ABSTRACT
Purpose: Rehabilitation to address modifiable factors associated with chronic hip-related groin pain (CHRGP) may lead to reduced pain and improved function, yet little is known about its effectiveness. We assessed the preliminary effects of two interventions that target two distinct mechanisms, sensory disturbances and abnormal movement patterns. Sensory disturbances such as peripheral and central sensitization may contribute to pain persistence long after initial injury. Joint mobilization (JtMob) may impart a neurophysiological response within the nervous system that results in pain reduction and improved mobility. Abnormal movement patterns may create altered mechanical stresses on hip joint structures, resulting in pain and activity limitations. Movement pattern training (MoveTrain) may improve movement patterns and thus patient function. Method(s): Patients with CHRGP, 18-40, were enrolled. Assessments included self-report questionnaires, clinical exam, and quantitative sensory testing. Outcomes included the Hip disability and Osteoarthritis Outcome Score (HOOS), a patient-reported outcome;frontal plane kinematics of hip, pelvis, and trunk during single leg squat;and pain pressure threshold (PPT) assessed at the anterior groin of the most bothersome hip and dominant thenar eminence (local and generalized pressure hypersensitivity, respectively). Patients were randomized to JtMob or MoveTrain in a 1:1 ratio stratified by sex and HOOS Symptoms. Treatment for both groups included 10 individualized visits over 12 weeks with a trained physical therapist (PT);assessment of patient goals and education which focused on patient-specific tasks reported by the patient to be symptom-producing;instruction in a home exercise program (HEP);and handouts that provided education, description and benefits of assigned treatment and instructions for HEP. The key element of JtMob was PT-provided manual techniques using specific criteria to determine the joint mobilization techniques and parameters used for each patient. The patient's symptom report to each technique was monitored and if indicated, the technique modified according to our outlined procedures. The HEP included flexibility exercises. The key element of MoveTrain was task-specific instruction to correct abnormal movement patterns displayed during daily and patient-specific tasks. For example, hip adduction was minimized during a step descent. The HEP included repeated practice of modified tasks. Task difficulty was progressed based on each patient's performance. Immediately after treatment completion, patients returned for follow up assessment. To assess treatment sustainability after the active treatment phase, we collected HOOS at 6 and 12 months (extended follow-up), and kinematics and PPT at 12 months. Data from patients who provided any data after baseline were analyzed with a repeated measures analysis of variance (RM-ANOVA) with baseline value as a covariate, patient as a random effect, and an autoregressive covariance structure. After adjusting for baseline, the between-group difference in change from post-treatment to each extended follow-up results from pre-planned statistical contrasts in a RM-ANOVA that includes main effects for treatment group, visit and the group by visit interaction. The within-group treatment effect at each extended follow-up was calculated by subtracting the earlier time point from the later follow-up within each treatment group. Dependent samples t-tests were used to assess the degree of within-group change. Result(s): Demographics and outcome data are provided in Tables 1 and 2, respectively. Thirty-three patients with CHRGP were randomized and 29 (88%) provided post-treatment data. Four patients did not complete treatment or post-treatment testing (3 due to COVID pandemic, 1 lost to follow up);6 patients did not complete 12 month laboratory testing (due to pandemic), but did complete 12 month questionnaires. Previously, we reported that both groups reported clinically important improvements in HOOS subscales and MoveTrain group improved hip and pelvis kinematics immediately after treatment compared to baseline. After adjusting for baseline, there were no between-group differences in change in outcomes between post-treatment and extended follow-up when comparing JtMob and MoveTrain, indicating that treatment effects immediately post-treatment were maintained at 12 months after treatment completion. Conclusion(s): Our preliminary findings suggest that 12 weeks of JtMob or MoveTrain, may result in improvements in patient-reported pain and function and these effects may persist 12 months after treatment completion. A future, larger trial to definitively assess the efficacy of JtMob and MoveTrain and identify factors associated with long-term outcomes will improve our ability to develop treatment strategies for people with CHRGP. [Formula presented] [Formula presented]Copyright © 2023
ABSTRACT
Background: The Coronavirus pandemic has impact on our community far beyond the acute phase, "Long COVID-19" is recognized as a new medical entity and resembles "fibromyalgia" which, likewise, lacks a clear mechanism. "Fibromyalgia" is a prevalent and misunderstood condition with significant burden and morbidity. "Central sensitization" and biopsychosocial theories describe "fibromyalgia" as the misfortunate neurological fate of traumatized and stressed individuals that have behavioral, cognitive, social, and/or genetic predisposition for an "infinite-positive- feedback of pain with no peripheral organic lesion/injury". Diagnostic criteria seem biologically arbitrary, treatments are insufficient, and physicians are frustrated. This work suggests a theoretical model with an organic mechanical mechanism to help explain "fibromyalgia", "long COVID-19" and "functional psycho/ somatic syndromes", based on cross-disciplinary empirical studies. A practical evidence-based treatment arsenal, which is derived from this model, is discussed briefly. Method(s): Systematically searched multiple phrases in MEDLINE, EMBASE, COCHRANE, PEDro, and medRxiv, majority with no time limit. Inclusion/exclusion based on title and , then full-text inspection. Additional literature added on relevant side topics. Review follows PRISMA-ScR guidelines. Result(s): 831 records included. The theory of "facial-armoring" suggests fibromyalgia-like entities may be a disease of connective-tissue driven by myofibroblast-generated- tensegrity- tension. This mechanism may explain fibromyalgia's pain, distribution of pain, decreased pressure-pain threshold, tender spots, fatigue, cardiovascular and metabolic abnormalities, autonomic abnormalities, absence of clear inflammation, silent imaging investigations, and other phenomena (e.g., complete resolution soon after surgery). "Long-COVID- 19" is predicted to involve fascial armoring. Conclusion(s): "Fibromyalgia" is a mild-moderate- chronic- compartment- like- syndrome- of- the- whole- body. Treatment should focus on lifestyle and non-pharmacological modalities. Early detection is key. The body and the mind are one being.
ABSTRACT
Purpose: A clear need exists to rigorously assess treatment strategies for chronic prearthritic hip disorders (PAHD). We assessed the preliminary effects of two physical therapist-led interventions that target two distinct mechanisms, abnormal movement patterns and sensory disturbances. Abnormal movement patterns, such as excessive hip adduction, may create altered mechanical stresses on hip joint structures, resulting in subsequent injury, pain and activity limitations. Movement pattern training (MoveTrain) may improve movement patterns and patient-reported outcomes, however further investigation is needed to be definitive. Sensory disturbances such as peripheral sensitization and central sensitization (aka nociplastic pain) may also contribute to pain persistence long after an initial injury. Joint mobilization (JtMob) is proposed to impart a neurophysiological response within the peripheral and central nervous system that results in pain reduction and improved mobility, yet the investigation of JtMob for the treatment of PAHD is limited. Methods: Patients, 18-40 years, with chronic PAHD were recruited. Baseline assessment included self-report questionnaire completion, clinical examination and quantitative sensory testing. The primary outcome was the Hip disability and Osteoarthritis Outcome Score (HOOS), a hip-specific, patient-reported outcome measure. Secondary outcomes included movement evoked pain assessed with a repetitive step down task and a repetitive deep squat task, and pain pressure threshold assessed at the anterior groin of the most bothersome hip (local pressure hypersensitivity) and the dominant thenar eminence (generalized pressure hypersensitivity). After baseline assessment, patients were randomized into 1 of 2 treatment groups, MoveTrain or JtMob. Randomization was stratified by sex and HOOS Symptoms quartile, as determined from data collected during previous study. Treatment was provided by 4 experienced physical therapists (2 in each treatment arm) who were trained in standardized procedures. Treatment for both groups included 10 supervised sessions over 12 weeks and incorporated assessment of patient goals, patient education and instruction in a home program. Patient education focused on patient-specific tasks, such as work or fitness activities, identified by each patient to be symptom-producing. The goal of MoveTrain was to reduce stresses on the hip joint by optimizing the biomechanics of daily and patient-specific tasks. The key element of MoveTrain was task-specific instruction to correct abnormal movement patterns demonstrated during daily tasks and patient-specific tasks. For example, hip adduction and femoral internal rotation were minimized during step-down tasks. The home program included repeated practice of the modified tasks. Difficulty of the tasks were progressed based on each patient’s performance. The goal of JtMob was to reduce pain and improve pain-free motion of the hip. The key element of JtMob was manual techniques provided by the physical therapist. Specific criteria were used to determine the joint mobilization techniques and parameters used for each patient. The patient’s symptom report to each technique was monitored and if indicated, the technique modified according to our outlined procedures. The home program included flexibility exercises. Immediately after treatment completion, patients returned for follow up assessment. Data collected at baseline and post-treatment were analyzed with analysis of covariance (ANCOVA) using a generalized linear model where change is the dependent variable and baseline is the covariate. The adjusted immediate treatment effect was calculated by subtracting the least squares mean change between baseline and post for MoveTrain minus JtMob from the ANCOVA, and assesses the between-group difference in change after adjusting for baseline. Results: Thirty-three patients with PAHD were randomized. Demographics are provided in Table 1. Four patients did not complete treatment or post-treatment testing (3 due to COVID pandemic, 1 lost t follow up);7 patients did not complete post-treatment laboratory testing (due to COVID), but did complete post-treatment questionnaires. Both groups demonstrated clinically important within-group improvements in the HOOS subscales and movement evoked pain ratings after treatment (Table 2). No changes were noted in pain pressure threshold for either group. After adjusting for baseline, there were no between-group differences in change in outcomes when comparing MoveTrain and JtMob. Conclusions: Our preliminary findings suggest that 12 weeks of physical therapist-led intervention, including either MoveTrain or JtMob, may result in improvements in patient-reported pain and activities limitations. Further investigation is needed to determine the sustained effects of each treatment and to determine if specific patient factors are associated with treatment prognosis. [Formula presented] [Formula presented]