Understanding social determinants of health and physical therapy outcomes in patients with low back pain: A scoping review.

BACKGROUND: Low back pain (LBP) is the number one cause of disability worldwide; however, it is not clear how social determinants of health (SDOH) impact care management and outcomes related to physical therapy (PT) services for patients with LBP. OBJECTIVE: The purposes of this scoping review are to examine and assimilate the literature on how SDOH and PT care relate to non-specific LBP outcomes and identify gaps in the literature to target for future research. METHODS: Data were extracted from eight electronic databases from January 2011 to February 2022. Reviewers independently screened all studies using the PRISMA extension for scoping review guidelines. Data related to study design, type of PT, type of non-specific LBP, patient demographics, PT intervention, SDOH, and PT outcomes were extracted from the articles. RESULTS: A total of 30,523 studies were screened, with 1961 articles undergoing full text review. Ultimately, 76 articles were identified for inclusion. Sex and age were the most frequent SDOH examined (88% and 78% respectively) followed by education level (18%). Approximately half of the studies that examined age, sex, and education level identified no effect on outcomes. The number of studies examining other factors was small and the types of outcomes evaluated were variable, which limited the ability to pool results. CONCLUSIONS: Sex and age were the most frequent SDOH examined followed by education level. Other factors were evaluated less frequently, making it difficult to draw conclusions. Study design and heterogeneity of determinants and outcomes were barriers to examining the potential impact on patients with LBP.

Kinesiophobia Is Associated With Poor Function and Modifiable Through Interventions in People With Patellofemoral Pain: A Systematic Review With Individual Participant Data Correlation Meta-Analysis.

OBJECTIVE: The aim of this systematic review and correlation meta-analysis was to identify factors associated with kinesiophobia in individuals with patellofemoral pain (PFP) and to identify interventions that may reduce kinesiophobia in individuals with PFP. METHODS: Seven databases were searched for articles including clinical factors associated with kinesiophobia or interventions that may reduce kinesiophobia in individuals with PFP. Two reviewers screened articles for inclusion, assessed risk of bias and quality, and extracted data from each study. A mixed-effects model was used to calculate correlations of function and pain with kinesiophobia using individual participant data. Meta-analyses were performed on interventional articles; Grading of Recommendations, Assessment, Development, and Evaluation was used to evaluate certainty of evidence. Results were reported narratively when pooling was not possible. RESULTS: Forty-one articles involving 2712 individuals were included. Correlation meta-analyses using individual participant data indicated a moderate association between self-reported function and kinesiophobia (n = 499; r = -0.440) and a weak association between pain and kinesiophobia (n = 644; r = 0.162). Low-certainty evidence from 2 articles indicated that passive treatment techniques were more effective than minimal intervention in reducing kinesiophobia (standardized mean difference = 1.11; 95% CI = 0.72 to 1.49). Very low-certainty evidence from 5 articles indicated that interventions to target kinesiophobia (psychobehavioral interventions, education, and self-managed exercise) were better in reducing kinesiophobia than physical therapist treatment approaches not specifically targeting kinesiophobia (standardized mean difference = 1.64; 95% CI = 0.14 to 3.15). CONCLUSION: Higher levels of kinesiophobia were moderately associated with poorer function and weakly associated with higher pain in individuals with PFP. Taping and bracing may reduce kinesiophobia immediately after use, and specific kinesiophobia-targeted interventions may reduce kinesiophobia following the full intervention; however, the certainty of evidence is very low. IMPACT: Assessment of kinesiophobia in clinical practice is recommended, on the basis of the relationships identified between kinesiophobia and other important factors that predict outcomes in individuals with PFP.

Use of accelerometers and inertial measurement units to quantify movement of tactical athletes: A systematic review.

The dynamic work environments of tactical athletes are difficult to replicate in a laboratory. Accelerometers and inertial measurement units provide a way to characterize movement in the field. This systematic review identified how accelerometers and inertial measurement units are currently being used to quantify movement patterns of tactical athletes. Seven research and military databases were searched, producing 26,228 potential articles with 78 articles included in this review. The articles studied military personnel (73.1%), firefighters (19.2%), paramedics (3.8%), and law enforcement officers (3.8%). Accelerometers were the most used type of sensor, and physical activity was the primarily reported outcome variable. Seventy of the studies had fair or poor quality. Research on firefighters, emergency medical services, and law enforcement officers was limited. Future research should strive to make quantified movement data more accessible and user-friendly for non-research personnel, thereby prompting increased use in tactical athlete groups, especially first responder agencies.

Functional connectivity patterns are altered by low back pain and cause different responses to sham and real dry needling therapies: a systematic review of fMRI studies.

BACKGROUND: There is a relationship between low back pain (LBP) and central nervous system dysfunction. Needling therapies (e.g. acupuncture, dry needling) are proposed to impact the nervous system, however their specific influence is unclear. PURPOSE: Determine how needling therapies alter functional connectivity and LBP as measured by functional magnetic resonance imaging (fMRI). METHODS: Databases were searched following PRISMA guidelines. Studies using fMRI on individuals with LBP receiving dry needling or acupuncture compared to control or sham treatments were included. RESULTS: Eight studies were included, all of which used acupuncture. The quality of studies ranged from good (n = 6) to excellent (n = 2). After acupuncture, individuals with LBP demonstrated significant functional connectivity changes across several networks, notably the salience, somatomotor, default mode network (DMN) and limbic networks. A meta-analysis demonstrated evidence of no effect to potential small effect of acupuncture in reducing LBP (SMD -0.28; 95% CI: -0.70, 0.13). CONCLUSION: Needling therapies, like acupuncture, may have a central effect on patients beyond the local tissue effects, reducing patients' pain and disability due to alterations in neural processing, including the DMN, and potentially other central nervous system effects. The meta-analysis should be interpreted with caution due to the narrow focus and confined sample used.

The effects of knee osteoarthritis on neural activity during a motor task: A scoping systematic review.

OBJECTIVE: To examine the evidence of neural activation with functional magnetic resonance imaging (fMRI), corticospinal excitability, and other central nervous system measurement differences during motor tasks between those with and without knee osteoarthritis (KOA). METHODS: A scoping review strategy was systematically performed. We searched PubMed, CINAHL, Embase, PsychInfo, SportDiscus, SCOPUS and Web of Science from database inception to April 2021. Any study investigating central nervous system measures during a motor task for individuals with KOA with or without a healthy control group for comparison was included. Two reviewers independently screened all studies in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses extension for scoping reviews. RESULTS: Thirteen studies met the inclusion criteria. KOA had reduced activation of the premotor cortex during a gait imagery task when examining the brain using fMRI. This hypoactivation was not significant when the task was combined with ankle movement. Individuals with KOA had decreased motor cortex activation during a force matching motor task. KOA was associated with gamma loop dysfunction of the quadriceps and increased responsiveness of the triceps surae muscles. Also, there was an increased soleus Hoffmann reflex during heel strike of gait cycle. The flexor withdrawal reflex was heighted for individuals with KOA with a lower threshold of the reflex occurring with increased joint compression, but this reflex was modulated with joint mobilizations. CONCLUSION: Individuals with KOA have motor deficits associated with decreased neural activation, central nervous system sensitization, decreased quadriceps muscle spindle responsiveness, and increased triceps surae muscle activity.

A preliminary analysis of physical therapist agreement regarding the perceived impairments in cases of runners with knee pain.

BACKGROUND: There is a scarcity of evidence describing how physical therapists use data from clinical examinations to inform the treatment of runners with knee pain. OBJECTIVE: Our purpose was to examine the between physical therapist agreement on the selection of perceived impairments in runners with knee pain. METHODS: Twelve physical therapists reviewed two cases of runners with knee pain. The cases included clinical subjective information, objective data, and review of videos of each participant running. Each rater selected up to three perceived impairments (from a list of eight) that each physical therapist would address at the next physical therapy session. Percent agreement was calculated to determine the between rater agreement on each individual perceived impairment selection and Fleiss Kappa was calculated for each unique combination of three perceived impairments per case. RESULTS: Twelve raters with 51 (18-156) months of clinical experience participated. Percent agreement ranged from 8%-100% for both cases for individual impairments. When assessing the unique combination of three impairments selected, inter-rater agreement was less than what is expected due to chance alone (κ = -0.09, p = .92; κ = -0.09, p = .98) for both cases. CONCLUSION: The 12 physical therapists demonstrated poor to excellent levels of agreement when selecting an individual perceived impairment. Agreement was worse than chance when selecting a combination of three unique impairments.

Prevalence and Incidence of Injury during Olympic-style Shooting Events: A Systematic Review.

BACKGROUND: Shooting sports are included in collegiate and Olympic events. However, there is minimal evidence examining injury prevalence and incidence for these athletes. HYPOTHESIS/PURPOSE: The purpose of this study was to systematically review the literature to examine the available evidence regarding the incidence, prevalence, and types of injuries that affect athletes in Olympic-style shooting events. STUDY DESIGN: Systematic review. METHODS: The electronic databases PubMed, Cochrane Library, Cinahl, MEDLINE, and SPORTDiscus were searched utilizing terms related to shooting and injuries. Studies were included if they reported prevalence or incidence of injury in collegiate or Olympic shooting events, and were excluded if inclusion criteria were not met, full text was unavailable, or not in English. Two reviewers independently screened articles in two phases: 1) screening of titles/abstracts 2) full text review. A third reviewer resolved conflicts. RESULTS: Nineteen studies were ultimately included. The sports identified were biathlon, rifle, pistol, and shotgun. Shooting events in both winter and summer Olympics had low percentages of injuries compared to other sports. Winter shooting events had a higher percentage of injuries (6.9%) compared to summer (2.3%). In summer, females demonstrated a higher percentage of injuries (6.9%) compared to males (1.7%). In winter, males had a higher percentage of injuries (8.6%) versus females (5.1%). CONCLUSION: Injury incidence and prevalence was low for athletes in shooting sports in the Olympics. Injury rate was higher in the winter Olympic shooting events likely from increased physiological demand. With injury surveillance focusing on acute injuries rather than chronic, the number of injuries may be underestimated. Females had higher injury rates than males in the summer Olympics while the opposite was observed in the winter Olympics, likely from sex differences and differences in physiological demand for each event. LEVEL OF EVIDENCE: Level 3.

Paresthesia Post Total Knee Arthroplasty Secondary to Severe Thoracic Spinal Cord Compression.

A 57-year-old obese man was referred to a physical therapist 14 weeks after left knee arthroplasty due to loss of function and worsening symptoms. Following examination, due to the worsening and progressive weakness that is atypical after this surgery, the physical therapist and surgeon agreed to refer the patient to the emergency department. Magnetic resonance imaging revealed T11-12 spinal canal stenosis with cord compression. J Orthop Sports Phys Ther 2020;50(12):724. doi:10.2519/jospt.2020.9655.

Systematic review of the diagnostic accuracy, reliability, and safety of the sharp-purser test.

Introduction: The Sharp-Purser Test (SPT) is used to assess for atlantoaxial instability (AI) in patients with rheumatoid arthritis (RA). The test is commonly used by clinicians; however, many experts argue it lacks reliability and validity along with concerns of safety. The primary purpose of this review is to determine the diagnostic accuracy of the SPT to detect AI.Methods: A search of five databases was performed from inception to 19 December 2018 using search terms related to the SPT. Studies were eligible for inclusion if the SPT was used on a patient/participant. Methodological quality assessment of diagnostic studies was performed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) for studies that reported data to calculate sensitivity (SN), specificity (SP), positive likelihood ratio (+LR), and negative likelihood ratio (-LR).Results: The search yielded 1009 articles, and 32 studies met the inclusion criteria for analysis. Meta-analysis on diagnostic accuracy studies assessing the SPT was not possible due to statistical heterogeneity. Six diagnostic accuracy studies assessed the SN of the SPT ranging from 0.19 to 1.00. Four of the studies assessed SP of the SPT ranging from 0.71 to 0.98. The +LR was identified in 4 studies was 0.655, 1.73, 22, and 17.25. The -LR was 1.14, 0.799, 0.571, and 0.323. Seven RCTs utilized the SPT to screen for AI, and the SPT was used in 18 case reports.Conclusion: The SPT may be inappropriate to use due to inconsistent validity, poor inter-rater reliability, and potential to cause harm.Level of evidence: 1.

RETURN TO ADVANCED STRENGTH TRAINING AND WEIGHTLIFTING IN AN ATHLETE POST-LUMBAR DISCECTOMY UTILIZING PAIN NEUROSCIENCE EDUCATION AND PROPER PROGRESSION: RESIDENT'S CASE REPORT.

STUDY DESIGN: Case Report. BACKGROUND AND PURPOSE: The use of pain neuroscience education (PNE) is indicated when there are psychosocial contributions to a person's pain experience. The scientific literature has established the efficacy of the use of PNE in a population with chronic pain but there is a paucity of evidence to support the use of PNE in athletic populations. The purpose of this case report is to describe the use of PNE and graded exposure exercises specific to an athlete returning to Olympic weightlifting. CASE DESCRIPTION: The patient underwent an L5-S1 discectomy to resolve paresthesia in his leg, completed a bout of post-operative rehabilitation but returned 15 months after the surgery. He presented with the chief complaint of low back tightness and fear of lumbar flexion. When asked to touch his toes during the lumbar flexion range of motion examination, he demonstrated aberrant lumbar movement by hinging at the hips with a straight back due to fear that flexing would damage his lumbar spine. The patient was seen for four weeks with a focus on PNE and graded exposure to weightlifting activities. OUTCOMES: The patient returned to Olympic weightlifting and decreased his Fear Avoidance Behavior Questionnaire (FABQ) score from 22 to 4 during the course of physical therapy. His Tampa Scale of Kinesiophobia (TSK) score also decreased from 55 to 31. By discharge, he was able to bend at the lumbar spine with full flexion and no longer believed the motion to cause damage. DISCUSSION: The case is unique because it describes the implementation of PNE in an athlete returning to weightlifting, and the scientific literature for use of PNE in this population is lacking. The identification of kinesiophobia and implementation of PNE and graded exposure exercises lead to an optimal outcome for this patient. LEVEL OF EVIDENCE: Level 4.

A review advocating caution with Major League Soccer expansion and investment in more rehabilitation professionals.

BACKGROUND AND PURPOSE: Major League Soccer (MLS) has aggressively expanded from 10 teams to 23 teams. With the addition of more teams, the league will have to dictate a schedule that maximizes the league's popularity, while also maintaining the health of the players. A longer season and congested game schedule could increase the risk of injury for players. The purpose of this commentary is to make recommendations for the prevention of injuries among MLS players with respect to proposed league expansion. DESCRIPTION OF TOPIC: MLS has lengthened the regular season with each expansion in teams. An increase in season length was seen in conjunction with the MLS expansion from 14 to 19 teams during the 2008 through 2013 seasons. Data from the inaugural MLS season found injury rates were higher in games compared to practices and more injuries occurred later in the season. With the expansion of MLS, anterior cruciate ligament tears appeared to have increased each year. DISCUSSION: Current evidence suggests the implementation of a proper preseason in addition to the once-per-week game frequency would best promote player health and well-being. Players may benefit from in-season injury prevention training and weekly load monitoring.

Cervical myelopathy causing numbness and paresthesias in lower extremities: A case report identifying the cause of a false positive Sharp-Purser test.

INTRODUCTION: The patient was referred to an outpatient physical therapy clinic for lumbar radiculopathy by a primary care physician and subsequently referred for imaging due to suspicion of cervical myelopathy. The case highlights the clinical reasoning of the physical therapist differentiating between lumbar stenosis, cervical myelopathy, and upper cervical instability. To the author's knowledge, this is the only case report in the literature to describe the mechanism that could underpin a false positive Sharp-Purser test (SPT). The case also highlights the importance of interpreting the outcomes of special tests cautiously. CASE DESCRIPTION: A 55-year-old female was referred to outpatient physical therapy for lumbar radiculopathy. The patient's complaint was a one-year history of intermittent bilateral lower buttock paresthesias radiating to the bilateral posterior thighs. She reported a three-month history of bilateral anterior thigh numbness that would present after sitting for 30 minutes. Lumbar stenosis was initially suspected, however the patient's failure to improve but rather worsen with flexed postures suggested this diagnosis was improbable. The patient experienced bilateral anterior thigh numbness with active cervical flexion, and had a reduction in symptoms with the SPT. OUTCOMES: Magnetic resonance imaging revealed multi-focal disc-osteophyte complexes with central canal stenosis from C4-7. The patient underwent an anterior cervical discectomy and fusion with a good outcome. DISCUSSION: A large disc herniation causing central canal stenosis could underpin a false positive SPT. Special tests should always be used with caution, as they can lead to inaccurate diagnoses if there is a false positive.

The Effects of Needling Therapies on Muscle Force Production: A Systematic Review and Meta-analysis.

BACKGROUND: Needling has been shown to decrease pain in the short term; however, its effects on muscle force production are unclear. OBJECTIVE: To evaluate the evidence regarding the comparative effects of needling on muscle force production. METHODS: In this systematic review, an electronic search was performed using key words related to needling. Methodological quality of articles was appraised and effect sizes were calculated. The strength of evidence was determined, and meta-analysis was performed when similar methods were used in studies for similar conditions. RESULTS: Twenty-one studies were included in this review, of which 9 were deemed to be of high quality (greater than 6/10 on the Physiotherapy Evidence Database [PEDro] scale), 11 of fair quality (5 to 6/10), and 1 of poor quality (less than 5/10). Three meta-analyses were performed. There was moderate strength of evidence and medium effect sizes for needling therapy to enhance force production in those with neck pain, and very low strength of evidence of no effect for individuals with nonspecific and postoperative shoulder pain and those with lateral epicondylalgia. Other studies not included in the 3 meta-analyses demonstrated no significant effect of needling on force production. These studies included individuals with carpal tunnel syndrome, knee osteoarthritis, ankle sprains, knee arthroscopy, or delayed-onset muscle soreness. CONCLUSION: The majority of studies suggest no effect of dry needling on force production. High-quality studies with adequate power that control for the placebo effect and follow accepted reporting standards could make valuable contributions to the literature. This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42017080318). LEVEL OF EVIDENCE: Therapy, level 1a. J Orthop Sports Phys Ther 2019;49(3):154-170. Epub 30 Nov 2018. doi:10.2519/jospt.2019.8270.

Differential examination, diagnosis and management for tingling in toes: fellow's case problem.

BACKGROUND: The diagnosis of chronic exertional compartment syndrome can be challenging as other pathologies involving bone, muscle, nerve and vascular structures can mimic the syndrome. The purpose of this Fellow's Case Problem is to describe the clinical decision-making and physical therapy differential diagnosis regarding a 25-year-old patient with un-resolved neurovascular complaints following chronic exertional compartment syndrome surgical release. DIAGNOSIS: After surgery, the patient's previous complaint of numbness and tingling in the plantar surfaces of her first and second toes of right foot was still present. The patient's concordant symptoms in toes were reproduced proximally in the lumbar spine and distally in the tarsal tunnel. DISCUSSION: The lumbar spine can refer symptoms to the lower extremities and needs to be ruled out as the source of the patient's complaint whenever neurovascular symptoms such as numbness and tingling are present. The discovery of the relationship of the lumbar spine with the tingling in the toes addressed one of the patient's primary concerns that was not resolved from the surgery. LEVEL OF EVIDENCE: 4.