Physiotherapy and osteoporosis: practice behaviors and clinicians’ perceptions—a survey

Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review

OBJECTIVES

Physicians often refer patients with musculoskeletal conditions to physical therapy. However, it is unclear to what extent physical therapists' treatment choices align with the evidence. The aim of this systematic review was to determine what percentage of physical therapy treatment choices for musculoskeletal conditions agree with management recommendations in evidence-based guidelines and systematic reviews.

DESIGN

Systematic review.

SETTING

We performed searches in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine, Scopus and Web of Science combining terms synonymous with 'practice patterns' and 'physical therapy' from the earliest record to April 2018.

PARTICIPANTS

Studies that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes and other methods (eg, audits of billing codes, clinical observation) were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Using medians and IQRs, we summarised the percentage of physical therapists who chose treatments that were recommended, not recommended and had no recommendation, and summarised the percentage of physical therapy treatments provided for various musculoskeletal conditions within the categories of recommended, not recommended and no recommendation. Results were stratified by condition and how treatment choices were assessed (surveys of physical therapists vs audits of clinical notes).

RESULTS

We included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits).

CONCLUSIONS

Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended.

PROSPERO REGISTRATION NUMBER

CRD42018094979.

Exercise or manual physiotherapy compared with a single session of physiotherapy for osteoporotic vertebral fracture: three-arm PROVE RCT

BACKGROUND

A total of 25,000 people in the UK have osteoporotic vertebral fracture (OVF). Evidence suggests that physiotherapy may have an important treatment role.

OBJECTIVE

The objective was to investigate the clinical effectiveness and cost-effectiveness of two different physiotherapy programmes for people with OVF compared with a single physiotherapy session.

DESIGN

This was a prospective, adaptive, multicentre, assessor-blinded randomised controlled trial (RCT) with nested qualitative and health economic studies.

SETTING

This trial was based in 21 NHS physiotherapy departments.

PARTICIPANTS

The participants were people with symptomatic OVF.

INTERVENTIONS

Seven sessions of either manual outpatient physiotherapy or exercise outpatient physiotherapy compared with the best practice of a 1-hour single session of physiotherapy (SSPT).

MAIN OUTCOME MEASURES

Outcomes were measured at 4 and 12 months. The primary outcomes were quality of life and muscle endurance, which were measured by the disease-specific QUALEFFO-41 (Quality of Life Questionnaire of the European Foundation for Osteoporosis - 41 items) and timed loaded standing (TLS) test, respectively. Secondary outcomes were (1) thoracic kyphosis angle, (2) balance, evaluated via the functional reach test (FRT), and (3) physical function, assessed via the Short Physical Performance Battery (SPPB), 6-minute walk test (6MWT), Physical Activity Scale for the Elderly, a health resource use and falls diary, and the EuroQol-5 Dimensions, five-level version.

RESULTS

A total of 615 participants were enrolled, with 216, 203 and 196 randomised by a computer-generated program to exercise therapy, manual therapy and a SSPT, respectively. Baseline data were available for 613 participants, 531 (86.6%) of whom were women; the mean age of these participants was 72.14 years (standard deviation 9.09 years). Primary outcome data were obtained for 69% of participants (429/615) at 12 months: 175 in the exercise therapy arm, 181 in the manual therapy arm and 173 in the SSPT arm. Interim analysis met the criteria for all arms to remain in the study. For the primary outcomes at 12 months, there were no significant benefits over SSPT of exercise [QUALEFFO-41, difference -0.23 points, 95% confidence interval (CI) -3.20 to 1.59 points; p = 1.000; and TLS test, difference 5.77 seconds, 95% CI -4.85 to 20.46 seconds; p = 0.437] or of manual therapy (QUALEFFO-41, difference 1.35 points, 95% CI -1.76 to 2.93 points; p = 0.744; TLS test, difference 9.69 seconds (95% CI 0.09 to 24.86 seconds; p = 0.335). At 4 months, there were significant gains for both manual therapy and exercise therapy over SSPT in the TLS test in participants aged < 70 years. Exercise therapy was superior to a SSPT at 4 months in the SPPB, FRT and 6MWT and manual therapy was superior to a SSPT at 4 months in the TLS test and FRT. Neither manual therapy nor exercise therapy was cost-effective relative to a SSPT using the threshold of £20,000 per quality-adjusted life-year. There were no treatment-related serious adverse events.

CONCLUSIONS

This is the largest RCT to date assessing physiotherapy in participants with OVFs. At 1 year, neither treatment intervention conferred more benefit than a single 1-hour physiotherapy advice session. The focus of future work should be on the intensity and duration of interventions to determine if changes to these would demonstrate more sustained effects.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49117867.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 44. See the NIHR Journals Library website for further project information.

Physiotherapy Rehabilitation for Osteoporotic Vertebral Fracture (PROVE): study protocol for a randomised controlled trial

Background

Osteoporosis and vertebral fracture can have a considerable impact on an individual’s quality of life. There is increasing evidence that physiotherapy including manual techniques and exercise interventions may have an important treatment role. This pragmatic randomised controlled trial will investigate the clinical and cost-effectiveness of two different physiotherapy approaches for people with osteoporosis and vertebral fracture, in comparison to usual care.

Methods/Design

Six hundred people with osteoporosis and a clinically diagnosed vertebral fracture will be recruited and randomly allocated to one of three management strategies, usual care (control - A), an exercise-based physiotherapy intervention (B) or a manual therapy-based physiotherapy intervention (C). Those in the usual care arm will receive a single session of education and advice, those in the active treatment arms (B + C) will be offered seven individual physiotherapy sessions over 12 weeks. The trial is designed as a prospective, adaptive single-blinded randomised controlled trial. An interim analysis will be completed and if one intervention is clearly superior the trial will be adapted at this point to continue with just one intervention and the control. The primary outcomes are quality of life measured by the disease specific QUALLEFO 41 and the Timed Loaded Standing test measured at 1 year.

Discussion

There are a variety of different physiotherapy packages used to treat patients with osteoporotic vertebral fracture. At present, the indication for each different therapy is not well defined, and the effectiveness of different modalities is unknown.

Trial registration

Reference number ISRCTN49117867.

Postgraduate physiotherapy training: interest and perceived barriers to participation in a clinical master's degree programme

PURPOSE

To (1) assess whether physiotherapists in a large Canadian province support the offering of a clinical master's degree programme; (2) identify what sector of this population is interested in participating in a clinical master's degree programme; (3) identify the most common personal/professional reasons for enrolling; (4) identify the type of programme that would appeal; and (5) assess barriers to participation in such a programme.

METHODS

The survey and accompanying cover letter explaining the study were sent by postal mail to all 2,552 physiotherapists registered with the College of Physical Therapists of British Columbia (CPTBC).

RESULTS

The response rate was 17%; 90% of respondents support offering this type of physiotherapy degree in BC, and 14% reported that they were likely to enrol. Orthopaedics/manual therapy (41%) was the clinical area of most interest.

CONCLUSIONS

There is strong support for a clinical master's degree in orthopaedic manual therapy in BC. There is greater support for a part-time programme with an inter-professional component, using a combination of e-learning and classroom teaching to reduce travel time and time away from family.

Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial

BACKGROUND

This randomised, single-blind controlled pilot trial aimed to determine the effectiveness of a physiotherapy program, including exercise and manual therapy, in reducing impairments and improving physical function and health-related quality of life in people with a history of painful osteoporotic vertebral fracture.

METHODS

20 participants were randomly allocated to an intervention (n = 11) or control (n = 9) group. The intervention group attended individual sessions with an experienced clinician once a week for 10 weeks and performed daily home exercises with adherence monitored by a self-report diary. The control group received no treatment. Blinded assessment was conducted at baseline and 11 weeks. Questionnaires assessed self-reported changes in back pain, physical function, and health-related quality of life. Objective measures of thoracic kyphosis, back and shoulder muscle endurance (Timed Loaded Standing Test), and function (Timed Up and Go test) were also taken.

RESULTS

Compared with the control group, the intervention group showed significant reductions in pain during movement (mean difference (95% CI) -1.8 (-3.5 to -0.1)) and at rest (-2.0 (-3.8 to -0.2)) and significantly greater improvements in Qualeffo physical function (-4.8 (-9.2 to -0.5)) and the Timed Loaded Standing test (46.7 (16.1 to 77.3) secs). For the perceived change in back pain over the 10 weeks, 9/11 (82%) participants in the intervention group rated their pain as 'much better' compared with only 1/9 (11%) participants in the control group.

CONCLUSION

Despite the modest sample size, these results support the benefits of exercise and manual therapy in the clinical management of patients with osteoporotic vertebral fractures, but need to be confirmed in a larger sample.

TRIAL REGISTRATION

NCT00638768.

Age differences in energy absorption in the upper extremity during a descent movement: implications for arresting a fall

BACKGROUND

Falls are the number one cause of unintentional injury in older adults. The protective response of "breaking the fall" with the outstretched hand is often essential for avoiding injury to the hip and head. In this study, we compared the ability of young and older women to absorb the impact energy of a fall in the outstretched arms.

METHODS

Twenty young (mean age = 21 years) and 20 older (M = 78 years) women were instructed to slowly lower their body weight, similar to the descent phase of a push-up, from body lean angles ranging from 15 degrees to 90 degrees . Measures were acquired of peak upper extremity energy absorption, arm deflection, and hand contact force.

RESULTS

On average, older women were able to absorb 45% less energy in the dominant arm than young women (1.7 +/- 0.5% vs 3.1 +/- 0.4% of their body weight x body height; p < .001). These results suggest that, even when both arms participate equally, the average energy content of a forward fall exceeds by 5-fold the average energy that our older participants could absorb and exceeds by 2.7-fold the average energy that young participants could absorb.

CONCLUSIONS

During a descent movement that simulates fall arrest, the energy-absorbing capacity of the upper extremities in older women is nearly half that of young women. Absorbing the full energy of a fall in the upper extremities is a challenging task even for healthy young women. Strengthening of upper extremity muscles should enhance this ability and presumably reduce the risk for injury to the hip and head during a fall.

Regional trabecular morphology assessed by micro-CT is correlated with failure of aged thoracic vertebrae under a posteroanterior load and may determine the site of fracture

INTRODUCTION

Spinal mobilization is commonly used in the treatment of patients with back pain, including individuals with osteoporosis. Previous data indicated that traditional predictors of skeletal failure-lateral or anteroposterior bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA) or geometry of the spinous process or vertebral body-do not predict failure load during posteroanterior spinal mobilization. Morphological differences and inhomogeneities in BMD may have important effects on vertebral strength but integral BMD values by DXA cannot reflect these potentially important differences. We investigated the determinants of spinal fracture using muCT.

MATERIALS AND METHODS

We measured failure load and failure site in 11 T5-8 cadaveric specimens (mean age 78 years) when a posteroanterior load was applied at the spinous process of T6 using a servohydraulic material testing machine. Radiography and CT scan were used to verify failure site. We observed no damage to the adjacent T7 vertebrae following the T6 posteroanterior failure test. The T7 vertebrae were sectioned to produce regional samples of the spinous process, the lamina and a vertebral body core. Each sample was scanned with muCT to measure bone microarchitectural parameters. We segmented and analysed four trabecular regions (spinous process base and middle, central lamina and central vertebral body). We used one-way repeated measures ANOVA to compare regions and computed Pearson correlations to assess the relation between PA failure load of T6 and the morphological parameters of T7.

RESULTS

The BV/TV at the base or middle of the T7 spinous process (fracture sites), Tb.N and Tb.Th at the base were significantly correlated with posteroanterior failure load of T6 (BV/TV base: r=0.74, p=0.01; BV/TV middle: r=0.73, p=0.01; Tb.N base: r=0.64, p=0.03; Tb.Th base: r=0.65, p=0.03). The Tb.Th of the lamina was significantly greater than Tb.Th of the spinous process base (p=0.002).

CONCLUSIONS

Whereas previous data indicated that BMD by DXA was not a good predictor of posteroanterior failure load, regional BV/TV of the spinous process base and middle regions, the sites of fracture, are correlated with posteroanterior failure load. Trabecular thickness differed significantly between the base of the spinous process and the lamina, and may have influenced the site of fracture.

Balance, aging, and osteoporosis: effects of cognitive exercises combined with physiotherapy

OBJECTIVE

To evaluate whether performing cognitive tasks while exercising influenced the effects of an exercise program designed to reduce the risk of falling in elderly women with osteoporosis.

METHODS

We included 68 osteoporotic women older than 70 years of age (mean age, 73.5 years+/-1.6) who followed a program of 12 sessions of balance, coordination, and ambulation exercises designed to lessen the risk of falling. The patients were divided into two groups based on proximity to the study centers. The groups were randomly allocated to the exercise program alone (N=31, single-task group) or to the same program combined with cognitive tasks performed while exercising (N=37, dual-task group). Timed up-and-go tests and one-leg balance (OLB) tests were done at baseline, at the end of the exercise program, and 3 months after the end of the exercise program.

RESULTS

In both groups, the exercise program produced significant improvements in up-and-go and OLB times. Additional improvements occurred over the first 3 months following the program. Adding cognitive exercises did not provide added efficacy.

CONCLUSIONS

Balance was improved after the exercise sessions. The improvements were clinically significant and increased over time.

Postural Health in Women: The Role of Physiotherapy

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