Patient education with or without manual therapy compared to a control group in patients with osteoarthritis of the hip. A proof-of-principle three-arm parallel group randomized clinical trial

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review

Objective: This review aimed to describe the quality and comprehensiveness of adverse event (AE) reporting in clinical trials incorporating manual therapy (MT) as an intervention for extremity conditions using the Consolidated Standards of Reporting Trials (CONSORT)-Harms extension as the benchmark. The secondary aim was to determine whether the quality of AE reporting improved after the availability of the CONSORT reporting checklist. Design: Systematic review. Methods: A literature search was conducted using multiple databases to identify trials where MT was used to treat extremity conditions. Studies that reported AEs were identified and evaluated using the CONSORT-Harms extension. The frequency of trials reporting study AEs before and after the publication of the updated 2010 CONSORT statement was calculated, along with the categorization of how study AEs were reported. Results: Of the 55,539 studies initially identified, 220 trials met all inclusion criteria. Eighty trials (36.4%) reported AE occurrence. None of the studies that reported AEs adhered to all 10 criteria proposed by the 2010 CONSORT-Harms extension. The most commonly reported criterion was number four, which clarified how AE-related information was collected (30% of trials). The least reported criterion was number six, which describes the participant withdrawals for each arm due to AEs and the experience with the allocated treatment (1.3% of trials). The nomenclature used to describe AEs varied substantially. Fifty-nine of 76 trials (33.3%) were published after the updated CONSORT Harms-checklist was available, compared to 21 of 44 trials (46.7%) published before it was available. Conclusion: Reporting of AEs in trials investigating MT for extremity conditions is poor. Every included trial lacked adherence to all 10 criteria proposed by the CONSORT-Harms Extension. The quality and comprehensiveness of AE reporting did not improve after the most recent CONSORT update recommending AE reporting. Clinicians must obtain informed consent before performing any intervention, including MT, which requires disclosing potential risks, which could be better known with improved tracking, analyzing, and reporting of AEs. The authors recommend improved adherence to best practices for adequately tracking and reporting AEs in future MT trials.

Efficacy of proprioceptive neuromuscular facilitation on functioning in patients with bilateral hip osteoarthritis: A pilot randomized controlled trial

BACKGROUND

Hip osteoarthritis (OA) is a chronic progressive disease that impresses a noticeable burden to society and healthcare systems. Physical exercise constitutes the first-line hip OA treatment approach, nevertheless, there is currently no gold standard method to treat this disease.

OBJECTIVE

To evaluate the efficacy of proprioceptive neuromuscular facilitation (PNF) on functioning in patients with hip OA.

METHOD

A pilot randomized controlled trial (RCT) was carried out on patients with painful bilateral hip OA with a body mass index (BMI) < 30 kg/m2. After the randomization, the experimental group was treated with PNF protocol and the control group with conventional physical therapy (10 sessions of manual therapy, 5 sessions/week for 2 weeks). The Harris Hip Score (HHS) was the primary outcome, whereas we assessed as secondary outcomes: pain, range of motion, and muscle strength of hip, physical performance, and quality of life.

RESULTS

Twenty patients (40 hips) were enrolled and randomized into two groups: PNF group (mean age: 70.7 ± 8.07; BMI: 25.1 ± 3.07; 7 females and 3 males) and control group (mean age: 74.9 ± 10.72; BMI: 26.8 ± 3.78; 6 females and 4 males). The results showed a statistically significant improvement of HHS in the study group (T1: 90.6 ± 5.63) than in the control group (T1: 77.3 ± 10.9) (between-group p value < 0.001). Three months after the treatment we have statistically significant maintenance in the PNF group (T2:89.6±6.32, within-group ΔT0-T2 p< 0.01) while the control group did not maintain the improvements recorded at T1 (T2: 71.4 ± 15.8).

CONCLUSION

The results of this pilot RCT showed that incorporating PNF exercises into the rehabilitation program yielded notable enhancements in improving lower limb function, strength and ROM in hip OA patients. Nonetheless, further prospective studies including wider sample size are needed to implement scientific knowledge on this physical therapy approach, in patients with hip osteoarthritis.

Stretching, Bracing, and Devices for the Treatment of Osteoarthritis-Associated Joint Contractures in Nonoperated Joints: A Systematic Review and Meta-Analysis

CONTEXT

Many patients with osteoarthritis (OA) develop range of motion (ROM) restrictions in their affected joints (contractures), associated with worse outcomes and rising healthcare costs. Effective treatment guidance for lost ROM in OA-affected joints is lacking.

OBJECTIVE

A systematic review and meta-analysis evaluating the effectiveness of stretching and/or bracing protocols on native (nonoperated) joint ROM in the setting of radiographically diagnosed OA.

DATA SOURCES

Seven databases, English-language.

STUDY SELECTION

Studies including participants with radiographically diagnosed OA in any native joint evaluating the effect of stretching or bracing on ROM.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

Two reviewers independently screened articles for inclusion and assessed risk of bias in included trials. Primary outcomes were ROM, pain, and adverse events (AEs).

RESULTS

We identified 6284 articles. A total of 9 randomized controlled trials, all evaluating the knee, met eligibility criteria. For stretching, 3 pooled studies reported total ROM, which improved by mean difference (MD) of 9.3° (95% CI 5.0°,13.5°) versus controls. Two pooled studies showed improved knee flexion ROM (MD 10.8° [7.3°,14.2°]) versus controls. Five studies were pooled for knee extension with mean improvement 9.1° [3.4°,14.8°] versus controls. Seven pooled studies showed reduced pain (standardized MD 1.9 [1.2,2.6]). One study reported improved knee extension of 3.7° [2.9°,4.5°] with use of a device. No studies used orthoses. One study reported on AEs, with none noted. Performance bias was present in all included studies, and only 3 studies clearly reported blinding of outcome assessors. Strength of evidence for primary outcomes was considered moderate.

CONCLUSION

There was moderate-quality evidence that stretching is an effective strategy for improving knee total, flexion and extension ROM, and pain. Our findings suggest that stretching to regain joint ROM in OA is not futile and that stretching appears to be an appropriate conservative intervention to improve patient outcomes as part of a comprehensive knee OA treatment plan before arthroplasty.

Changes Over Time in the Strain on the Inferior Iliofemoral Ligament During a Sustained 5-Minute High-Force Long-Axis Distraction Mobilization: A Cadaveric Study

OBJECTIVE

To analyze the changes over time in the strain on the inferior iliofemoral (IIF) ligament when a constant high-force long-axis distraction mobilization (LADM) was applied over 5 minutes.

DESIGN

A cross-sectional laboratory cadaveric study.

SETTING

Anatomy laboratory.

PARTICIPANTS

Thirteen hip joints from 9 fresh-frozen cadavers (mean age, 75.6±7.8 years; N=13).

INTERVENTIONS

High-force LADM in open-packed position was sustained for a period of 5 minutes.

MAIN OUTCOME MEASURE(S)

Strain on IFF ligament was measured over time with a microminiature differential variable reluctance transducer. Strain measurements were taken at every 15 seconds for the first 3 minutes and every 30 seconds for the next 2 minutes.

RESULTS

Major changes in strain occurred in the first minute of high-force LADM application. The greatest increase in strain on the IFF ligament occurred at the first 15 seconds (7.3±7.2%). At 30 seconds, the increase in strain was 10.1±9.6%, the half of the total increase at the end of the 5-minute high-force LADM (20.2±8.5%). Significant changes in strain measures were shown to occur at 45 seconds of high-force LADM (F=18.11; P<.001).

CONCLUSIONS

When a 5-minute high-force LADM was applied, the major changes in the strain on IIF ligament occurred in the first minute of the mobilization. A high-force LADM mobilization should be sustained at least 45 seconds to produce a significant change in the strain of capsular-ligament tissue.

The influence of manual therapy dosing on outcomes in patients with hip osteoarthritis: a systematic review

OBJECTIVE

To 1) Determine if specific dosing parameters of manual therapy are related to improved pain, disability, and quality of life outcomes in patients with hip osteoarthritis and 2) to provide recommendations for optimal manual therapy dosing based on our findings.

DESIGN

A systematic review of randomized controlled trials from the PubMed, CINAHL, and OVID databases that used manual therapy interventions to treat hip osteoarthritis was performed. Three reviewers assessed the risk of bias for included studies and extracted relevant outcome data based on predetermined criteria. Baseline and follow-up means and standard deviations for outcome measures were used to calculate effect sizes for within and between-group differences.

RESULTS

Ten studies were included in the final analyses totaling 768 participants, and half were graded as high risk of bias. Trends emerged: 1) large effect sizes were seen using long-axis distraction, mobilization and thrust manipulation, 2) mobilization with movement showed large effects for pain and range of motion, and (3) small effects were associated with graded mobilization. Durations of 10 to 30 minutes per session, and frequency 2-3 times per week for 2-6 weeks were the most common dosing parameters.

CONCLUSIONS

There were varied effect sizes associated with pain, function, and quality of life for both thrust and non-thrust mobilizations, and mobilization with movement into hip flexion and internal rotation. Due to the heterogeneity of MT dosage, it is difficult to recommend a specific manual therapy dosage for those with hip osteoarthritis.

Long-Term Clinical Outcomes of a Remote Digital Musculoskeletal Program: An Ad Hoc Analysis from a Longitudinal Study with a Non-Participant Comparison Group

Digital solutions have emerged as an alternative to conventional physiotherapy, particularly for chronic musculoskeletal pain (CMP) management; however, its long-term effects remain largely unexplored. This study focuses on patients reporting CMP, assessing 1-year clinical outcomes after a multimodal digital care program (DCP) versus non-participants, who enrolled in the program but never engaged in a single exercise session or partook of the educational content made available to them. In this longitudinal study ad-hoc analysis, pain and functionality outcomes at 1-year reassessment were studied, focusing on the odds of reaching minimal clinically important difference (MCID) and, overall average reduction in both outcomes. Healthcare utilization was additionally studied within the same period. From 867 individuals allocated to the study, 460 completed the 1-year reassessment (intervention group: 310; comparison group: 150). The intervention group presented sustained and greater pain reduction until 1-year reassessment than the comparison group, reflecting greater odds ratio of achieving the MCID both in pain and functionality (1.90 95% CI: 1.27-2.86, p = 0.002 and 2.02 95% CI: 1.31-3.12, p = 0.001, respectively). A lower healthcare utilization during the 1-year follow-up was observed in the intervention group than in the comparison group. This study suggests that a digital CMP program may have a lasting impact on improved pain and functionality in patients with CMP.

Adjunctive therapies in addition to land-based exercise therapy for osteoarthritis of the hip or knee

BACKGROUND

Land-based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non-pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land-based exercise therapy is lacking.

OBJECTIVES

To evaluate the benefits and harms of adjunctive therapies used in addition to land-based exercise therapy compared with placebo adjunctive therapy added to land-based exercise therapy, or land-based exercise therapy only for people with hip or knee osteoarthritis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land-based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land-based exercise therapy, or land-based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant-reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short-term (6 months), medium-term (6 to 12 months) and long-term (12 months onwards) effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE.

MAIN RESULTS

We included 62 trials (60 RCTs and 2 quasi-RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 59 included people with knee osteoarthritis only. Thirty-six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty-one trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in eight (13%) trials. Comparing adjunctive therapies plus land-based exercise therapy against placebo therapies plus exercise up to six months (short-term), we found low-certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate-certainty evidence indicates that adjunctive therapies did not improve QOL (SF-36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low-certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant-reported global assessment was not measured in any studies. Compared with land-based exercise therapy, low-certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short-term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise-only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (45 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (45 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low-certainty evidence). Moderate-certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant-reported global assessment (short-term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI -0.32 to -0.18 mm); 12% relative improvement (6% better to 18% better). Low-certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27).

AUTHORS' CONCLUSIONS

Moderate- to low-certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant-reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short-term effects, with limited medium- or long-term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis.

Minimally Invasive Therapies for Osteoarthritic Hip Pain: a Comprehensive Review

PURPOSE OF REVIEW

Osteoarthritis (OA) is a highly prevalent cause of chronic hip pain, affecting 27% of adults aged over 45 years and 42% of adults aged over 75 years. Though OA has traditionally been described as a disorder of "wear-and-tear," recent studies have expanded on this understanding to include a possible inflammatory etiology as well, damage to articular cartilage produces debris in the joint that is phagocytosed by synovial cells which leads to inflammation.

RECENT FINDINGS

Patients with OA of the hip frequently have decreased quality of life due to pain and limited mobility though additional comorbidities of diabetes, cardiovascular disease, poor sleep quality, and obesity have been correlated. Initial treatment with conservative medical management can provide effective symptomatic relief. Physical therapy and exercise are important components of a multimodal approach to osteoarthritic hip pain. Patients with persistent pain may benefit from minimally invasive therapeutic approaches prior to consideration of undergoing total hip arthroplasty. The objective of this review is to provide an update of current minimally invasive therapies for the treatment of pain stemming from hip osteoarthritis; these include intra-articular injection of medication, regenerative therapies, and radiofrequency ablation.

The effect of a single high velocity low amplitude hip mobilization on strength in subjects with knee injuries

BACKGROUND

Manual therapy have been used as a disinhibitory intervention to increase muscle activation before performing functional tasks that are limited by weakness. Knee injuries are commonly associated with weakness in quadriceps and gluteus. Currently, there is no evidence to support anecdotal experience that a hip distraction mobilization improves muscle performance in subjects with knee injuries and lower extremity weakness.

OBJECTIVES

To determine if a hip distraction mobilization would result in an immediate change of maximal force output of the quadriceps and gluteus.

DESIGN

Non-controlled observational pre-post design.

METHODS

Forty individuals with knee pathology were included. Subjects underwent quadriceps, gluteus maximus, and gluteus medius muscle strength assessment before a single hip distraction of the symptomatic side. An immediate re-assessment of muscle strength of both symptomatic and asymptomatic sides followed the mobilization.

RESULTS

/findings: Comparing pre-to post-mobilization strength on the symptomatic side, a significant increase was found with the gluteus maximus (average change = 2.0 kg [95%CI 0.6-3.4]; p < 0.01) but not gluteus medius (0.2 kg [-0.7-1.0]; p = 0.71) or quadriceps (0.1 kg [-1.4-1.7]; p = 0.86). When comparing the strength on the symptomatic side in subjects with weakness greater than the MDD₉₅ (0.7-2.9 kg), a significant increase was again found for gluteus maximus (4.7 kg [2.6-6.8]; p < 0.01) but not for gluteus medius (0.2 kg [-1.0-1.4]; p = 0.71) or quadriceps (1.6 kg [-0.7-3.9]; p = 0.15).

CONCLUSION

A single hip distraction resulted in a significant increase in gluteus maximus strength but did not produce a change in gluteus medius or quadriceps strength in subjects with knee injuries.

Effects of dry needling in HIP muscles in patients with HIP osteoarthritis: A randomized controlled trial

BACKGROUND

Dry needling (DN) in active myofascial trigger points (MTrPs) is effective to reduce pain, increase range of motion (ROM) and improve physical function in different musculoskeletal disorders. However, there is a lack of studies evaluating the effects of DN in active MTrPs in hip osteoarthritis (OA).

OBJECTIVE

To determine the short-term effects of DN on pain, hip ROM and physical function in patients with hip OA.

DESIGN

Double-blind randomized controlled trial.

METHODS

Thirty patients with unilateral hip OA were randomized into two groups: DN group and sham group. Participants received three treatment sessions. The treatment was applied in active MTrPs of the iliopsoas, rectus femoris, tensor fasciae latae and gluteus minimus muscles. Pain intensity (visual analogic scale), passive hip ROM (universal goniometer and digital inclinometer) and physical function (30s chair-stand test and 20m walk test) were assessed at baseline and after the three treatment sessions.

RESULTS

There was decreased pain intensity, increased hip ROM, and improved physical function following the DN treatment. These improvements were statistically significant (p < 0.05) compared to the sham group. The sham group had increased pain intensity and decreased hip ROM (p < 0.05).

CONCLUSION

Pain, hip ROM, and physical function improved after the application of DN in active MTrPs of the hip muscles in patients with hip OA.

Effects of non-pharmacological conservative treatment on pain, range of motion and physical function in patients with mild to moderate hip osteoarthritis. A systematic review

OBJECTIVE

The purpose of this review was to identify the effects of non-pharmacological conservative treatment on pain, range of motion and physical function in patients with mild to moderate hip osteoarthritis.

DESIGN

A systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

SETTING

We searched MEDLINE, PEDro, Scopus and the Cochrane Library databases for randomized controlled trials related to non-pharmacological conservative treatments for hip osteoarthritis with the following keywords: "hip osteoarthritis," "therapeutics," "physical therapy modalities," and "combined physical therapy". The PEDro scale was used for methodological quality assessment and the Oxford Centre of Evidence-Based Medicine scale was used to assess the level of evidence. Outcomes measures related to pain, hip range of motion and physical function were extracted from these studies.

RESULTS

Twelve studies met the inclusion criteria. Most of the studies showed high level of evidence and only two showed low level of evidence. High quality of evidence showed that manual therapy and exercise therapy are effective in improving pain, hip range of motion and physical function. However, high quality studies based on combined therapies showed controversy in their effects on pain, hip range of motion and physical function.

CONCLUSIONS

Exercise therapy and manual therapy and its combination with patient education provides benefits in pain and improvement in physical function. The effects of combined therapies remain unclear. Further investigation is necessary to improve the knowledge about the effects of non-pharmacological conservative treatments on pain, hip range of motion and physical function.

Pain management using a multimodal physiotherapy program including a biobehavioral approach for chronic nonspecific neck pain: a randomized controlled trial

Objective: To determine the effectiveness of a therapeutic patient education (TPE) intervention based on a biobehavioral approach combined with manual therapy (MT) to reduce pain in patients with chronic nonspecific neck pain (CNSNP). In addition, this study intended to assess the effectiveness of a multimodal physiotherapy program including TPE to reduce pain in patients with CNSNP. Design: Single-blind randomized controlled trial. Interventions: A total of 47 patients with CNSNP were randomized into three groups: (1) MT (control group); (2) MT plus TPE based on a biobehavioral approach (Exp1); and (3) MT plus TPE based on a biobehavioral approach, and therapeutic exercise (Exp2). Main Outcome Measurements: The clinical outcomes were recorded at baseline and at 1 and 4 months after the initiation of treatment. The primary outcome was pain intensity (Visual Analog Scale), and the secondary outcomes were pain catastrophizing (Pain Catastrophizing Scale), illness severity and global improvement (Clinical Global Impression Scale), and mechanosensitivity of the median nerve (Upper Limb Neural Test) and the cervical region (Modified Passive Neck Flexion Test). Results: Statistically significant differences in pain intensity were found when Exp2 was compared with Exp1 and the control group at 4 months (p = 0.015 and p = 0.001, respectively), but no difference was found between Exp1 and the control group at the same follow-up period (p = 0.86). Exp2 showed statistically significant differences in all of the secondary outcomes except for pain catastrophizing when compared with the control group at 4 months. Conclusions: The Exp2 group was more effective than Exp1 and the control group in terms of reducing pain intensity at 4 months; at post-treatment, only Exp2 was more effective than the control group.

The schism in chiropractic through the eyes of a 1st year chiropractic student

Since its inception, the chiropractic profession has been divided along ideological fault lines. These divisions have led to a profession wide schism, which has limited mainstream acceptance, utilisation, social authority and integration. The authors explore the historical origins of this schism, taking time to consider historical context, religiosity, perpetuating factors, logical fallacies and siege mentality. Evidence is then provided for a way forward, based on the positioning of chiropractors as mainstream partners in health care.

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.

Pain distribution in primary care patients with hip osteoarthritis

BACKGROUND

Hip osteoarthritis (OA) is the most common diagnosis in primary care adult patients presenting with hip pain but pain location and pain distribution in primary care patients with hip OA have been reported inadequately.

OBJECTIVE

To describe pain location and pain distribution in primary care patients with clinical and radiographic confirmed hip OA.

METHODS

Primary care patients with unilateral clinical and radiographic hip OA living on the island of Funen, Denmark were recruited from primary care to participate in a randomized clinical trial. At baseline, patients recorded pain intensity using an 11-box numeric rating scale and the distribution of hip pain using a manikin displaying three separate views: front, back and lateral. Pain drawings were analysed using a template to determine the most frequent pain locations and distribution of pain.

RESULTS

Pain drawings were completed by 109 patients of which 108 (99%) were valid. The mean age of patients was 65 (SD 9) years and 44% were females. The mean pain intensity was 5.4 (SD 2.0). A total of 77% had marked the greater trochanter area, 53% the groin area, 42% the anterior/lateral thigh area, 38% the buttock area, 17% the knee and 15% the lower leg area. No patients marked pain exclusively in the areas of the knee, posterior thigh or lower leg.

CONCLUSION

The most common pain locations of patients with hip OA presenting to primary care are the greater trochanter, groin, thigh and buttock areas. No patients recorded pain exclusively in the knee or lower leg.

Quality of reporting of randomised controlled trials in chiropractic using the CONSORT checklist

BACKGROUND

Reviews indicate that the quality of reporting of randomised controlled trials (RCTs) in the medical literature is less than optimal, poor to moderate, and require improving. However, the reporting quality of chiropractic RCTs is unknown. As a result, the aim of this study was to assess the reporting quality of chiropractic RCTs and identify factors associated with better reporting quality. We hypothesized that quality of reporting of RCTs was influenced by industry funding, positive findings, larger sample sizes, latter year of publication and publication in non-chiropractic journals.

METHODS

RCTs published between 2005 and 2014 were sourced from clinical trial registers, PubMed and the Cochrane Reviews. RCTs were included if they involved high-velocity, low-amplitude (HVLA) spinal and/or extremity manipulation and were conducted by a chiropractor or within a chiropractic department. Data extraction, and reviews were conducted by all authors independently. Disagreements were resolved by consensus.

OUTCOMES

a 39-point overall quality of reporting score checklist was developed based on the CONSORT 2010 and CONSORT for Non-Pharmacological Treatments statements. Four key methodological items, based on allocation concealment, blinding of participants and assessors, and use of intention-to-treat analysis (ITT) were also investigated.

RESULTS

Thirty-five RCTs were included. The overall quality of reporting score ranged between 10 and 33 (median score 26.0; IQR = 8.00). Allocation concealment, blinding of participants and assessors and ITT analysis were reported in 31 (87 %), 16 (46 %), 25 (71 %) and 21 (60 %) of the 35 RCTs respectively. Items most underreported were from the CONSORT for Non-Pharmacological Treatments statement. Multivariate regression analysis, revealed that year of publication (t32 = 5.17, p = 0.000, 95 % CI: 0.76, 1.76), and sample size (t32 = 3.01, p = 0.005, 95 % CI: 1.36, 7.02), were the only two factors associated with reporting quality.

CONCLUSION

The overall quality of reporting RCTs in chiropractic ranged from poor to excellent, improving between 2005 and 2014. This study suggests that quality of reporting, was influenced by year of publication and sample size but not journal type, funding source or outcome positivity. Reporting of some key methodological items and uptake of items from the CONSORT Extension for Non-Pharmacological Treatments items was suboptimal. Future recommendations were made.

Conservative care with or without manipulative therapy in the management of back and neck pain in Danish children aged 9-15. Study protocol for a randomized controlled trial

Background

Complaints in the musculoskeletal system often start early in life and back and neck pain in children are well-established predictors for similar problems in adulthood. Despite lack of evidence of effectiveness, manipulative therapy is one of the most commonly used treatment modalities for back and neck pain in children.

The primary objective of this study is to evaluate the effectiveness of manipulative therapy when added to an approach consisting of manual soft tissue treatment, exercises and advice as needed, in children aged 9–15 complaining of back and neck pain.

Method

The project is nested in the Childhood Health, Activity and Motor Performance School Study, which includes around 1200 children aged 9–15, who were all invited to participate in this randomized controlled trial in case they experienced back and/or neck pain during the two year inclusion period. Parents received text messages (SMS) on a weekly basis inquiring about the child’s musculoskeletal pain. If pain was reported, the child was evaluated for inclusion into the trial and, if eligible, randomized into one of two intervention groups:

Pragmatic advice, manual soft tissue treatment and exercises

The above plus manipulative therapy

By the end of data collection 237 children were included in the study. The primary outcome measure is number of recurrences of back and neck pain during the follow-up period (3–27 months). Secondary outcome measures are average duration of complaint time for each episode, total duration of complaint time, global perceived effect after two weeks, and change in pain intensity after 2 weeks. Baseline information includes quality of life, expectations to treatment, expectations to future course, age, gender, social class and physical education at school.

Discussion

For most common non-traumatic musculoskeletal complaints no standardized and evidence based treatment strategy exists. We want to evaluate the effectiveness of manipulative therapy in addition to an approach consisting of manual soft tissue treatment, exercises and advice as needed, in children aged 9–15 complaining of back and neck pain.

To our knowledge this is the first large scale randomized controlled trial investigating the effectiveness of commonly used treatments for back and neck pain in children.

Trial registration

ClinicalTrials NCT01504698

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-016-0086-y) contains supplementary material, which is available to authorized users.

Femoroacetabular Impingement: A Retrospective Case Study With 8-Year Follow-Up

OBJECTIVE

The purpose of this case report is to describe a patient with femoroacetabular impingement (FAI) who was initially misdiagnosed and treated for a hip flexor strain.

CLINICAL FEATURES

A 36-year-old male patient presented with insidious onset of progressive anterior right hip and groin pain of 7 years' duration. He was diagnosed with a right-sided hip flexor muscle strain and was discharged from care 1 month later. The patient then returned to the office 8 years later for treatment of unrelated lower back pain. This time, the doctor of chiropractic learned that the patient was misdiagnosed years before. The patient's past radiographs in fact revealed FAI, including severe hip joint osteoarthritis on the right and mild osteoarthritis on the left. As a result, the patient had undergone right hip joint replacement surgery. Recent radiographs also revealed FAI in the contralateral hip.

INTERVENTION AND OUTCOME

After investigating for FAI, the doctor of chiropractic was able to identify through symptomatology, history, physical examination, and radiographs the presence of FAI in the patient's left hip. An "active surveillance" approach is being taken.

CONCLUSION

This case illustrates the importance of an increasing awareness of FAI, as doctors of chiropractic are frequently the primary contact for patients with this condition.

The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To determine whether manual therapy or exercise therapy or both is beneficial for people with hip osteoarthritis in terms of reduced pain, improved physical function and improved quality of life.

METHODS

Databases such as Medline, AMED, EMBASE, CINAHL, SPORTSDiscus, PubMed, Cochrane Library, Web of Science, Physiotherapy Evidence Database, and SCOPUS were searched from their inception till September 2015. Two authors independently extracted and assessed the risk of bias in included studies. Standardised mean differences for outcome measures (pain, physical function and quality of life) were used to calculate effect sizes. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for assessing the quality of the body of evidence for each outcome of interest.

RESULTS

Seven trials (886 participants) that met the inclusion criteria were included in the meta-analysis. There was high quality evidence that exercise therapy was beneficial at post-treatment (pain-SMD-0.27,95%CI-0.5to-0.04;physical function-SMD-0.29,95%CI-0.47to-0.11) and follow-up (pain-SMD-0.24,95%CI- 0.41to-0.06; physical function-SMD-0.33,95%CI-0.5to-0.15). There was low quality evidence that manual therapy was beneficial at post-treatment (pain-SMD-0.71,95%CI-1.08to-0.33; physical function-SMD-0.71,95%CI-1.08to-0.33) and follow-up (pain-SMD-0.43,95%CI-0.8to-0.06; physical function-SMD-0.47,95%CI-0.84to-0.1). Low quality evidence indicated that combined treatment was beneficial at post-treatment (pain-SMD-0.43,95%CI-0.78to-0.08; physical function-SMD-0.38,95%CI-0.73to-0.04) but not at follow-up (pain-SMD0.25,95%CI-0.35to0.84; physical function-SMD0.09,95%CI-0.5to0.68). There was no effect of any interventions on quality of life.

CONCLUSION

An Exercise therapy intervention provides short-term as well as long-term benefits in terms of reduction in pain, and improvement in physical function among people with hip osteoarthritis. The observed magnitude of the treatment effect would be considered small to moderate.

Effects of exercise and manual therapy on pain associated with hip osteoarthritis: a systematic review and meta-analysis

AIM

To explore the effects of exercise (water-based or land-based) and/or manual therapies on pain in adults with clinically and/or radiographically diagnosed hip osteoarthritis (OA).

METHODS

A systematic review and meta-analysis was performed, with patient reported pain assessed using a visual analogue scale (VAS) or the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain subscale. Data were grouped by follow-up time (0-3 months=short term; 4-12 months=medium term and; >12 months=long term), and standardised mean differences (SMD) with 95% CIs were used to establish intervention effect sizes. Study quality was assessed using modified PEDro scores.

RESULTS

19 trials were included. Four studies showed short-term benefits favouring water-based exercise over minimal control using the WOMAC pain subscale (SMD -0.53, 95% CI -0.96 to -0.10). Six studies supported a short-term benefit of land-based exercise compared to minimal control on VAS assessed pain (SMD -0.49, 95% CI -0.70 to -0.29). There were no medium (SMD -0.23, 95% CI -0.48 to 0.03) or long (SMD -0.22, 95% CI -0.51 to 0.06) term benefits of exercise therapy, or benefit of combining exercise therapy with manual therapy (SMD -0.38, 95% CI -0.88 to 0.13) when compared to minimal control.

CONCLUSIONS

Best available evidence indicates that exercise therapy (whether land-based or water-based) is more effective than minimal control in managing pain associated with hip OA in the short term. Larger high-quality RCTs are needed to establish the effectiveness of exercise and manual therapies in the medium and long term.

Osteoarthritis year in review 2014: rehabilitation and outcomes

OBJECTIVE

To highlight research studies examining rehabilitation for hip and knee osteoarthritis (OA), as well as the outcome measures used to assess treatment efficacy, published in 2013.

DESIGN

A systematic search was performed in Medline, CIHAHL and Embase databases from January to December 2013. The search was limited to 2013, human studies, and English. Rehabilitation intervention studies included were prospective controlled designs. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the quality of evidence. First, individual articles were rated for quality. Second, articles were grouped based on outcome: OA disease markers, pain, physical function (self-reported, performance), and health.

RESULTS

Of 503 titles reviewed, 36 studies were included. The outcome measures related to OA disease markers were organized into subthemes of anthropometrics, biomechanics and physiology. The quality of evidence was of moderate, high, and low quality for anthropometric, biomechanical and physiological measures respectively. These studies supported the use of diet for weight loss combined with exercise. Bodies of evidence that showed the efficacy of exercise and passive strategies (thermal/electrical modalities, traction, manual therapy) for reducing pain were of low and moderate quality respectively. The evidence supporting diet and exercise, physiotherapy, and passive strategies to improve physical function was of moderate quality. Evidence supporting exercise to improve psychological factors was of moderate quality.

CONCLUSIONS

Exercise combined with diet for weight loss should be the mainstays of rehabilitation for people with knee and hip OA to provide benefit to OA disease markers, pain, physical function, and health.

Is it all about a pain in the back?

Multisite musculoskeletal pain is common among people suffering from low back pain. Although the mechanisms behind co-occurrence of multiple somatic symptoms and musculoskeletal pain are still unknown, patients with co-morbidities and co-occurring musculoskeletal symptoms tend to have worse functional status, a poorer prognosis and respond less favourably to treatment. Evidence also suggests that the more pain sites a patient reports, the more reduced their physical and mental function will be regardless of location of pain. At the same time, evidence suggests that strategies for diagnosis and treatment of low back pain and other musculoskeletal disorders such as neck pain and lower limb osteoarthritis are very similar. In this chapter, we discuss the prevalence, consequences, and implications of commonalities between low back pain, pain in other sites and co-occurring pain. In addition, we propose a conceptual framework for a common stepwise approach to the diagnosis and management of back and musculoskeletal pain.