effects need investigation.     

Incidence and effect of leg length discrepancy following total hip arthroplasty

Objectives

The clinical importance of a leg length discrepancy (LLD) following total hip arthroplasty (THA) remains controversial. This study was undertaken to determine the effects of LLD on clinical outcomes at up to 3 years follow-up.

Design and setting

Prospective, multicentre study.

Participants

Nine hundred and eighty-seven cases of primary THA, categorised into two main groups: the NoLLD group (LLD of less than 10 mm) and the LLD group (LLD of 10 mm or more).

Main outcome measures

The primary outcome measure was the change in Oxford Hip Score (ΔOHS) at up to 3 years follow-up. Secondary outcome measures were length of operating time and hospital stay, and revision and dislocation rates. Potential predisposing factors for LLD, including body mass index, age and type of anaesthesia employed, were examined.

Results

At 3 years, the LLD group had a significantly worse ΔOHS [22.0; 95% confidence interval (CI) 20.5 to 23.5] compared with the NoLLD group (23.8; 95% CI 23.1 to 24.5) (P = 0.034). There were no significant differences in revision (P = 0.389) or dislocation (P = 0.220) rates between the two groups. Use of an epidural was associated with a decreased incidence of developing an LLD of 10 mm (P = 0.004).

Conclusion

A postoperative LLD of 10 mm or more leads to poorer functional outcomes. Further studies are needed to assess the impact of an LLD on clinical outcomes in the longer term.     

Self-referral, access and physiotherapy: patients’ knowledge and attitudes—results of a national trial

Objectives

To identify service users’ views and attitudes to access, physiotherapy and patient-autonomous health-seeking behaviours.

Study design

Mixed qualitative and quantitative questionnaire.

Setting

Twenty-six locations representing a range of socio-economic and geographical settings throughout Scotland.

Participants

Three thousand and ten patients over 16 years of age.

Methods

Postal questionnaires containing a mix of open and closed questions, attitude statements and free text for comments were sent to all consenting patients 4 weeks after discharge from physiotherapy. Responses were analysed by referral group: self-referred patients; patients referred by their general practitioner (GP); and patients referred at the suggestion of their GP.

Results

A response rate of 72% (2177/3010) was achieved. Males, females and all age groups were represented. Strong support for the effectiveness of physiotherapy was reported by all groups (>90%). Despite more than 80% of respondents claiming that they were able to confidently predict when they needed physiotherapy, less than 23% reported being knowledgeable or very knowledgeable about physiotherapy, with no significant association between level of knowledge and referral group (P = 0.129). Self-referred patients were more satisfied (P < 0.001), more supportive of being able to self-refer (83% vs 69% of GP-referred patients and 71% of patients referred at the suggestion of their GP), and more supportive of physiotherapists making decisions about their fitness for work or activities (59% vs 53% of GP-referred patients and 53% of patients referred at the suggestion of their GP).

Conclusions

Physiotherapy was regarded positively by all referral groups, particularly by self-referred patients, despite there being a distinct lack of knowledge about the profession. There is a clear need to raise awareness and knowledge of physiotherapy if autonomous health-seeking behaviours are to be encouraged and self-referral schemes progressed appropriately.     

A Preliminary Report on the Efficacy of a Dynamic Jaw Opening Device (Dynasplint Trismus System) as Part of the Multimodal Treatment of Trismus in Patients With Head and Neck Cancer

Stubblefield MD, Manfield L, Riedel ER. A preliminary report on the efficacy of a dynamic jaw opening device (Dynasplint Trismus System) as part of the multimodal treatment of trismus in patients with head and neck cancer.

Objective

To examine the effectiveness of a dynamic jaw opening device as part of a multimodal treatment strategy for trismus in patients with head and neck cancer.

Design

Retrospective cohort study.

Setting

Tertiary care cancer center.

Participants

Patients with head and neck cancer and trismus (N=20).

Intervention

All patients underwent assessment by a board-certified physiatrist and were referred to physical therapy for delivery of the DTS and instructed to progress use of the DTS to 30 minutes 3 times a day. Additional modalities for the treatment of trismus including pain medications and botulinum toxin injections were prescribed as clinically indicated.

Main Outcome Measures

Change in maximal interincisal distance (MID) as documented in the medical record.

Results

The use of the DTS as part of multimodal therapy including physical therapy, pain medications, and botulinum toxin injections as deemed clinically appropriate resulted in an overall improvement of the MID from 16.5mm to 23.5mm (P<.001). Patients who could comply with the treatment recommendations for DTS treatment did better than those who could not, with an improvement of the MID from 16mm to 27mm (P<.001) versus 17mm to 22mm (P=.88).

Conclusions

The DTS is a safe and effective component of a multimodal strategy for improving trismus associated with head and neck cancer and its treatment. Further investigation is needed to determine the relative efficacy of the treatment modalities available for trismus including physical therapy and other jaw stretching devices.