Outcomes of direct access telehealth physical therapy for patients with musculoskeletal pain: a single cohort observational retrospective study.

BACKGROUND: Telehealth direct access physical therapy is becoming more prevalent in the management of outpatient musculoskeletal pain. This innovative model affords more opportunity to reach potential patients who otherwise would not be able to access services due to geographical isolation, travel barriers, and timely access to quality care. OBJECTIVE: The purpose of the study was to investigate if pain, function, and ability to perform jobs improved after direct access telehealth physical therapy in patients with musculoskeletal pain. METHODS: A single cohort retrospective design was implemented to offer telehealth physical therapy to patients with musculoskeletal pain from March to November 2021. Eligible patients were at least 18 years old, located in California, and had a history of peripartum pelvic dysfunction, muscle pain, joint pain, or neural symptoms. Paired-samples t-tests and the Wilcoxon signed-rank test were used to analyze normally distributed and non-parametric data (α = 0.05), respectively, to compare pretest and post scores. RESULTS: Based on 89 participants, paired-samples t-tests showed statistically significant differences in function [t(87) = 20.71, p < .0001] and pain [t(82) = -8.15, p < .0001]. Wilcoxon's signed-rank test showed statistically significant differences in ability to perform job (Z = -7.345, p < .0001). CONCLUSION: This study demonstrated that in a cohort of individuals with multiregional musculoskeletal pain, there was a decrease in pain and improvements in function and ability to perform job after direct access telehealth physical therapy.

Manual therapy and exercise for adhesive capsulitis: a systematic review with meta-analysis.

BACKGROUND: Adhesive capsulitis (AC) affects approximately 1% of the general population. Current research lacks clear guidance on the dosage of manual therapy and exercise interventions. OBJECTIVE: The purpose of this systematic review was to assess the effectiveness of manual therapy and exercise in the management of AC, with a secondary aim of describing the available literature present on the dosage of interventions. METHODS: Eligible studies were randomized clinical/quasi-experimental trials with complete data analysis and no limits on date of publication, published in English, recruited participants >18 years of age with primary adhesive capsulitis, that had at least two groups with one group receiving manual therapy (MT) alone, exercise alone, or MT and exercise, that included at least one outcome measure of pain, disability, or external rotation range of motion, and that had dosage of visits clearly defined. An electronic search was conducted using PubMed, Embase, Cochrane, Pedro, and clinicaltrials.gov. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias 2 Tool. The Grading of Recommendations Assessment, Development, and Evaluation was used to provide an overall assessment of the quality of evidence. Meta-analyses were conducted when possible, and dosage was discussed in narrative form. RESULTS: Sixteen studies were included. All meta-analyses revealed non-significant effects of pain, disability, and external rotation range of motion at short- and long-term follow-up, with an overall level of evidence ranging from very low to low. CONCLUSION: Non-significant findings with low-to-very-low-quality of evidence were found across meta-analyses, preventing seamless transition of research evidence to clinical practice. Lack of consistency in study designs, manual therapy techniques, dosing parameters, and duration of care impedes the ability to make strong recommendations regarding optimal dosage of physical therapy for individuals with AC.

Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions.

BACKGROUND: Lumbar spinal stenosis (LSS) has a substantial impact on mobility, autonomy, and quality of life. Previous reviews have demonstrated inconsistent results and/or have not delineated between specific nonsurgical interventions. OBJECTIVE: The purpose of this systematic review is to assess the effectiveness of interventions in the management of LSS. METHODS: Eligible studies were randomized controlled trials (RCTs) or prospective studies, included patients with LSS, assessed the effectiveness of any interventions (rehabilitation, surgical, injection, medication), included at least two intervention groups, and included at least one measure of pain, disability, ambulation assessment, or LSS-specific symptoms. Eighty-five articles met inclusion criteria. Meta-analyses were conducted across outcomes. Effect sizes were calculated using Hedge's g and reported descriptively. Formal grading of evidence was conducted. RESULTS: Meta-analysis comparing rehabilitation to no treatment/placebo demonstrated significant effects on pain favoring rehabilitation (mean difference, MD -1.63; 95% CI: -2.68, -0.57; I2 = 71%; p = .002). All other comparisons to no treatment/placebo revealed nonsignificant findings. The level of evidence ranged from very low to high for rehabilitation and medication versus no treatment/placebo for pain, disability, ambulation ability, and LSS symptoms. CONCLUSIONS: Although the findings of this review are inconclusive regarding superiority of interventions, this accentuates the value of multimodal patient-centered care in the management of patients with LSS.

The Prevalence of Tibiofemoral Knee Osteoarthritis Following Arthroscopic Partial Meniscectomy Is Variably Reported in General, and Over Time: A Systematic Review With a Minimum of 5-Year Follow-Up.

Purpose: To assess the prevalence of tibiofemoral (TF) osteoarthritis (OA) following arthroscopic partial meniscectomy (APM) with a minimum follow-up of 5 years, to explore the prevalence of symptomatic TF OA, and to identify potential risk factors for the development of TF OA following APM. Methods: An electronic search was conducted using PubMed, CINAHL, Pedro, AMED, Embase, the Cochrane Library, and clinicaltrials.gov. Prospective/retrospective studies including participants with a mean age ≥18 years old, undergoing isolated APM, reported radiographic assessment of knee OA as an outcome, had at least 5-year follow-up, and were written in English were included. Two authors extracted relevant data. Four authors assessed methodologic quality using the Center of Reviews and Dissemination and the Downs and Black checklist. The prevalence of TF OA after APM was reported for each study, with the range provided across studies for each time period (5 years to <10 years, 10 years to <15 years, ≥15 years). Results: Twenty-two studies were included. Radiologic TF OA prevalence following APM ranged from 35% to 90%, 23% to 100%, and 52% to 57.7% at an average follow-up of 5 years to <10 years, 10 years to <15 years, and ≥15 years, respectively. Prevalence of symptomatic TF OA ranged from 24.1% to 67% according to individual operational definitions, with 2 studies reporting correlations between function and radiological findings. Conclusions: APM results in a prevalence of radiographic TF OA ranging from 23% to 100% across follow-up periods of 5 or more years with the lowest prevalence reported between 5 and <10 years and the highest prevalence reported between 10 and <15 years follow-up. Considerably less data was available to assess symptomatic TF OA or risk factors associated with TF OA. Level of Evidence: Level III, systematic review of Level II and III studies.

Sling Exercise in the Management of Chronic Low Back Pain: A Systematic Review and Meta-Analysis.

ABSTRACT: Drummond, C, Lebedeva, V, Kirker, K, and Masaracchio, M. Sling exercise in the management of chronic low back pain: A systematic review and meta-analysis. J Strength Cond Res XX(X): 000-000, 2021-The purpose of this systematic review is to assess the effectiveness of sling exercise therapy (SET) in individuals with chronic low back pain (LBP). Eligible studies were randomized clinical trials or prospective cohort studies published in the English language that assessed SET on measures of pain, disability, or muscle attributes in chronic LBP. The search identified 1,204 studies, with 12 studies meeting the inclusion criteria. The average score was 7.3 on the Cochrane Risk of Bias Criteria. Meta-analysis comparing SET with general exercise revealed a nonsignificant effect for pain (mean difference [MD] 0.14; 95% confidence interval [CI]: -0.58, 0.87). Meta-analysis comparing SET with motor control training/lumbar stabilization revealed a significant effect favoring SET for pain (MD -4.13; 95% CI: -7.82 to -0.45) and disability (MD -3.19; 95% CI: -4.63 to -1.76). Meta-analysis comparing SET with no treatment revealed a significant effect favoring SET for pain (MD -1.05; 95% CI: -2.82 to -0.71). Meta-analysis comparing SET plus modalities with modalities revealed a significant effect favoring the SET plus modalities group for pain (MD -1.19; 95% CI: -1.48 to -0.89) and a nonsignificant effect for disability (MD -6.67; 95% CI: -17.25 to 3.92). Sling exercise therapy was more effective than all comparisons for various muscle attributes. The overall level of evidence ranged from very low to moderate. Sling exercise therapy is effective in reducing pain, disability, and improving core muscle activation, strength, thickness, and onset in patients with chronic LBP. Because SET demonstrated comparable outcomes with common active interventions, it provides an opportunity to implement pain-free exercises based on the patient's initial functional level early in the plan of care.

Minimal physical therapy utilization compared with higher physical therapy utilization for patients with low back pain: a systematic review.

Aim: Currently there is a large and perhaps unwarranted variation regarding physical therapy utilization for individuals with low back pain (LBP).  The purpose of this systematic review was to compare the effects of minimal physical therapy utilization/education (two visits or less) versus typical physical therapy utilization (three visits or more) on patient-important outcomes for patients with LBP. Methods: Two independent reviewers searched Cochrane, Medline, CINAHL, Web of Science, and PEDro from database inception until March 2017. Eligible studies used a randomized design, included subjects with LBP, and compared minimal versus higher utilization. The GRADE approach was used to provide an overall level of evidence regarding utilization. Eight articles (1153 individual subjects) met the inclusion criteria. Effect sizes for each outcome measure were calculated using Hedge's g and were adjusted for baseline values at each time period. Findings: When compared with minimal utilization, higher utilization demonstrated no significant differences on pain, disability, or quality of life at the 1-year follow-up. However, two of the three studies that analyzed cost-effectiveness found higher utilization to be more cost-effective at 1-year follow-up. Moreover, there was insufficient evidence available to investigate patient subgroups (acuity, risk for chronicity), multiple levels of utilization dosage (low, typical, and high), or intervention type. Conclusions: This review identifies the need for further research on the dosage of physical therapy among various subgroups of patients with LBP. While higher utilization may not result in significant improvements in patient-important outcomes, it may be more cost-effective for patients with chronic or complex LBP conditions when compared to minimal utilization.

Examination and Management of a 4-Year-Old Following a Femoral Aneurysmal Bone Cyst: A Case Report.

PURPOSE: The literature lacks recommendations for postoperative rehabilitation following removal of aneurysmal bone cysts (ABCs). This case report describes the rehabilitation with return to age-appropriate functional activities for a 4-year-old following surgical fixation of a femoral ABC, with emphasis on clinical decision-making in the absence of definitive treatment algorithms. SUMMARY OF KEY POINTS: The child improved in range of motion, strength, balance, transfers, gait, stair negotiation, and percentile rank on the Test of Gross Motor Development 2. CONCLUSION: This case is successful outcomes of a 4-year-old girl (GP) following surgical fixation for an ABC. RECOMMENDATIONS FOR CLINICAL PRACTICE: This case fills a current void in the literature emphasizing clinical decision-making and attainment of GP-specific functional goals. A goal-driven approach incorporating key elements of the International Classification of Function model resulted in successful return to age-appropriate activity following surgical fixation of a femoral fracture due to an ABC.

Thoracic spine manipulation for the management of mechanical neck pain: A systematic review and meta-analysis.

OBJECTIVE: To investigate the role of thoracic spine manipulation (TSM) on pain and disability in the management of mechanical neck pain (MNP). DATA SOURCES: Electronic databases PubMed, CINAHL, Pedro, Embase, AMED, the Cochrane Library, and clinicaltrials.gov were searched in January 2018. STUDY SELECTION: Eligible studies were completed RCTs, written in English, had at least 2 groups with one group receiving TSM, had at least one measure of pain or disability, and included patients with MNP of any duration. The search identified 1717 potential articles, with 14 studies meeting inclusion criteria. STUDY APPRAISAL AND SYNTHESIS METHODS: Methodological quality was evaluated independently by two authors using the guidelines published by the Cochrane Collaboration. Pooled analyses were analyzed using a random-effects model with inverse variance methods to calculate mean differences (MD) and 95% confidence intervals for pain (VAS 0-100mm, NPRS 0-10pts; 0 = no pain) and disability (NDI and NPQ 0-100%; 0 = no disability). RESULTS: Across the included studies, there was increased risk of bias for inadequate provider and participant blinding. The GRADE approach demonstrated an overall level of evidence ranging from very low to moderate. Meta-analysis that compared TSM to thoracic or cervical mobilization revealed a significant effect favoring the TSM group for pain (MD -13.63; 95% CI: -21.79, -5.46) and disability (MD -9.93; 95% CI: -14.38, -5.48). Meta-analysis that compared TSM to standard care revealed a significant effect favoring the TSM group for pain (MD -13.21; 95% CI: -21.87, -4.55) and disability (MD -11.36; 95% CI: -18.93, -3.78) at short-term follow-up, and a significant effect for disability (MD -4.75; 95% CI: -6.54, -2.95) at long-term follow-up. Meta-analysis that compared TSM to cervical spine manipulation revealed a non-significant effect (MD 3.43; 95% CI: -7.26, 14.11) for pain without a distinction between immediate and short-term follow-up. LIMITATIONS: The greatest limitation in this systematic review was the heterogeneity among the studies making it difficult to assess the true clinical benefit, as well as the overall level of quality of evidence. CONCLUSIONS: TSM has been shown to be more beneficial than thoracic mobilization, cervical mobilization, and standard care in the short-term, but no better than cervical manipulation or placebo thoracic spine manipulation to improve pain and disability. TRIAL REGISTRATION: PROSPERO CRD42017068287.

Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: A systematic review with meta-analysis.

OBJECTIVE: To investigate the role of early initiation of rehabilitation on length of stay (LOS) and cost following total hip arthroplasty, total knee arthroplasty, or unicompartmental knee arthroplasty. DATA SOURCES: Electronic databases PubMed, CINAHL, Pedro, Embase, AMED, and the Cochrane Library were searched in July 2016. Five additional trials were identified through reference list scanning. STUDY SELECTION: Eligible studies were published in English language peer-reviewed journals; included participants that had undergone total hip arthroplasty, total knee arthroplasty, or unicompartmental knee arthroplasty reported clearly defined timing of rehabilitation onset for at least two groups; and reported at least one measure of LOS or cost. Inclusion criteria were applied by 2 independent authors, with disagreements being determined by a third author. Searching identified 1,029 potential articles, of which 17 studies with 26,614 participants met the inclusion criteria. DATA EXTRACTION: Data was extracted independently by 2 authors, with disagreements being determined by a third author. Methodological quality of each study was evaluated independently by 2 authors using the Downs and Black checklist. Pooled analyses were analyzed using a random-effects model with inverse variance methods to calculate standardized mean differences (SMD) and 95% confidence intervals for LOS. DATA SYNTHESIS: When compared with standard care, early initiation of physical therapy demonstrated a decrease in length of stay for the 4 randomized clinical trials (SMD = -1.90; 95% CI -2.76 to -1.05; I2 = 93%) and for the quasi-experimental and 5 prospective studies (SMD = -1.47; 95% CI -1.85 to -1.10; I2 = 88%). CONCLUSION: Early initiation of rehabilitation following total hip arthroplasty, total knee arthroplasty, or unicompartmental knee arthroplasty is associated with a shorter LOS, a lower overall cost, with no evidence of an increased number of adverse reactions. Additional high quality studies with standardized methodology are needed to further examine the impact of early initiation of physical therapy among patients with joint replacement procedures.

AN INTERVENTION-BASED CLINICAL REASONING FRAMEWORK TO GUIDE THE MANAGEMENT OF THORACIC PAIN IN A DANCER: A CASE REPORT.

BACKGROUND AND PURPOSE: As a result of the anatomical proximity of the thoracic spine to the cervical, lumbar, and shoulder regions, dysfunction in the thoracic spine can influence pain, mobility, and stability across these areas. Currently, a paucity of evidence exists addressing treatment of individuals with primary thoracic pain, especially in young, athletic patients. Furthermore, current research discussing clinical reasoning frameworks focus on the differential diagnostic process. The purpose of this case report was to present a framework that describes the clinical reasoning process for the implementation and sequencing of procedural interventions for the management of a dancer with thoracic pain. CASE DESCRIPTION: A 21-year-old female dancer presented to physical therapy with a medical diagnosis of thoracic pain. The patient reported exacerbation of left thoracic pain with prolonged sitting, twisting/arching her back during dance, and lifting >15 lbs overhead. Examination revealed hypomobility with positive pain provocation during mobility testing of T1-T3 and the sternocostal junction of ribs 2-4, with associated muscle guarding palpated in the left iliocostalis thoracis and levator scapulae. OUTCOMES: Following 10 visits, the patient had no pain, no functional deficits, and a Global Rating of Change (GROC) of + 6. She returned to full competition, and a 3-month follow-up revealed continued success with dancing and a GROC of +7. DISCUSSION: This case report described the successful management of a dancer with primary thoracic pain using a clinical reasoning framework for the sequencing of procedural interventions, while incorporating Olson's impairment-based classification system. A combination of manual therapy techniques and neuromuscular control exercises were incorporated to address mobility, stability, mobility on stability, and skill level impairments, which allowed the patient to return to dance activities safely. Future studies should consider the development of further treatment-based clinical reasoning frameworks that illustrate the importance of the sequencing within a session and across the episode of care. LEVEL OF EVIDENCE: 4.