Improved range of motion after manipulation under anesthesia versus physiotherapy for stage two frozen shoulder: a randomized controlled trial.

Background: Frozen shoulder (FS) is a common cause of shoulder pain and stiffness. Conservative treatment is sufficient for the majority of patients with long-term recovery of shoulder function. Manipulation under anesthesia (MUA) is known as a well-established treatment option if conservative treatment fails. It is unknown whether MUA does indeed shorten the duration of symptoms or leads to a superior outcome compared to conservative treatment. The objective of the current trial is to evaluate the effectiveness of MUA followed by a physiotherapy (PT) program compared to a PT program alone in patients with stage 2 FS. Methods: A prospective, single-center randomized controlled trial was performed. Patients between 18 and 70 years old with stage 2 FS were deemed eligible if an initial course of conservative treatment consisting of PT and intra-articular corticosteroid infiltration was considered unsatisfactory. Patients were randomized, and data was collected with an online data management platform (CASTOR). MUA was performed by a single surgeon under interscalene block, and intensive PT treatment protocol was started within 4 hours after MUA. In the PT group, patients were referred to instructed physiotherapist, and treatment was guided by tissue irritability. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score. Secondary outcomes were pain, range of motion (ROM), Oxford Shoulder Score, quality of life, and ability to work. Results: In total, 82 patients were included, 42 in the PT group and 40 in the MUA group. There was a significant improvement in SPADI, Oxford Shoulder Score, pain, ROM, and quality of life in both groups at 1-year follow-up. SPADI scores at three months were significantly improved in favor of MUA. MUA showed a significantly bigger increase in anteflexion and abduction compared to PT at all points of follow-up. No significant differences between both groups were found for all other parameters. No fractures, dislocations, or brachial plexus injuries occurred in this trial. Conclusion: MUA in stage 2 FS can be considered safe and results in a faster recovery of ROM and improved functional outcome, measured with SPADI scores, compared to PT alone in the short term. After 1 year, except for slightly better ROM scores for MUA, the result of MUA is equal to PT.

Validity and Reliability of Elbow Range of Motion Measurements Using Digital Photographs, Movies, and a Goniometry Smartphone Application.

INTRODUCTION: Range of motion (ROM) is closely monitored before and after surgery for stiff elbow and during rehabilitation. Measurements in the home environment may be helpful to increase involvement and adherence of the patient. Therefore, our objective is to investigate the validity and inter- and intraobserver reliability of 3 alternative methods to assess the ROM by the patient in a home-based situation, in comparison to the universal goniometer (UG). We hypothesize that all 3 alternative methods will be valid alternatives and show a level of reliability equivalent to UG. METHODS: Goniometric measurements of elbow flexion, extension, pronation and supination using photography, movie, and a smartphone application were obtained. The validity of these measurement methods was compared to UG. The interobserver and intraobserver reliability were calculated for all measurement methods. RESULTS: Photography and movie based goniometry of the elbow showed good validity in flexion and extension. The interobserver and intraobserver reliability were found to be good to excellent for photo and movie but moderate to poor for UG and the smartphone application. CONCLUSIONS: Photo or movie based goniometry seems to be a useful option for initial and follow-up measurement of the elbow ROM, both in the outpatient clinic and in a home environment. Based on our study, the smartphone application we used is not recommended.

Considerable variety in usual care rehabilitation after knee arthroplasty : a survey amongst physiotherapists.

Knee arthroplasty (KA) is increasingly performed, but rehabilitation and the possibility of returning to sports after KA are understudied areas. A web-based survey amongst physiotherapists was conducted to obtain insight in current rehabilitation methods and their return to sports advice after KA. 82 physiotherapists (62%) completed the survey. Broad agreement existed concerning important goals of rehabilitation, including the improvement of ROM, muscle strength, coordination and gait pattern. However, physiotherapists use a wide variety of treatment strategies to achieve these goals. Return to low-impact sports is mostly recommended, while return to intermediate- and high-impact sports is either advised against or considered impossible. The development of new evidence-based guidelines on physiotherapy after KA could lead to a more uniform approach in the rehabilitation for KA patients. Furthermore, investigating effects of individualization in the rehabilitation may prove valuable in optimising both patient outcomes and cost-effectiveness of this worldwide increasingly performed intervention.

Continuous passive motion and physical therapy (CPM) versus physical therapy (PT) versus delayed physical therapy (DPT) after surgical release for elbow contractures; a study protocol for a prospective randomized controlled trial.

BACKGROUND: The elbow is prone to stiffness after trauma. To regain functional elbow motion several conservative- and surgical treatment options are available. Conservative treatment includes physical therapy, intra-articular injections with corticosteroids and a static progressive or dynamic splinting program. If conservative treatment fails, an operative release of the posttraumatic stiff elbow is often performed. The best Evidence-Based rehabilitation protocol for patients after an operative release is unknown to date and differs per surgeon, hospital and country. Options include early- or delayed motion supervised by a physical therapist, immediate continuous passive motion (CPM), (night) splinting and a static progressive or dynamic splinting program. METHODS/DESIGN: The SET-Study (Stiff Elbow Trial) is a single-centre, prospective, randomized controlled trial. The primary objective of this study is to compare the active Range of Motion (ROM) (flexion arc and rotational arc) twelve months after surgery between three groups. The first group will receive in-hospital CPM in combination with early motion Physical Therapy (PT) supervised by a physical therapist, the second group will receive only in-hospital early motion PT supervised by a physical therapist and the third group will receive outpatient supervised PT from postoperative day seven till ten. Secondary outcome measures will be Patient Reported Outcome Measures (PROMs) including the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES), the quick Disabilities of Arm, Shoulder and Hand (qDASH) score, Visual Analogue pain Scale in rest and activity (VAS), Pain Catastrophizing Scale (PCS), the Short Form (SF)-36, the Centre for Epidemiological Studies Depression Scale Revised (CESD-R) and the Work Rehabilitation Questionnaire (WORQ) for the upper limb. DISCUSSION: A successful completion of this trial will provide evidence on the best rehabilitation protocol in order to (re)gain optimal motion after surgical release of the stiff elbow. TRIAL REGISTRATION: The trial is registered at the Dutch Trial Register: NTR6067 , 31-8-2016.

Manipulation under anesthesia versus physiotherapy treatment in stage two of a frozen shoulder: a study protocol for a randomized controlled trial.

BACKGROUND: There is no consensus about the optimal treatment strategy for frozen shoulders (FS). Conservative treatment consisting of intra-articular corticosteroid infiltrations and physiotherapy are considered appropriate for most patients. However, with a conservative strategy, patients experience a prolonged rehabilitation period with a considerable amount of pain and disabilities in daily life. Also, at long term, a residual amount of pain and restriction of range of motion is frequently reported. Manipulation under anesthesia is a short and relative simple procedure with the potential to rapidly reduce symptoms and restore the range of motion. The objective of this trial is to evaluate the effectiveness of MUA followed by a PT program compared to a PT program alone, in the treatment of patients with a stage two FS. We hypothesize that the course of the disease can be shortened with MUA with a quicker functional recovery. METHODS: This is a prospective, single center, randomized controlled trial. Eligible patients will be allocated to either the manipulation (MUA) group or the physiotherapy alone (PT) group. In the MUA group manipulation will be performed under interscalene block, directly followed by an intensive physiotherapy treatment protocol, with the goal to maintain the obtained range of motion. Patients allocated to the PT group are given advice and education and receive a written protocol to hand out to their physical therapist based on the recent guideline of the Dutch Shoulder Network for the treatment of frozen shoulders. Descriptive statistics will be used to describe the sample size, patients demographics, presence of diabetes mellitus, range of motion, duration of symptoms till randomization and will be presented for each treatment group. The SPADI is used as primary functional outcome parameter. Secondary outcome parameters are; OSS, NPRS, EQ-5D 3-L, passive range of motion, WORQ-UP, duration of symptoms, usage of analgesics and adverse events. A sample size of 41 subjects in each group was calculated. Follow up is planned after 1,3 and 12 months. The length of physiotherapy treatment in both groups is variable, depending on individual progression. Differences between groups in outcome parameters will be analysed using the linear mixed modelling and the restricted maximum likelihood ratio technique for estimating the model parameters. DISCUSSION: Successful completion of this trial will provide evidence on the best treatment strategy for patients with a stage two frozen shoulder. The results of this study can lead to a better understanding for the role of manipulation in the treatment of frozen shoulders. TRIAL REGISTRATION: This trial is registered in the Dutch Trial Register under the number NTR6182 on the 20th of February 2017.

Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study.

STUDY DESIGN: Diagnostic accuracy study. OBJECTIVE: To evaluate the diagnostic accuracy of the Thessaly test compared with an arthroscopic examination in patients with suspected meniscal tears. BACKGROUND: The Thessaly test was introduced to improve the diagnostic accuracy of the clinical examination in detecting meniscal tears. This test appears to be a valuable alternative to other meniscal clinical tests usually performed, but additional diagnostic accuracy data are required. METHODS: Patients with suspected meniscal tears, referred to a hospital for arthroscopic surgery, were eligible. The Thessaly test alone and the combination of the Thessaly and McMurray tests were considered as index tests, and arthroscopy was used as the reference test. Experienced physical therapists performed the Thessaly test at 20° of flexion and the McMurray test for both knees. The physical therapist was blinded to patient information, the affected knee, and the results from possible earlier diagnostic imaging. An orthopaedic surgeon blinded to the clinical test results from the physical therapist performed the arthroscopic examination. RESULTS: A total of 593 patients were included, of whom 493 (83%) had a meniscal tear, as determined by the arthroscopic examination. The Thessaly test had a sensitivity of 64% (95% confidence interval [CI]: 60%, 68%), specificity of 53% (95% CI: 43%, 63%), positive predictive value of 87% (95% CI: 83%, 90%), negative predictive value of 23% (95% CI: 18%, 29%), and positive and negative likelihood ratios of 1.37 (95% CI: 1.10, 1.70) and 0.68 (95% CI: 0.59, 0.78), respectively. The combination of positive Thessaly and McMurray tests showed a sensitivity of 53% and specificity of 62%. CONCLUSION: The results of the Thessaly test alone or combined with the McMurray test do not seem useful to determine the presence or absence of meniscal tears. LEVEL OF EVIDENCE: Diagnosis, level 2b.