Manipulative Therapy for Lower Extremity Conditions: Update of a Literature Review

Evaluate the Influencing Factors of Congruency of the First Metatarsophalangeal Joint in Hallux Valgus Based on Weightbearing CT

The purpose of this study was to explore the difference between congruency and incongruency of the first metatarsophalangeal (MTP) joint in hallux valgus using weightbearing CT (WBCT) and to identify the risk factors for incongruency. From January 2019 to January 2021, WBCT scans were retrospectively analyzed for 110 (191 feet) consecutive patients. According to whether the metatarsal articular surface and phalanx articular surface were parallel, they were divided into congruency (73 feet) and incongruency groups (118 feet). The age, intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular surface angle (DMAA), first metatarsal coronal pronation angle (α angle), tibial sesamoid 7 positions (TSP), and tibial sesamoid coronal grading (TSCG) were compared between the 2 groups. Binary logistic regression was used to analyze the influencing factors of incongruency. Receiver operating characteristic (ROC) curve analysis was applied to determine the cutoff value. There were significant differences in IMA, HVA, DMAA, α angle, age, TSP, and TSCG between congruency and incongruency groups (p < .05). Binary logistic regression analysis showed that TSCG, HVA, α angle were the influencing factors of incongruency. ROC curve analysis demonstrated that the cutoff values for incongruency were 1 position for TSCG (sensitivity: 0.835; specificity: 0.884) with the area under curve (AUC) of 0.892, 30° (sensitivity: 0.795; specificity: 0.812) for HVA with the AUC of 0.878, and 24° (sensitivity: 0.530; specificity: 0.797) for α angle with the AUC of 0.686. Incongruency of the first MTP joint indicated a more severe hallux valgus, and was associated with increased HVA, α angle, and TSCG.

Physiotherapeutic Strategies and Their Current Evidence for Canine Osteoarthritis

Osteoarthritis (OA) is a common and debilitating condition in domestic dogs. Alongside pharmaceutical interventions and weight loss, exercise and physiotherapy (PT) are important measures in maintaining patient mobility and quality of life. Physiotherapy for OA aims to reduce pain, optimize muscular function and maintain joint function. Physiotherapeutic plans typically include PT exercises combined with therapeutic modalities, lifestyle and environmental modifications to improve the patient's overall quality of life and function. Information on therapeutic clinical efficacy of physiotherapeutic measures for canine OA is still very limited. Thus, physiotherapeutic strategies are still primarily based on evidence extrapolated from human protocols tailored to people with OA. The authors propose a simple systematic PT approach for canine OA, prioritizing measures according to simplicity, cost effectiveness and practicality. This guide (the "Physiotherapy Pyramid") aims to provide a clear stratified approach to simplify decision making and planning for owners, veterinarians and veterinary physiotherapists, leading to more straightforward design and implementation of treatment plans. Measures are implemented starting at the base of the pyramid, subsequently progressing to the top, allowing effective and practical interventions to be prioritized. The levels of the pyramid are in ascending order: environmental modification, exercise plan, OA-specific home exercises and treatment by a veterinary physiotherapist.

The Effect of Manual Therapy Plus Exercise in Patients with Lateral Ankle Sprains: A Critically Appraised Topic with a Meta-Analysis

A high percentage of patients with lateral ankle sprains report poor outcomes and persistent neuromuscular impairment leading to chronic ankle instability and re-injury. Several interventions have been proposed and investigated, but the evidence on manual therapy combined with therapeutic exercise for pain reduction and functional improvement is still uncertain. The purpose was to study the effectiveness of adding manual therapy to therapeutic exercise in patients with lateral ankle sprains through a critically appraised topic. The literature search was performed in PubMed, PEDro, EMBASE and CINAHL databases, and only randomized clinical trials were included according to following criteria: (1) subjects with acute episodes of lateral ankle sprains, (2) administered manual therapy plus therapeutic exercise, (3) comparisons with therapeutic exercise alone and (4) reported outcomes for pain and function. Three randomized clinical trials (for a total of 180 patients) were included in the research. Meta-analyses revealed that manual therapy plus exercise was more effective than only exercises in improving dorsal (MD = 8.79, 95% CI: 6.81, 10.77) and plantar flexion (MD = 8.85, 95% CI 7.07, 10.63), lower limb function (MD = 1.20, 95% CI 0.63, 1.77) and pain (MD = -1.23; 95% IC -1.73, -0.72). Manual therapy can be used with therapeutic exercise to improve clinical outcome in patients with lateral ankle sprains.

Acute Ankle Sprain Management: An Umbrella Review of Systematic Reviews

Even though ankle sprains are among the most frequent musculoskeletal injuries seen in emergency departments, management of these injuries continues to lack standardization. Our objective was to carry out an umbrella review of systematic reviews to collect the most effective evidence-based treatments and to point out the state-of-the-art management for this injury. PubMed, Scopus, Web of Science, and the Cochrane library were searched from January 2000 to September 2020. After removing duplicates and applying the eligibility criteria, based on titles and abstracts, 32 studies were screened. At the end of the process, 24 articles were included in this umbrella review with a mean score of 7.7/11 on the AMSTAR quality assessment tool. We found evidence supporting the effectiveness of non-surgical treatment in managing acute ankle sprain; moreover, functional treatment seems to be preferable to immobilization. We also found evidence supporting the use of paracetamol or opioids as effective alternatives to non-steroidal anti-inflammatory drugs to reduce pain. Furthermore, we found evidence supporting the effectiveness of manipulative and supervised exercise therapy to prevent re-injury and restore ankle dorsiflexion.

Talonavicular joint mobilization and foot core strengthening in patellofemoral pain syndrome: a single-blind, three-armed randomized controlled trial

Background

Patellofemoral pain syndrome (PFPS) is defined as pain around the patella while performing activities such as squats, running, and climbing steps. One of the inherent risk factors for PFPS is an excessively pronated foot posture. The aim of this study was to investigate the effect of foot intervention, talonavicular joint mobilization (TJM) and foot core strengthening (FCS), on PFPS.

Methods

Forty-eight patients with PFPS (mean age, 21.96 ± 2.34 years; BMI, 22.77 ± 2.95 kg/m²) were enrolled in the study. Participants were randomly assigned in a 1:1:1 ratio to three groups, and received 12 sessions of TJM, FCS, and blended intervention at university laboratory for 4 weeks. The primary outcomes were pain while the secondary outcomes were lower extremity function, valgus knee, foot posture, and muscle activity ratio measured at baseline, after 12 sessions, and at the 4-week follow-up.

Results

The two-way repeated-measures ANOVA revealed significant interactions in all groups (p < 0.05). TJM reduced pain more than the FCS at post-test (mean difference, − 0.938; 95% Confidence interval [CI], − 1.664 to − 0.211; p < 0.05), and blended intervention improved lower extremity function (mean difference, 6.250; 95% CI, 1.265 to 11.235; p < 0.05) and valgus knee (mean difference, − 11.019; 95% CI, − 17.007 to − 5.031; p < 0.05) more than the TJM at 4 weeks follow-up. TJM was more effective in post-test (mean difference, − 1.250; 95% CI, − 2.195 to − 0.305; p < 0.05), and TJM (mean difference, − 1.563; 95% CI, − 2.640 to − 0.485; p < 0.05) and blended intervention (mean difference, − 1.500; 95% CI, − 2.578 to − 0.422; p < 0.05) were more effective in foot posture than the FCS in 4 weeks follow-up. Blended intervention displayed greater improvement in muscle activity than the TJM (mean difference, 0.284; 95% CI, 0.069 to 0.500; p < 0.05) and the FCS (mean difference, 0.265; 95% CI, 0.050 to 0.481; p < 0.05) at 4 weeks follow-up.

Conclusions

Our study is a novel approach to the potential impact of foot interventions on patellofemoral pain. Foot intervention including TJM and FCS is effective for pain control and function improvement in individuals with PFPS.

Trial registration

KCT0003176, 16/08/2018 (retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05099-x.

A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis

The number of systematic review and meta-analyses on plantar fasciitis is expanding. The purpose of this review was to provide a comprehensive summary of reviews on the topic pertaining to plantar fasciitis, identify any conflicting and inconsistent results, and propose future research direction. A qualitative review of all systematic reviews and meta-analyses related to plantar fasciitis up to February 2021 was performed using PubMed, Embase, Web of Science, and the Cochrane Database. A total of 1052 articles were initially identified and 96 met the inclusion criteria. Included articles were summarized and divided into the following topics: epidemiology, diagnosis, and treatment. While the majority of reviews had high level of heterogeneity and included a small number of studies, there was general consensus on certain topics, such as BMI as a risk factor for plantar fasciitis and extracorporeal shockwave therapy as an effective mode of therapy. A qualitative summary of systematic reviews and meta-analyses published on plantar fasciitis provides a single source of updated information for clinicians. Evidence on topics such as the epidemiology, exercise therapy, or cost-effectiveness of treatment options for plantar fasciitis are lacking and warrant future research.

The Efficacy of Manual Therapy in Patients with Knee Osteoarthritis: A Systematic Review

Background and objectives: Osteoarthritis (OA) is among the most common degenerative diseases that induce pain, stiffness and reduced functionality. Various physiotherapy techniques and methods have been used for the treatment of OA, including soft tissue techniques, therapeutic exercises, and manual techniques. The primary aim of this systemic review was to evaluate the short-and long-term efficacy of manual therapy (MT) in patients with knee OA in terms of decreasing pain and improving knee range of motion (ROM) and functionality. Materials and Methods: A computerised search on the PubMed, PEDro and CENTRAL databases was performed to identify controlled randomised clinical trials (RCTs) that focused on MT applications in patients with knee OA. The keywords used were 'knee OA', 'knee arthritis', 'MT', 'mobilisation', 'ROM' and 'WOMAC'. Results: Six RCTs and randomised crossover studies met the inclusion criteria and were included in the final analysis. The available studies indicated that MT can induce a short-term reduction in pain and an increase in knee ROM and functionality in patients with knee OA. Conclusions: MT techniques can contribute positively to the treatment of patients with knee OA by reducing pain and increasing functionality. Further research is needed to strengthen these findings by comparing the efficacy of MT with those of other therapeutic techniques and methods, both in the short and long terms.

Effectiveness of local exercise therapy versus spinal manual therapy in patients with patellofemoral pain syndrome: medium term follow-up results of a randomized controlled trial

Background

Increasing evidence has shown benefits of spinal manipulations in patients with patellofemoral pain syndrome (PFPS). There is scarcity regarding medium term effects of spinal manual therapy on outcome measures in PFPS patients. Therefore, the aim of the present study was to compare the effectiveness of local exercise therapy and spinal manual therapy for knee pain, function and maximum voluntary peak force (MVPF) velocity of the quadriceps in PFPS patients.

Methods

Forty-three patients with PFPS were randomly assigned to a local exercise or spinal manual therapy group. The local exercise group received six sessions (one session per week) of supervised training of the knee-and hip muscles with mobilization of the patellofemoral joint. The spinal manual therapy group received six interventions (one intervention per week) of high velocity low thrust manipulations at the thoracolumbar region, sacroiliac joint, and/or hip. All patients were also asked to do home exercises. Maximum, minimum and current pain were measured using the visual analogue scale. Function was assessed with the anterior knee pain scale (AKPS) and MPFV was recorded using a Biodex System 3 dynamometer. Patients were assessed before intervention, after 6 weeks of intervention and after 6 weeks of follow-up. Between-group differences at assessments were analysed by way of analysis of covariance with Bonferroni correction.

Results

Pain and functionality improved more following spinal manipulative therapy than local exercise therapy. After 6 weeks of intervention the between-group difference (local versus spinal) for maximal pain was 23.4 mm [95% CI: 9.3, 37.6; effect size (ES): 1.04] and − 12.4 [95% CI: − 20.2, − 4.7; ES: 1.00] for the AKPS. At 6 weeks of follow-up the between-group difference for maximal pain was 18.7 mm [95% CI: 1.4, 36.0; ES: 0.68] and − 11.5 [95% CI: − 19.9, − 3.3; ES: − 0.87] for the AKPS.

Conclusions

This study suggests that spinal manual therapy is more effective than local exercise therapy in improving pain and function in patients with PFPS in the medium term. We suggest for future research to investigate whether combining local exercise therapy and spinal manual therapy is more effective than either single intervention on its own.

This clinical trial study was approved by the Medical Ethics Committee METC Z under registration number NL57207.096. and registered retrospectively in ClinicalTrials.gov PRS with registration ID number NCT04748692 on the 10th of February 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04310-9.

The functional capacity and morphological characteristics of the intrinsic foot muscles in subjects with Hallux Valgus deformity: A systematic review

BACKGROUND

The intrinsic foot muscles are vital for maintaining normal foot function. This study was conducted to systematically review the literature on the functional capacity and morphological characteristics of the intrinsic foot muscles in subjects with Hallux Valgus (HV) deformity.

METHODS

A search was carried out in all available electronic databases, including Pub Med, Scopus, Embase and Web of Science, for identifying any relevant studies published from 1990 to October 2018.

RESULTS

Three studies had investigated intrinsic foot muscle size using ultrasound imaging; two had reported electromyography parameters and four had measured the muscle force capacity. The results of the present review suggested that the functional capacity and morphological characteristics of intrinsic foot muscles are different in subjects with HV compared to those without this deformity.

CONCLUSION

This review found scientific evidence on muscle performance impairment in the abductor hallucis and flexor hallucis brevis in subjects with HV deformity.

Chiropractic Day: A Historical Review of a Day Worth Celebrating

OBJECTIVE

The purpose of this paper is to review and discuss historical concepts about the celebration of Chiropractic Day.

DISCUSSION

Daniel David Palmer attributed September 18, 1895 to be the day that he delivered the first chiropractic adjustment. As the chiropractic profession grew, the celebration of Chiropractic Day became more widespread throughout the United States and the world. This paper offers suggestions about how to celebrate Chiropractic Day. Activities include educating, learning, honoring, volunteering, and engaging.

CONCLUSION

The chiropractic profession celebrates its birth on September 18. Regardless of the many different names used over the past 125 years, including Chiropractic Founder's Day, Chiropractic Rally Day, Chiropractic Anniversary, and Chiropractic Discovery Day, the celebration of this special day provides an opportunity to reflect on how far the profession has come and how chiropractors continue to help and serve their patients.

Physical Therapist Management of Anterior Knee Pain

PURPOSE OF REVIEW

Anterior knee pain is a common musculoskeletal complaint among people of all ages and activity levels. Non-operative approaches with an emphasis on physical therapy management are the recommended initial course of care. The purpose of this review is to describe the current evidence for physical therapist management of anterior knee pain with consideration of biomechanical and psychosocial factors.

RECENT FINDINGS

The latest research suggests anterior knee pain is a combination of biomechanical, neuromuscular, behavioral, and psychological factors. Education strategies to improve the patient's understanding of the condition and manage pain are supported by research. Strong evidence continues to support the primary role of exercise therapy and load progression to achieve long-term improvements in pain and function. Preliminary studies suggest blood flow restriction therapy and movement retraining may be useful adjunct techniques but require further well-designed studies. Anterior knee pain includes multiple conditions with patellofemoral pain being the most common. An insidious onset is typical and often attributed to changes in activity and underlying neuromuscular impairments. A thorough clinical history and physical examination aim to identify the patient's pain beliefs and behaviors, movement faults, and muscle performance that will guide treatment recommendations. Successful physical therapist management involves a combination of individualized patient education, pain management, and load control and progression, with an emphasis on exercise therapy.

Arthrofibrosis of the Ankle

Arthrofibrosis is a common, but often overlooked, condition that imparts significant morbidity following injuries and surgery to the foot and ankle. The most common etiologies are related to soft tissue trauma with subsequent fibrotic and contractile scar tissue formation within the ligaments and capsule of the ankle. This leads to pain, alterations in gait, and ankle dysfunction. Initial treatment often includes extensive physical therapy, however, if severe enough surgical options exist. Although the literature regarding ankle arthrofibrosis is scarce, this review article provides a greater understanding of the pathogenesis of arthrofibrosis and describes the current and future therapeutic options to treat fibrotic joints. Level of Evidence: Level V, expert opinion.

Manual Therapy (Postisometric Relaxation and Joint Mobilization) in Knee Pain and Function Experienced by Patients with Rheumatoid Arthritis: A Randomized Clinical Pilot Study

Objectives

The purpose of this study was to evaluate the impact of manual therapy on the management of rheumatoid arthritis (RA) patients with knee pain.

Materials and Methods

This was a small, randomized clinical pilot study. Subjects were 46 patients with diagnosed RA, randomly assigned to the manual therapy group (postisometric relaxation and joint mobilization) or control group (standard exercise). Subjects in each group had 10 sessions of interventions, once a day with one day break after the sixth day. Outcomes included the pain intensity of knee, Knee Society Score, Oxford Knee Score, and Health Assessment Questionnaire.

Results

There were no statistically significant differences between groups, except for the pain intensity of the knee.

Conclusions

This study suggests that manual therapy (postisometric relaxation and joint mobilization) may have clinical benefits for treating knee pain and function in rheumatoid patients. Further extended studies are expected to determine the effectiveness of manual therapy in RA patients with knee pain.

The Biomechanical Relationship between Hallux Valgus Deformity and Metatarsal Pain

Metatarsal pain is a common pathological outcome in patients with a hallux valgus (HV) deformity. However, the relationship between the degree of HV deformity and metatarsal pain has not been systematically examined. The purpose of the present study was to investigate the correlation between metatarsal pain and the degree of HV deformity. Between October 2017 and September 2018, 512 HV patients (944 feet) participated in an evaluation of their HV angle (HVA) using X-ray images. The participants were divided into four groups corresponding to their HVA (<15°, 15° to 20°, 21° to 40°, or >40°). Load rate, impulse, contact duration, and contact area were measured and recorded as dynamic gait parameters using the RsScan system. Data were evaluated using SPSS statistical software. The visual analog scale (VAS) was used to assess metatarsal pain. For the four HV deformity groups, the peak value of impulse and contact duration was concentrated on the second and third metatarsals (Meta2 and Meta3) (P < 0.05); contact area was also shown on metatarsals 1, 2, and 5 (P < 0.05). Metatarsal pain on Meta2 had the highest VAS score (VAS: 6.57), followed by Meta3 (Mean VAS: 5.72). In the HV > 40° group, the load location on Meta2 was transferred to Meta1. The percent of pain attributed to Meta2 and Meta3 was also increased in this group. These findings illustrated that metatarsal pain was primarily located on Meta2 and Meta3 in the different degrees of HV deformity. This information can provide the location to target for pain relief and help guide further rehabilitation.

Assessment and Management of Somatic Dysfunctions in Patients With Patellofemoral Pain Syndrome

Context

Patellofemoral pain syndrome (PFPS) is one of the most common determinants of knee pain. The causes of PFPS are multifactorial, and most treatment approaches are conservative. There are many kinds of therapy for this syndrome, which are based on building strength, flexibility, proprioception, and endurance. Training is functional and progression is gradual. Our hypothesis is that total-body osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) focused on the management of somatic dysfunctions could be useful for managing the pain of patients with PFPS.

Objective

To investigate the effect of OMTh on pain reduction in patients with PFPS.

Methods

This pilot study was randomized, controlled, and single-blinded with 2 months of follow-up. Qualified participants were randomly assigned to 1 of 2 groups: OMTh group or placebo group. Each participant received either 4 sessions of OMTh or 4 sessions of manual placebo intervention that consisted of passive touching without joint mobilization in a protocolled order. A visual analogue scale (VAS) was used to assess general knee pain, peripatellar pain, pain after prolonged sitting, pain during the patellar compression test, and pain during stair ascent and descent. Pain assessment was performed before the baseline (T0), second (T1), third (T2), and fourth (T3) sessions, and follow-up (T4) was performed 8 weeks after T3.

Results

Thirty-five participants were enrolled the study. The VAS score was significantly reduced and clinically relevant in the OMTh group after each treatment and after 2 months of follow-up. The change in the VAS score before each treatment indicates that the most improved areas at T1 compared with T0 were lumbar and sacral with improvements in 83% and 40% of patients, respectively. At T2 compared with T1, the most improved areas were cervical and sacral with improvements found in 58% and 36% of patients, respectively. The number of dysfunctions that were diagnosed decreased during the baseline to T3 period (40% change). The correlation analysis showed significant results for the dysfunction and the compression test at T2 (P=.01, ρ=0.543).

Conclusion

Significant differences in VAS scores were found between the OMTh and placebo groups. These findings underline how OMTh can lead to reduced pain in patients with PFPS.

Effectiveness of Manual Therapy, Customised Foot Orthoses and Combined Therapy in the Management of Plantar Fasciitis-a RCT

Background: Plantar fasciitis (PF) is one of the most common causes of plantar heel pain. Objective: To evaluate the effectiveness of three different treatment approaches in the management of PF. Methods: Sixty-three patients (44 female, 19 men; 48.4 ± 9.8 years) were randomly assigned into a manual therapy (MT), customised foot orthosis (FO) and a combined therapy (combined) group. The primary outcomes of pain and function were evaluated using the American Orthopaedic Foot and Ankle Society-Ankle Hindfoot Scale (AOFAS-AHS) and the patient reported outcome measure (PROM) Foot Pain and Function Scale (FPFS). Data were evaluated at baseline (T0) and at follow-up sessions after 1 month, 2 months and 3 months (T1–T3). Results: All three treatments showed statistically significant (p < 0.01) improvements in both scales from T0 to T1. However, the MT group showed greater improvements than both other groups (p < 0.01). Conclusion: Manual therapy, customised foot orthoses and combined treatments of PF all reduced pain and function, with the greatest benefits shown by isolated manual therapy.

Biomechanical evaluation of the first ray in pre-/post-operative hallux valgus: A comparative study

BACKGROUND

Deformity of the first ray in hallux valgus patient has been deemed to mainly contribute to instability of the metatarsophalangeal joint. However, it is not clear whether the fixation of the distal osteotomy fragment and transposition of the sesamoid represent the best method for hallux valgus treatment. The aim of this study was to examine how postoperative hallux valgus osteotomy affects the stability of the first ray.

METHODS

To accurately investigate the biomechanical behavior of the first ray in pre-/postoperative hallux valgus patients, we described the relative displacement and stress distribution of the first metatarsal bone and sesamoid by imageology, test measurement and foot finite element model.

FINDINGS

Compared with the preoperative hallux valgus, the plantar pressure decreased by 47.8% and was redistributed on second metatarsal region. The peak stress and relative displacement of the distal osteotomy fragment increased by +55.7% and -59.9%, respectively. The movement of this component shifted toward the positive sagittal axis direction. In addition, the relative displacement of sesamoid decreased by 87.4% (0.18 mm) in vertical axis direction and the stress was also redistributed on medial and lateral region. Moreover, the strain of the medial main ligament was more favorable to reconstruct function of the first ray.

INTERPRETATION

The findings showed that the osteotomy method was helpful for stability of the first ray. This would provide the stability suggestions for postoperative hallux valgus fixation and guide further rehabilitation.

Rehabilitation of Tibial Plateau Fracture Following Anterior Cruciate Ligament Reconstruction: A Case Report

Objective

The purpose of this case report was to describe the management of a tibial plateau fracture in a patient who had undergone anterior cruciate ligament (ACL) reconstruction 3.5 years earlier.

Clinical Features

A 36-year-old man presented with pain and edema following a fall from a height of approximately 2 m while skateboarding. The patient reported having undergone arthroscopic ACL reconstruction with allograft and bioabsorbable screws 3.5 years earlier. Computed tomography scan revealed a comminuted fracture extending through the graft tunnel, as well as evidence of tunnel widening and incomplete bone resorption and generation within the tibial tunnel.

Intervention and Outcome

A trauma surgeon repaired the plateau fracture with internal fixation. The patient was non-weight bearing for 8 weeks while undergoing rehabilitation in a chiropractic clinic (spinal manipulation, physiotherapy, nutritional support) twice per week and returned to full activity within 3 months.

Conclusions

The patient responded favorably to the treatment protocol, which included rehabilitation by a doctor of chiropractic and co-management with a trauma surgeon.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to hip pain and mobility deficits. J Orthop Sports Phys Ther. 2017;47(6):A1-A37. doi:10.2519/jospt.2017.0301.

The risk associated with spinal manipulation: an overview of reviews

BACKGROUND

Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. We performed an overview of reviews to elucidate and quantify the risk of serious adverse events (SAEs) associated with SMT.

METHODS

We searched five electronic databases from inception to December 8, 2015. We included reviews on any type of studies, patients, and SMT technique. Our primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Since there were insufficient data for calculating incidence rates of SAEs, we used an alternative approach; the conclusions regarding safety of SMT were extracted for each review, and the communicated opinion were judged by two reviewers independently as safe, harmful, or neutral/unclear. Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated.

RESULTS

We identified 283 eligible reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) expressed that SMT is harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present, with a median of 4 of 11 AMSTAR items met (interquartile range, 3 to 6). Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe.

CONCLUSIONS

It is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015030068 .

Chiropractic Identity: A Neurological, Professional, and Political Assessment

OBJECTIVE

The purpose of this article is to propose a focused assessment of the identity of chiropractic and its profession, triangulating multiple viewpoints converging upon various aspects and definitions of neurology, manual medicine, and alternative or mainstream medicine.

DISCUSSION

Over 120 years since its inception, chiropractic has struggled to achieve an identity for which its foundations could provide optimal health care. Despite recognition of the benefits of spinal manipulation in various government guidelines, advances in US military and Veterans Administration, and persistently high levels of patient satisfaction, the chiropractic profession remains underrepresented in most discussions of health care delivery. Distinguishing characteristics of doctors of chiropractic include the following: (1) they embrace a model of holistic, preventive medicine (wellness); (2) they embrace a concept of neurological imbalance in which form follows function, disease follows disturbed biochemistry, and phenomenology follows physiology; (3) they diagnose, and their institutions of training are accredited by a body recognized by the US Department of Education; (4) they manage patients on a first-contact basis, often as primary care providers in geographical areas that are underserved; (5) the spine is their primary-but not exclusive-area of interaction; (6) they deliver high-velocity, low-amplitude adjustments with a superior safety record compared with other professions; and (7) they use a network of institutions worldwide that have shown increasing commitments to research.

CONCLUSION

This article provides an overview of chiropractic identity from 6 points of view: (1) concepts of manual medicine; (2) areas of interest beyond the spine; (3) concepts of the chiropractic subluxation; (4) concepts of neurology; (5) concepts of mainstream or alternative health care; and (6) concepts of primary care, first-contact provider, or specialist.

Joint Manipulation Under Anesthesia for Arthrofibrosis After Hallux Valgus Surgery

Arthrofibrosis is a known complication of hallux valgus surgery. Joint manipulation under anesthesia has been studied for adhesive capsulitis of the shoulder; however, a paucity of published data exists on the use of this modality in the foot and ankle. The purpose of the present study was to investigate the outcomes of first metatarsophalangeal joint manipulation for arthrofibrosis that occurred as a complication of bunion surgery. The study population consisted of patients attending a single foot and ankle specialty clinic who were evaluated for arthrofibrosis after bunion surgery. Patients who underwent joint manipulation under anesthesia were asked to complete a research visit in which a clinical examination was performed and the presence and severity of joint pain were assessed. A total of 38 patients (34 females, 4 males, 53 feet), with a mean age of 55.7 ± 11.8 (range 30 to 83) years, agreed to participate. The mean follow-up period was 6.5 ± 3.4 (range 1 to 17) years. The visual analog scale scores improved significantly from baseline to the final follow-up visit (baseline 6.5 ± 1.5, range 2 to 10; final follow-up visit 2.3 ± 1.5, range 0 to 6; p < .001). Furthermore, joint motion had increased significantly (p < .001) for both dorsiflexion and plantarflexion at the final follow-up examination. The final range of motion (dorsiflexion, r = -0.431, p = .002; plantarflexion, r = -0.494, p < .001) correlated highly with patient self-reported pain in the first metatarsophalangeal joint. Our findings suggest that joint manipulation could be a useful modality for increasing first metatarsophalangeal joint mobility and alleviating pain in patients who experience arthrofibrosis after surgical correction of hallux valgus.

Knee orthoses for treating patellofemoral pain syndrome

BACKGROUND

Patellofemoral pain syndrome (PFPS) is a painful musculoskeletal condition, which is characterised by knee pain located in the anterior aspect (front) and retropatellar region (behind) of the knee joint. Various non-operative interventions are suggested for the treatment of this condition. Knee orthoses (knee braces, sleeves, straps or bandages) are worn over the knee and are thought to help reduce knee pain. They can be used in isolation or in addition to other treatments such as exercise or non-steroidal anti-inflammatory medications.

OBJECTIVES

To assess the effects (benefits and harms) of knee orthoses (knee braces, sleeves, straps or bandages) for treating PFPS.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (11 May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015 Issue 5), MEDLINE (1946 to 8 May 2015), EMBASE (1980 to 2015 Week 18), SPORTDiscus (1985 to 11 May 2015), AMED (1985 to 8 May 2015), CINAHL (1937 to 11 May 2015), PEDro (1929 to June 2015), trial registries and conference proceedings.

SELECTION CRITERIA

Randomised and quasi-randomised controlled clinical trials evaluating knee orthoses for treating people with PFPS. Our primary outcomes were pain and function.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility, assessed study risk of bias and extracted data. We calculated mean differences (MD) or, where pooling data from different scales, standardised mean differences (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CIs for binary outcomes. We pooled data using the fixed-effect model.

MAIN RESULTS

We included five trials (one of which was quasi-randomised) that reported results for 368 people who had PFPS. Participants were recruited from health clinics in three trials and were military recruits undergoing training in the other two trials. Although no trials recruited participants who were categorised as elite or professional athletes, military training does comprise intensive exercise regimens. All five trials were at high risk of bias, including performance bias reflecting the logistical problems in these trials of blinding of participants and care providers. As assessed using the GRADE approach, the available evidence for all reported outcomes is 'very low' quality. This means that we are very uncertain about the results.The trials covered three different types of comparison: knee orthosis and exercises versus exercises alone; one type of orthosis versus another; and knee orthosis versus exercises. No trials assessed the mode of knee orthosis use, such as whether the orthosis was worn all day or only during physical activity. Two trials had two groups; two trials had three groups; and one trial had four groups.All five trials compared a knee orthosis (knee sleeve, knee brace, or patellar strap) versus a 'no treatment' control group, with all participants receiving exercises, either through a military training programme or a home-based exercise programme. There is very low quality evidence of no clinically important differences between the two groups in short-term (2 to 12 weeks follow-up) knee pain based on the visual analogue scale (0 to 10 points; higher scores mean worse pain): MD -0.46 favouring knee orthoses, 95% CI -1.16 to 0.24; P = 0.19; 234 participants, 3 trials). A similar lack of clinically important difference was found for knee function (183 participants, 2 trials). None of the trials reported on quality of life measures, resource use or participant satisfaction. Although two trials reported on the impact on sporting or occupational participation, one trial (35 participants) did not provide data split by treatment group on the resumption of sport activity and the other reported only on abandonment of military training due to knee pain (both cases were allocated a knee orthosis). One trial (59 participants, 84 affected knees) recording only adverse events in the two knee orthoses (both were knee sleeves) groups, reported 16 knees (36% of 44 knees) had discomfort or skin abrasion.Three trials provided very low quality evidence on single comparisons of different types of knee orthoses: a knee brace versus a knee sleeve (63 participants), a patella strap with a knee sleeve (31 participants), and a knee sleeve with a patellar ring versus a knee sleeve only (44 knees). None of three trials found an important difference between the two types of knee orthosis in pain. One trial found no clinically important difference in function between a knee brace and a knee sleeve. None of the three trials reported on quality of life, resource use or participant satisfaction. One trial comparing a patella strap with a knee sleeve reported that both participants quitting military training due to knee pain were allocated a knee sleeve. One poorly reported trial found three times as many knees with adverse effects (discomfort or skin abrasion) in those given knee sleeves with a patella ring than those given knee sleeves only.One trial compared a knee orthosis (knee brace) with exercise (66 participants). It found very low quality evidence of no clinically important difference between the two intervention groups in pain or knee function. The trial did not report on quality of life, impact on sporting or occupational participation, resource use, participant satisfaction or complications.

AUTHORS' CONCLUSIONS

Overall, this review has found a lack of evidence to inform on the use of knee orthoses for treating PFPS. There is, however, very low quality evidence from clinically heterogeneous trials using different types of knee orthoses (knee brace, sleeve and strap) that using a knee orthosis did not reduce knee pain or improve knee function in the short term (under three months) in adults who were also undergoing an exercise programme for treating PFPS. This points to the need for good-quality clinically-relevant research to inform on the use of commonly-available knee orthoses for treating PFPS.

Manipulative and Multimodal Therapies in the Treatment of Osteoarthritis of the Great Toe: A Case Series

OBJECTIVE

The objective of this case series is to describe manual manipulative therapy with exercise for 3 patients with mild to moderate osteoarthritis of the great toe.

CLINICAL FEATURES

Three patients, a 32-year-old man, a 55-year-old woman, and a 49-year-old woman, had great toe pain of 8, 1, and 2 years, respectively. Each had a palpable exostosis, a benign outgrowth of bone projecting outward from the bone surface, and decreased dorsiflexion with a hard end-feel.

INTERVENTION AND OUTCOME

Manual manipulative therapy with exercise, the Brantingham protocol, was used with patients receiving 6, 9, and 12 treatments over 6 weeks. Specific outcome measures for hallux rigidus and the foot were chosen to document the effects of this intervention including digital inclinometry, the lower extremity functional scale, the foot functional index, overall therapy effectiveness and Visual Analogue Scale (VAS). Each patient had an increase in range of motion that surpassed the minimal clinically important change, an increase in the overall therapy effectiveness and a decrease in the foot functional index that surpassed the minimally clinically important difference. Most importantly for the patients, each reported a decrease in both usual and worst pain on the VAS that exceeded the minimally clinically important difference of 20 to 30 mm.

CONCLUSION

The 3 patients reported decreased pain measured by the VAS, increased range of motion and minimally clinically important difference in 3 other outcome measures.

The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

BACKGROUND

Musculoskeletal disorders (MSDs) of the upper and lower extremities are common in the general population and place a significant burden on the health care system. Manual therapy is recommended by clinical practice guidelines for the management of these injuries; however, there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of manual therapy in adults or children with MSDs of the upper or lower extremity.

METHODS

Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of manual therapy were eligible. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best-evidence synthesis principles. Where available, we computed mean changes between groups, relative risks and 95 % CI.

RESULTS

We screened 6047 articles. Seven RCTs were critically appraised and three had low risk of bias. For adults with nonspecific shoulder pain of variable duration, cervicothoracic spinal manipulation and mobilization in addition to usual care may improve self-perceived recovery compared to usual care alone. For adults with subacromial impingement syndrome of variable duration, neck mobilization in addition to a multimodal shoulder program of care provides no added benefit. Finally, for adults with grade I-II ankle sprains of variable duration, lower extremity mobilization in addition to home exercise and advice provides greater short-term improvements in activities and function over home exercise and advice alone. No studies were included that evaluated the effectiveness of manual therapy in children or for the management of other extremity injuries in adults.

CONCLUSIONS

The current evidence on the effectiveness of manual therapy for MSDs of the upper and lower extremities is limited. The available evidence supports the use of manual therapy for non-specific shoulder pain and ankle sprains, but not for subacromial impingement syndrome in adults. Future research is needed to determine the effectiveness of manual therapy and guide clinical practice.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42014009899.

Efficacy of musculoskeletal manual approach in the treatment of temporomandibular joint disorder: A systematic review with meta-analysis

BACKGROUND

Temporomandibular joint disorder (TMD) requires a complex diagnostic and therapeutic approach, which usually involves a multidisciplinary management. Among these treatments, musculoskeletal manual techniques are used to improve health and healing.

OBJECTIVES

To assess the effectiveness of musculoskeletal manual approach in temporomandibular joint disorder patients.

DESIGN

A systematic review with meta-analysis.

METHODS

During August 2014 a systematic review of relevant databases (PubMed, The Cochrane Library, PEDro and ISI web of knowledge) was performed to identify controlled clinical trials without date restriction and restricted to the English language. Clinical outcomes were pain and range of motion focalized in temporomandibular joint. The mean difference (MD) or standard mean difference (SMD) with 95% confidence intervals (CIs) and overall effect size were calculated at every post treatment. The PEDro scale was used to demonstrate the quality of the included studies.

RESULTS/FINDINGS

From the 308 articles identified by the search strategy, 8 articles met the inclusion criteria. The meta-analysis showed a significant difference (p < 0.0001) and large effect on active mouth opening (SMD, 0.83; 95% CI, 0.42 to 1.25) and on pain during active mouth opening (MD, 1.69; 95% CI, 1.09 to 2.30) in favor of musculoskeletal manual techniques when compared to other conservative treatments for TMD.

CONCLUSIONS

Musculoskeletal manual approaches are effective for treating TMD. In the short term, there is a larger effect regarding the latter when compared to other conservative treatments for TMD.

Correlation of lumbar-hip kinematics between trunk flexion and other functional tasks

OBJECTIVE

The purpose of this study was to explore the relationship between the kinematic profiles of flexion of the upper lumbar and lower lumbar (LL) spine and hip and 3 sagittally dominant functional tasks (lifting, stand-to-sit, and sit-to-stand).

METHODS

Fifty-three participants were recruited for this study. Four sensors were attached to the skin over the S1, L3, T12, and lateral thigh. Relative angles between adjacent sensors were used to quantify the motion for the hip, LL, and upper lumbar spine. Pearson correlation coefficients were used to explore the relationship between the movements and more functional tasks. One-way analysis of variance was used to determine the significance of differences between the variables.

RESULTS

Flexion resulted in a greater or similar range of motion (ROM) to the other tasks investigated for both spinal regions but less ROM for the hip. Strong correlations for ROM are reported between forward flexion tasks and lifting for the LL spine (r = 0.83) and all regions during stand-to-sit and sit-to-stand (r = 0.70-0.73). No tasks were strongly correlated for velocity (r = 0.03-0.55).

CONCLUSION

Strong correlations were only evident for the LL spine ROM between lifting and flexion; all other tasks afforded moderate or weak correlations. This study suggests that sagittal tasks use different lumbar-hip kinematics and place different demands on the lumbar spine and hip.

Heel pain-plantar fasciitis: revision 2014

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to nonarthritic heel pain.

Midfoot and forefoot osteoarthritis

BACKGROUND

Foot osteoarthritis (OA) is linked with chronic foot pain and functional impairment.

OBJECTIVE

To review the current knowledge on midfoot and forefoot OA.

METHODS

PubMed, CINAHL, PEDro, and the ISI Web of Science databases (1950-2013) were searched for keywords: foot OA, midfoot OA, forefoot OA and metatarsal OA. The search was limited to reports in human subjects and English language. Published cohort, cross-sectional studies and clinical trials relating to epidemiology, clinical features, functional impairment, risk factors and treatment were included.

RESULTS

We found heterogeneity in the design, radiographic views and grading systems used among studies. Most of the literature focused on radiographic OA, being the prevalence between 0.1% and 61%, depending on gender, age and joint evaluated. The age and female gender were the main associated factors, whereas structural (bone length) and mechanical factors (hypermobility, altered tarso-metatarsal stress, etc.) seemed to be related. Various treatments are widely used, i.e. physical therapy, orthotics, steroid injection, analgesics and arthrodesis. However, scarce research supports their efficacy.

CONCLUSION

Most of the current knowledge comes from observational and small case-control studies. Future population-based studies as well as controlled studies are essential to understand the risk factors and to evaluate the effectiveness of treatment options.

[Proposed global treatment algorithm for hallux rigidus according to evidence-based medicine]

INTRODUCTION

Hallux rigidus is the most common arthritis of the foot and ankle. There are numerous reviews on the surgical treatment, but few publications that address the effectiveness of conservative treatment.

OBJECTIVE

To present a comprehensive algorithm for treatment of all grades of this disease.

METHODS

Literature search in the following sources: Pubmed and PEDro database (physiotherapy evidence database) until October 2013 for articles on treatment hallux rigidus to record levels of evidence.

RESULTS

A total of 112 articles were obtained on conservative treatment and 609 on surgical treatment. Finally, only 4 met the inclusion criteria.

CONCLUSIONS

The use of orthoses or footwear modifications, infiltration with hyaluronate, cheilectomy in moderate degrees and the metatarsophalangeal arthrodesis for advanced degrees, are the only procedures contrasted with grade B or moderate evidence in the treatment of hallux rigidus.

Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report

BACKGROUND

This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report.

METHODS

A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added.

RESULTS

25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive.

CONCLUSIONS

Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted.

Manual physical therapy and exercise versus supervised home exercise in the management of patients with inversion ankle sprain: a multicenter randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVE

To compare the effectiveness of manual therapy and exercise (MTEX) to a home exercise program (HEP) in the management of individuals with an inversion ankle sprain.

BACKGROUND

An in-clinic exercise program has been found to yield similar outcomes as an HEP for individuals with an inversion ankle sprain. However, no studies have compared an MTEX approach to an HEP.

METHODS

Patients with an inversion ankle sprain completed the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, the FAAM sports subscale, the Lower Extremity Functional Scale, and the numeric pain rating scale. Patients were randomly assigned to either an MTEX or an HEP treatment group. Outcomes were collected at baseline, 4 weeks, and 6 months. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance. The hypothesis of interest was the 2-way interaction (group by time).

RESULTS

Seventy-four patients (mean ± SD age, 35.1 ± 11.0 years; 48.6% female) were randomized into the MTEX group (n = 37) or the HEP group (n = 37). The overall group-by-time interaction for the mixed-model analysis of variance was statistically significant for the FAAM activities of daily living subscale (P<.001), FAAM sports subscale (P<.001), Lower Extremity Functional Scale (P<.001), and pain (P ≤.001). Improvements in all functional outcome measures and pain were significantly greater at both the 4-week and 6-month follow-up periods in favor of the MTEX group.

CONCLUSION

The results suggest that an MTEX approach is superior to an HEP in the treatment of inversion ankle sprains. Registered at clinicaltrials.gov (NCT00797368).

LEVEL OF EVIDENCE

Therapy, level 1b-.

Knee osteoarthritis related pain: a narrative review of diagnosis and treatment

BACKGROUND

Osteoarthritis is a common progressive joint disease, involving not only the joint lining but also cartilage, ligaments, and bone. For the last ten years, majority of published review articles were not specific to osteoarthritis of the knee, and strength of evidence and clinical guidelines were not appropriately summarized.

OBJECTIVES

To appraise the literature by summarizing the findings of current evidence and clinical guidelines on the diagnosis and treatment of knee osteoarthritis pain.

METHODOLOGY

English journal articles that focused on knee osteoarthritis related pain were searched via PubMed (1 January 2002 - 26 August 2012) and Physiotherapy Evidence Database (PEDro) databases, using the terms 'knee', 'osteoarthritis' and 'pain'. In addition, reference lists from identified articles and related book chapters were included as comprehensive overviews.

RESULTS

For knee osteoarthritis, the highest diagnostic accuracy can be achieved by presence of pain and five or more clinical or laboratory criteria plus osteophytes. Some inconsistencies in the recommendations and findings were found between the clinical guidelines and systematic reviews. Generally, paracetamol, oral and topical non-steroidal anti-inflammatory drugs, opioids, corticosteroid injections and physical therapy techniques, such as therapeutic exercises, joint manual therapy and transcutaneous electrical nerve stimulation, can help reduce pain and improve function. Patient education programs and weight reduction for overweight patients are important to be considered.

CONCLUSIONS

Some inconsistencies in the recommendations and findings were found between the clinical guidelines and systematic reviews. However, it is likely that a combination of pharmacological and non-pharmacological treatments is most effective in treating patients with knee osteoarthritis.

Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review

OBJECTIVE

The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ).

METHODS

A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of "A, B, C and I" were applied.

RESULTS

Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term.

CONCLUSION

The information from this study will help guide practitioners in the use of MMT, soft tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence.

Immediate effects of bilateral grade III mobilization of the talocrural joint on the balance of elderly women

OBJECTIVE

The purpose of this study was to evaluate the immediate effects of a single treatment session of bilateral grade III mobilization of the talocrural joint on the balance of elderly women.

METHODS

Thirty-two elderly women (age, 65-80 years) with low physical activity levels completed balance evaluation using baropodometry, the Functional Reach Test and the Timed Up and Go Test, and plantar flexion and dorsiflexion range of motion (ROM), before and immediately after the mobilization (n = 16) or sham (n = 16). Each subject was submitted to a total of twelve 30-second grade III mobilizations, 6 for each ankle, in a single treatment session.

RESULTS

No significant difference was found for intragroup and intergroup comparisons in the balance of elderly women during the following evaluations: Functional Reach Test (P = .851), Timed Up and Go Test (P = .653), anteroposterior oscillation with eyes opened (P = .333) and with eyes closed (P = .652), and mediolateral oscillation with eyes opened (P = .486) and with eyes closed (P = .602). In addition, no significant difference was observed in right (P = .881) and left (P = .060) plantar flexion ROM and in right (P = .540) and left (P = .341) dorsiflexion ROM.

CONCLUSION

The results of this study suggest that a single session of bilateral grade III mobilization of the talocrural joint does not immediately improve balance and ROM in elderly women with low physical activity levels.