Physical therapies for Achilles tendinopathy: systematic review and meta-analysis.

BACKGROUND: Achilles tendinopathy (AT) is a common condition, causing considerable morbidity in athletes and non-athletes alike. Conservative or physical therapies are accepted as first-line management of AT; however, despite a growing volume of research, there remains a lack of high quality studies evaluating their efficacy. Previous systematic reviews provide preliminary evidence for non-surgical interventions for AT, but lack key quality components as outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement. The aim of this study was to conduct a systematic review and meta-analysis (where possible) of the evidence for physical therapies for AT management. METHODS: A comprehensive strategy was used to search 11 electronic databases from inception to September 2011. Search terms included Achilles, tendinopathy, pain, physical therapies, electrotherapy and exercise (English language full-text publications, human studies). Reference lists of eligible papers were hand-searched. Randomised controlled trials (RCTs) were included if they evaluated at least one non-pharmacological, non-surgical intervention for AT using at least one outcome of pain and/or function. Two independent reviewers screened 2852 search results, identifying 23 suitable studies, and assessed methodological quality and risk of bias using a modified PEDro scale. Effect size calculation and meta-analyses were based on fixed and random effects models respectively. RESULTS: Methodological quality ranged from 2 to 12 (/14). Four studies were excluded due to high risk of bias, leaving 19 studies, the majority of which evaluated midportion AT. Effect sizes from individual RCTs support the use of eccentric exercise. Meta-analyses identified significant effects favouring the addition of laser therapy to eccentric exercise at 12 weeks (pain VAS: standardised mean difference -0.59, 95% confidence interval -1.11 to -0.07), as well as no differences in effect between eccentric exercise and shock wave therapy at 16 weeks (VISA-A:-0.55,-2.21 to 1.11). Pooled data did not support the addition of night splints to eccentric exercise at 12 weeks (VISA-A:-0.35,-1.44 to 0.74). Limited evidence from an individual RCT suggests microcurrent therapy to be an effective intervention. CONCLUSIONS: Practitioners can consider eccentric exercise as an initial intervention for AT, with the addition of laser therapy as appropriate. Shock wave therapy may represent an effective alternative. High-quality RCTs following CONSORT guidelines are required to further evaluate the efficacy of physical therapies and determine optimal clinical pathways for AT.

Is physiotherapy effective for children with complex regional pain syndrome type 1?

OBJECTIVES: This study synthesized current research evidence on the effectiveness of physiotherapy for the management of children diagnosed with complex regional pain syndrome type 1 (CRPS-1), to provide up-to-date physiotherapy treatment recommendations, and to identify areas that require further investigation. METHODS: Nine electronic databases were searched for quantitative studies that evaluated the effect of physiotherapy on children with CRPS-1. The methodological quality of the studies was evaluated using the Critical Review Form. Data were extracted regarding the study design, participant characteristics, types of outcome measures used, and physiotherapy technique used and its effectiveness. RESULTS: The search strategy identified 303 potential studies, of which 12 met the inclusion criteria (1 randomized controlled trial, 1 comparative study, 10 case series). The methodological quality of all studies was rated as poor to fair. The "stand-alone" value of physiotherapy could not be determined as physiotherapy was prescribed in conjunction with psychological and medical interventions. There is low volume and poor-to-fair quality evidence which suggests that physiotherapy prescribed with other interventions may lead to short-term improvement in the signs and symptoms of CRPS-1 or functional ability in children with CRPS-1, and the relapse rate may be moderately high. DISCUSSION: High-quality studies are required in this area. These studies should evaluate a package of care (which includes physiotherapy); they should investigate the effects of physiotherapy treatments that have proven effectiveness in adults with CRPS-1; they should use psychometrically sound measures to evaluate outcome; and the nature of physiotherapy should be detailed in future publications to enable replication in the clinical setting.

Clinimetric evaluation of questionnaires used to assess activity after traumatic brachial plexus injury in adults: a systematic review.

OBJECTIVES: To identify upper limb questionnaires used in the brachial plexus injury (BPI) literature to assess activities and to evaluate their clinimetric properties. DATA SOURCES; STUDY SELECTION; DATA EXTRACTION: This systematic review was undertaken in 2 stages. In stage 1, 10 electronic databases and 1 Internet journal were searched for quantitative studies (ie, randomized controlled trials, comparative studies, case series, and case studies) that evaluated outcome after BPI, irrespective of language or date of publication, from date of database inception to September 2010. All outcome instruments used were extracted and classified using the International Classification of Functioning, Disability and Health framework. Questionnaires were identified that apportioned >50% of the total score to the assessment of upper limb activity. In stage 2, 4 electronic databases were searched for papers that evaluated the clinimetric properties of all identified activity questionnaires with respect to peripheral nerve injuries of the upper limb. Two independent reviewers assessed the clinimetric properties of identified questionnaires according to standardized criteria. DATA SYNTHESIS: Stage 1 identified 4324 papers, of which 265 met the inclusion criteria. One hundred and three outcome measures were identified, the majority of which assess body function or body structure. Twenty-nine questionnaires assessed upper limb activity. Two questionnaires, the ABILHAND and Disability of the Arm, Shoulder and Hand (DASH), attributed >50% of the overall score to activity of the upper limb. The DASH had some published evidence of clinimetric properties in individuals with peripheral nerve injuries. Neither had been clinimetrically evaluated for BPI, nor met all quality criteria. CONCLUSIONS: Day-to-day activities of the upper limb are infrequently evaluated after BPI. While attempts have been made to measure activity, there is a paucity of clinimetric evidence on activity questionnaires for individuals with BPI. We recommend that a core set of items be developed which evaluate activity, as well a body structure, body function, and participation.

Does evidence support physiotherapy management of adult Complex Regional Pain Syndrome Type One? A systematic review.

OBJECTIVE: To source and critically evaluate the evidence on the effectiveness of Physiotherapy to manage adult CRPS-1. DESIGN: Systematic literature review. METHODS: Electronic databases, conference proceedings, clinical guidelines and text books were searched for quantitative studies on CRPS-1 in adults where Physiotherapy was a sole or significant component of the intervention. Data were extracted according to predefined criteria by two independent reviewers. Methodological quality was assessed using the Critical Review Form. RESULTS: The search strategy identified 1320 potential articles. Of these, 14 articles, representing 11 studies, met inclusion criteria. There were five randomised controlled trials, one comparative study and five case series. Methodological quality was dependent on study type, with randomised controlled trials being higher in quality. Physiotherapy treatments varied between studies and were often provided in combination with medical management. This did not allow for the 'stand-alone' value of Physiotherapy to be determined. Heterogeneity across the studies, with respect to participants, interventions evaluated and outcome measures used, prevented meta-analysis. Narrative synthesis of the results, based on effect size, found there was good to very good quality level II evidence that graded motor imagery is effective in reducing pain in adults with CRPS-1, irrespective of the outcome measure used. No evidence was found to support treatments frequently recommended in clinical guidelines, such as stress loading. CONCLUSIONS: Graded motor imagery should be used to reduce pain in adult CRPS-1 patients. Further, the results of this review should be used to update CRPS-1 clinical guidelines.

Activity limitations and compensatory mechanism use following limited wrist fusion.

OBJECTIVE: To document the activity limitations experienced by patients who had undergone a 4-corner wrist fusion, and the compensatory mechanisms they use in daily life. METHODS: Patients completed 2 copies of the Adelaide Questionnaire, a measure with a standardized section and an individualized section. The test-retest reliability of the questionnaire was evaluated. RESULTS: Twenty-five patients were recruited to the study, and 21 completed both questionnaires. Excellent test-retest reliability was gained for both the standardized and individualized sections of the Adelaide Questionnaire. CONCLUSION: Patients with 4-corner wrist fusions report activity limitations following surgery, particularly with daily tasks that involve hand/forearm rotation and grip strength. Various compensatory mechanisms are used by the majority of patients. The impact of these mechanisms on activity limitations varies between patients, but often decreases impact of the activity limitations on everyday life.

Prevalence, risk factors, and natural history of positional plagiocephaly: a systematic review.

This review synthesized current research evidence on the prevalence, risk factors, and natural history of positional plagiocephaly. Research published between 1985 and 2007 was sourced from 13 databases. Evidence was categorized according to a hierarchy and rated on a standardized critical appraisal tool. These evaluations were incorporated into a narrative synthesis of the main results. Eighteen studies met inclusion criteria (prevalence: n=3, risk factors: n=17, natural history: n=1). The methodological quality of studies was fair. The point prevalence of positional plagiocephaly appears to be age-dependent and may be as high as 22.1% at 7 weeks of age. Point prevalence tends to decrease with age and may be as low as 3.3% at 2 years. When compared with historical data, the prevalence of positional plagiocephaly appears to have remained stable over the last four decades. Assisted delivery, first born child, male sex, cumulative exposure to the supine position, and neck problems may increase the risk of positional plagiocephaly. To reduce the risk of positional placiocephaly, infants should experience a variety of positions, other than supine, while they are awake and supervised, and early treatment may be warranted for infants with neck problems and/or strong head preference.

Patellar taping and bracing for the treatment of chronic knee pain: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the evidence for patellar taping and bracing in the management of chronic knee pain. METHODS: Randomized or quasi-randomized studies assessing patellar taping or bracing effects on chronic knee pain were sourced from 7 electronic databases (to November 2006), and assessed using the Physiotherapy Evidence Database scale. Weighted mean differences were determined, and pooled estimates of taping and bracing effects were obtained using random-effects models. RESULTS: Of 16 eligible trials, 13 investigated patellar taping or bracing effects in individuals with anterior knee pain, and 3 investigated taping effects in individuals with knee osteoarthritis (OA). The methodologic quality of the taping studies was significantly higher than the bracing studies (mean+/-SD 4.8+/-2.1 versus 2.8+/-0.8; P<0.05). On a 100-mm scale, tape applied to exert a medially-directed force on the patella decreased chronic knee pain compared with no tape by 16.1 mm (95% confidence interval [95% CI] -22.2, -10.0; P<0.001) and sham tape by 10.9 mm (95% CI -18.4, -3.4; P<0.001). For anterior knee pain and OA, medially-directed tape decreased pain compared with no tape by 14.7 mm (95% CI -22.8, -6.9; P<0.001) and 20.1 mm (95% CI -26.0, -14.3; P<0.001), respectively. There was disputable evidence from low-quality studies for patellar bracing benefits. CONCLUSION: There was evidence that tape applied to exert a medially-directed force on the patella produces a clinically meaningful change in chronic knee pain. There was limited evidence to demonstrate the efficacy of patellar bracing. These outcomes were limited by the presence of high heterogeneity between study outcomes and significant publication bias.

The reliability of knee joint position testing using electrogoniometry.

BACKGROUND: The current investigation examined the inter- and intra-tester reliability of knee joint angle measurements using a flexible Penny and Giles Biometric electrogoniometer. The clinical utility of electrogoniometry was also addressed. METHODS: The first study examined the inter- and intra-tester reliability of measurements of knee joint angles in supine, sitting and standing in 35 healthy adults. The second study evaluated inter-tester and intra-tester reliability of knee joint angle measurements in standing and after walking 10 metres in 20 healthy adults, using an enhanced measurement protocol with a more detailed electrogoniometer attachment procedure. Both inter-tester reliability studies involved two testers. RESULTS: In the first study, inter-tester reliability (ICC[2,10]) ranged from 0.58-0.71 in supine, 0.68-0.79 in sitting and 0.57-0.80 in standing. The standard error of measurement between testers was less than 3.55 degrees and the limits of agreement ranged from -12.51 degrees to 12.21 degrees . Reliability coefficients for intra-tester reliability (ICC[3,10]) ranged from 0.75-0.76 in supine, 0.86-0.87 in sitting and 0.87-0.88 in standing. The standard error of measurement for repeated measures by the same tester was less than 1.7 degrees and the limits of agreement ranged from -8.13 degrees to 7.90 degrees . The second study showed that using a more detailed electrogoniometer attachment protocol reduced the error of measurement between testers to 0.5 degrees . CONCLUSION: Using a standardised protocol, reliable measures of knee joint angles can be gained in standing, supine and sitting by using a flexible goniometer.

Comparison of visual and objective quantification of elbow and shoulder movement in children with obstetric brachial plexus palsy.

BACKGROUND: The Active Movement Scale is a frequently used outcome measure for children with obstetric brachial plexus palsy (OBPP). Clinicians observe upper limb movements while the child is playing and quantify them on an 8 point scale. This scale has acceptable reliability however it is not known whether it accurately depicts the movements observed. In this study, therapist-rated Active Movement Scale grades were compared with objectively-quantified range of elbow flexion and extension and shoulder abduction and flexion in children with OBPP. These movements were chosen as they primarily assess the C5, C6 and C7 nerve roots, the most frequently involved in OBPP. Objective quantification of elbow and shoulder movements was undertaken by two-dimensional motion analysis, using the v-scope. METHODS: Young children diagnosed with OBPP were recruited from the Royal Children's Hospital (Melbourne, Australia) Brachial Plexus registry. They participated in one measurement session where an experienced paediatric physiotherapist facilitated maximal elbow flexion and extension, shoulder abduction and extension through play, and quantified them on the Active Movement Scale. Two-dimensional motion analysis captured the same movements in degrees, which were then converted into Active Movement Score grades using normative reference data. The agreement between the objectively-quantified and therapist-rated grades was determined using percentage agreement and Kappa statistics. RESULTS: Thirty children with OBPP participated in the study. All were able to perform elbow and shoulder movements against gravity. Active Movement Score grades ranged from 5 to 7. Two-dimensional motion analysis revealed that full range of movement at the elbow and shoulder was rarely achieved. There was moderate percentage agreement between the objectively-quantified and therapist-rated methods of movement assessment however the therapist frequently over-estimated the range of movement, particularly at the elbow. When adjusted for chance, agreement was equal to chance. CONCLUSION: Visual estimates of elbow and shoulder movement in children with OBPP may not provide true estimates of motion. Future work is required to develop accurate, clinically-acceptable methods of quantifying upper limb active movements. Since few children attained full range of motion, elbow and shoulder movement should be monitored and maintained over time to reduce disability later in life.

Reliability of the V-scope system in the measurement of arm movement in children with obstetric brachial plexus palsy.

This study reports on a novel methodology using the V-scope to quantify elbow and shoulder movement in young children with obstetric brachial plexus palsy (OBPP), and the intra- and interreliability of this method. The V-scope, a portable, inexpensive movement analysis system, was configured in an L-shape, with two transmitting towers placed on the floor and one 1.35m off the ground. These towers received ultrasonic pulses from buttons that were placed over standardized landmarks of the child's trunk, chest, and upper limb. Two physiotherapists (a paediatric and a generalist) facilitated the maximum range of active elbow flexion/extension and shoulder abduction/flexion in 30 children with OBPP (18 females, 12 males; age range 6mo-4y 7mo; mean age 2y 6mo [SD 1y 2mo]). Assessments were conducted on two occasions, one week apart. The V-scope was found to be feasible to use by a specialist and a generalist physiotherapist, demonstrating moderate to high reliability coefficients, small measurement errors, and lack of missing data. The pediatric physiotherapist was more reliable in measuring elbow and shoulder movement compared with the generalist physiotherapist, which suggests that the same experienced, pediatric physiotherapist should assess elbow and shoulder movement across all occasions of testing.

Conservative interventions for positional plagiocephaly: a systematic review.

This review aimed to synthesize current research evidence to determine the effectiveness of conservative interventions for infants with positional plagiocephaly. A systematic review was conducted, where papers were sourced from 13 library and internet databases. Research was included if published in English between 1983 and 2003. Level of evidence and quality of each paper was assessed to determine studies' magnitude of inherent bias. Results were synthesized in a narrative format and were considered with respect to homogeneity of participants, response rate, and outcome measures. Sixteen papers met inclusion criteria: 12 were case series and four were comparative studies. The methodological quality of the studies was moderate to poor, thus their results should be interpreted with caution. A consistent finding was that counterpositioning +/- physiotherapy or helmet therapy may reduce skull deformity; however, it was not possible to draw conclusions regarding the relative effectiveness of these interventions. Further investigation is required to compare the effect of helmet therapy with counterpositioning alone or when combined with physiotherapy. First, there is a need to develop an outcome measurement battery which incorporates psychometrically-sound measures from the perspectives of clinicians and patients.

A systematic review of the content of critical appraisal tools.

BACKGROUND: Consumers of research (researchers, administrators, educators and clinicians) frequently use standard critical appraisal tools to evaluate the quality of published research reports. However, there is no consensus regarding the most appropriate critical appraisal tool for allied health research. We summarized the content, intent, construction and psychometric properties of published, currently available critical appraisal tools to identify common elements and their relevance to allied health research. METHODS: A systematic review was undertaken of 121 published critical appraisal tools sourced from 108 papers located on electronic databases and the Internet. The tools were classified according to the study design for which they were intended. Their items were then classified into one of 12 criteria based on their intent. Commonly occurring items were identified. The empirical basis for construction of the tool, the method by which overall quality of the study was established, the psychometric properties of the critical appraisal tools and whether guidelines were provided for their use were also recorded. RESULTS: Eighty-seven percent of critical appraisal tools were specific to a research design, with most tools having been developed for experimental studies. There was considerable variability in items contained in the critical appraisal tools. Twelve percent of available tools were developed using specified empirical research. Forty-nine percent of the critical appraisal tools summarized the quality appraisal into a numeric summary score. Few critical appraisal tools had documented evidence of validity of their items, or reliability of use. Guidelines regarding administration of the tools were provided in 43% of cases. CONCLUSIONS: There was considerable variability in intent, components, construction and psychometric properties of published critical appraisal tools for research reports. There is no "gold standard' critical appraisal tool for any study design, nor is there any widely accepted generic tool that can be applied equally well across study types. No tool was specific to allied health research requirements. Thus interpretation of critical appraisal of research reports currently needs to be considered in light of the properties and intent of the critical appraisal tool chosen for the task.

Application of current research evidence to clinical physiotherapy practice.

This paper reviews the nature of physiotherapy intervention studies published in core physiotherapy journals (Australian Journal of Physiotherapy, Physiotherapy Theory and Practice, Physical Therapy, Physiotherapy, and Physiotherapy Canada) between October 2001 and September 2002. The clinical applicability of their evidence was considered in light of the clinical relevance of diagnostic criteria used for subject recruitment, the nature of the interventions tested, and the outcome measures used to determine effectiveness of the intervention. Most studies investigated a "package of care" and used clinician-oriented measures of outcomes to determine the effectiveness of an intervention. This mirrors current clinical practice. However, few studies used tissue-based diagnostic criteria for subject recruitment, tested interventions within an episode-of-care model, or measured outcome from multiple stakeholders' perspectives. These findings highlight potential barriers for clinicians in the uptake and sustained application of research evidence in the clinical setting. Both clinical and research physiotherapists need to be involved in producing generalizable research findings to ensure that evidence-based practice can be widely and readily adopted.

Development of a patient-focused wrist outcome instrument.

Many types of wrist outcome instruments are used in the clinical setting to determine the effectiveness of treatment. The authors have previously identified that the individual's perspective and the use of compensatory mechanisms are important factors to consider in the measurement of outcome following a wrist disorder. No published wrist outcome instrument currently addresses these factors, however. Therefore, the aim of this study was to develop a wrist outcome instrument that assessed, from the wrist-injured individual's perspective, their actual ability to perform activities of daily living following a wrist disorder. This article reports on the rationale and procedures used to construct the new instrument and presents the results of preliminary psychometric testing of the wrist outcome instrument.

Validity of the patient-focused wrist outcome instrument: do impairments represent functional ability?

The development of outcome instruments has been reported to be a long process, often taking years to complete. In a previous article, we reported on the rationale behind the construction of a new wrist outcome instrument that assesses, from the wrist-injured individual's perspective, their ability to perform activities of daily living following a wrist disorder. Content validity and test-retest reliability of the wrist outcome instrument also was demonstrated. Here we report on the results of the assessment of other aspects of validity, specifically construct validity of the wrist outcome instrument and the ability of the instrument to detect change over time. We evaluated these psychometric properties against frequently used clinical tests that assess impairments and thus report on the relationship between the ability to perform activities of daily living and impairment measures.

Difficulties associated with wrist disorders--a qualitative study.

OBJECTIVE: To explore the range of functional difficulties and compensatory mechanisms reported by individuals with a wrist disorder, to provide a basis for development of a patient-focused outcome instrument. DESIGN: Descriptive study using a qualitative, interview-based framework. SETTING/SUBJECTS: A volunteer sample of individuals, who were diagnosed with a unilateral, localized wrist disorder, were recruited from a wide range of health care settings situated in different socio-economic and geographic areas of Adelaide, Australia. Recruitment continued until theoretical saturation of the data occurred. INTERVENTIONS: Semi-structured, audiotaped interviews were conducted with each individual to elicit information concerning 'how your wrist disorder has affected your ability to perform daily activities'. MAIN OUTCOME MEASURES: Trends regarding reporting of difficult activities and compensatory mechanisms used. RESULTS: Forty-two individuals were interviewed. This was the point where theoretical saturation of research information had been reached. A few individuals reported difficulty with functional tasks prior to wrist injury. Following diagnosis, a wide range of difficulties, which included heavy, gross and fine motor activities, was reported. Compensatory mechanisms were used by all individuals, with requesting someone else to do the task, using the other hand, and using other parts of the body to lift or grasp being the most common. CONCLUSIONS: Current wrist outcome instruments do not contain the full range of difficult activities that were elicited from our sample, which casts doubt on these instruments' ability to fully measure change in capacity. Our results should provide the basis for the development of a relevant, sensitive, patient-focused outcome instrument.