BACKGROUND:Total knee arthroplasty is an effective means for relieving the symptoms associated with degenerative arthritis of the knee. Rehabilitation is a necessary adjunct to surgery and is ...important in regaining optimum function. Access to high-quality rehabilitation services is not always possible, especially for those who live in rural or remote areas. The aim of this study was to evaluate the equivalence of an Internet-based telerehabilitation program compared with conventional outpatient physical therapy for patients who have had a total knee arthroplasty.
METHODS:This investigation was a single-blinded, prospective, randomized, controlled noninferiority trial. Sixty-five participants were randomized to receive a six-week program of outpatient physical therapy either in the conventional manner or by means of an Internet-based telerehabilitation program. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) measured at baseline and six weeks by a blinded independent assessor. Secondary outcomes included the Patient-Specific Functional Scale, the timed up-and-go test, pain intensity, knee flexion and extension, quadriceps muscle strength, limb girth measurements, and an assessment of gait. Noninferiority was assessed through the comparison of group differences with a noninferiority margin and with linear mixed model statistics.
RESULTS:Baseline characteristics between groups were similar, and all participants had significant improvement on all outcome measures with the intervention (p < 0.01 for all). After the six-week intervention, participants in the telerehabilitation group achieved outcomes comparable to those of the conventional rehabilitation group with regard to flexion and extension range of motion, muscle strength, limb girth, pain, timed up-and-go test, quality of life, and clinical gait and WOMAC scores. Better outcomes for the Patient-Specific Functional Scale and the stiffness subscale of the WOMAC were found in the telerehabilitation group (p < 0.05). The telerehabilitation intervention was well received by participants, who reported a high level of satisfaction with this novel technology.
CONCLUSIONS:The outcomes achieved via telerehabilitation at six weeks following total knee arthroplasty were comparable with those after conventional rehabilitation.
LEVEL OF EVIDENCE:Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.
Several classification schemes, each with its own philosophy and categorizing method, subgroup low back pain (LBP) patients with the intent to guide treatment. Physiotherapy derived schemes usually ...have a movement impairment focus, but the extent to which other biological, psychological, and social factors of pain are encompassed requires exploration. Furthermore, within the prevailing 'biological' domain, the overlap of subgrouping strategies within the orthopaedic examination remains unexplored. The aim of this study was "to review and clarify through developer/expert survey, the theoretical basis and content of physical movement classification schemes, determine their relative reliability and similarities/differences, and to consider the extent of incorporation of the bio-psycho-social framework within the schemes".
A database search for relevant articles related to LBP and subgrouping or classification was conducted. Five dominant movement-based schemes were identified: Mechanical Diagnosis and Treatment (MDT), Treatment Based Classification (TBC), Pathoanatomic Based Classification (PBC), Movement System Impairment Classification (MSI), and O'Sullivan Classification System (OCS) schemes. Data were extracted and a survey sent to the classification scheme developers/experts to clarify operational criteria, reliability, decision-making, and converging/diverging elements between schemes. Survey results were integrated into the review and approval obtained for accuracy.
Considerable diversity exists between schemes in how movement informs subgrouping and in the consideration of broader neurosensory, cognitive, emotional, and behavioural dimensions of LBP. Despite differences in assessment philosophy, a common element lies in their objective to identify a movement pattern related to a pain reduction strategy. Two dominant movement paradigms emerge: (i) loading strategies (MDT, TBC, PBC) aimed at eliciting a phenomenon of centralisation of symptoms; and (ii) modified movement strategies (MSI, OCS) targeted towards documenting the movement impairments associated with the pain state.
Schemes vary on: the extent to which loading strategies are pursued; the assessment of movement dysfunction; and advocated treatment approaches. A biomechanical assessment predominates in the majority of schemes (MDT, PBC, MSI), certain psychosocial aspects (fear-avoidance) are considered in the TBC scheme, certain neurophysiologic (central versus peripherally mediated pain states) and psychosocial (cognitive and behavioural) aspects are considered in the OCS scheme.
Abstract Background The craniocervical flexion test (CCFT) is a clinical test of the anatomical action of the deep cervical flexor muscles, the longus capitis, and colli. It has evolved over 15 years ...as both a clinical and research tool and was devised in response to research indicating the importance of the deep cervical flexors in support of the cervical lordosis and motion segments and clinical observations of their impairment with neck pain. Special Features The CCFT could be described as a test of neuromotor control. The features assessed are the activation and isometric endurance of the deep cervical flexors as well as their interaction with the superficial cervical flexors during the performance of five progressive stages of increasing craniocervical flexion range of motion. It is a low-load test performed in the supine position with the patient guided to each stage by feedback from a pressure sensor placed behind the neck. While the test in the clinical setting provides only an indirect measure of performance, the construct validity of the CCFT has been verified in a laboratory setting by direct measurement of deep and superficial flexor muscle activity. Summary Research has established that patients with neck pain disorders, compared to controls, have an altered neuromotor control strategy during craniocervical flexion characterized by reduced activity in the deep cervical flexors and increased activity in the superficial flexors usually accompanied by altered movement strategies. Furthermore, they display reduced isometric endurance of the deep cervical flexor muscles. The muscle impairment identified with the CCFT appears to be generic to neck pain disorders of various etiologies. These observations prompted the use of the craniocervical flexion action for retraining the deep cervical flexor muscles within a motor relearning program for neck pain patients, which has shown positive therapeutic benefits when tested in clinical trials.
The importance of the biopsychosocial model in assessment and management of chronic musculoskeletal conditions is recognized. Physical therapists have been encouraged to develop psychologically ...informed practice. Little is known about the process of physical therapists' learning and delivering of psychological interventions within the practice context.
The aim of this study was to investigate physical therapists' experiences and perspectives of a cognitive-behavioral-informed training and intervention process as part of a randomized controlled trial (RCT) involving adults with painful knee osteoarthritis.
A qualitative design was used. Participants were physical therapists trained to deliver pain coping skills training (PCST).
Eight physical therapists trained to deliver PCST were interviewed by telephone at 4 time points during the 12-month RCT period. Interviews were audiorecorded, transcribed verbatim into computer-readable files, and analyzed using Framework Analysis.
Thematic categories identified were: training, experience delivering PCST, impact on general clinical practice, and perspectives on PCST and physical therapist practice. Physical therapists reported positive experiences with PCST and program delivery. They thought that their participation in the RCT had enhanced their general practice. Although some components of the PCST program were familiar, the therapists found delivering the program was quite different from regular practice. Physical therapists believed the PCST program, a 3- to 4-day workshop followed by formal mentoring and performance feedback from a psychologist for 3 to 6 months and during the RCT, was critical to their ability to effectively deliver the PCST intervention. They identified a number of challenges in delivering PCST in their normal practice.
Physical therapists can be trained to confidently deliver a PCST program. The physical therapists in this study believed that training enhanced their clinical practice. Comprehensive training and mentoring by psychologists was crucial to ensure treatment fidelity.
Neck pain is a major health issue with high rates of recurrence. It presents with a variety of altered sensorimotor functions. Exercise is a cornerstone of rehabilitation and many training methods ...are used. Exercise is evaluated in most randomized controlled trials on its pain relieving effects. No review has assessed the effect of exercise on the altered physiological functions or determined if there are differential effects of particular training methods. This review investigated the effects of deep cervical flexor (DCF) training, a training method commonly used for patients with neck pain, and compared it to other training methods or no training on outcomes of cervical neuromuscular function, muscle size, kinematics and kinetics.
Web of Science, Scopus, CINAHL, PubMed were searched from inception until January 2018. Twelve randomized controlled trials were included that compared DCF training as sole intervention to other training or no interventions in persons with neck pain. The Cochrane Risk of Bias tool was used to assess the method quality. All outcome measures were analysed descriptively and meta-analyses were performed for measures evaluated in three or more studies.
DCF training was compared to cervical endurance, strength, proprioception and mobility training, muscle stretching, and no intervention control groups. Physiological outcome measures included neuromuscular co-ordination (craniocervical flexion test), functional tasks, muscle fatigability, muscle size, kinematics (joint position sense, posture and range of motion) and kinetics (strength, endurance and contraction accuracy). Strong evidence was found for effectiveness of DCF training on neuromuscular coordination, but it had no or small effects on strength and endurance at higher loads. DCF training improved head and cervical posture, while evidence was limited or contradictory for other measures.
DCF training can successfully address impaired neuromuscular coordination, but not cervical flexor strength and endurance at higher contraction intensities. A multimodal training regime is proposed when the aim is to specifically address various impaired physiological functions associated with neck pain.
Retrospective secondary analysis of data.
To investigate the external validity of the whiplash clinical prediction rule (CPR).
We recently derived a whiplash CPR to consolidate previously established ...prognostic factors for poor recovery from a whiplash injury and predicted 2 recovery pathways. Prognostic factors for full recovery were being less than 35 years of age and having an initial Neck Disability Index (NDI) score of 32% or less. Prognostic factors for ongoing moderate/severe pain and disability were being 35 years of age or older, having an initial NDI score of 40% or more, and the presence of hyperarousal symptoms. Validation is required to confirm the reproducibility and accuracy of this CPR. Clinician feedback on the usefulness of the CPR is also important to gauge acceptability.
A secondary analysis of data from 101 individuals with acute whiplash-associated disorder who had previously participated in either a randomized controlled clinical trial or prospective cohort study was performed using accuracy statistics. Full recovery was defined as NDI score at 6 months of 10% or less, and ongoing moderate/severe pain and disability were defined as an NDI score at 6 months of 30% or greater. In addition, a small sample of physical therapists completed an anonymous survey on the clinical acceptability and usability of the tool. Results The positive predictive value of ongoing moderate/severe pain and disability was 90.9% in the validation cohort, and the positive predictive value of full recovery was 80.0%. Surveyed physical therapists reported that the whiplash CPR was simple, understandable, would be easy to use, and was an acceptable prognostic tool.
External validation of the whiplash CPR confirmed the reproducibility and accuracy of this dual-pathway tool for individuals with acute whiplash-associated disorder. Further research is needed to assess prospective validation, the impact of inclusion on practice, and to examine the efficacy of linking treatment strategies with predicted prognosis.
Prognosis, level 1b.
ObjectivesNeck pain commonly accompanies recurrent headaches such as migraine, tension-type and cervicogenic headache. Neck pain may be part of the headache symptom complex or a local source. ...Patients commonly seek neck treatment to alleviate headache, but this is only indicated when cervical musculoskeletal dysfunction is the source of pain. Clinical presentation of reduced cervical extension, painful cervical joint dysfunction and impaired muscle function collectively has been shown to identify cervicogenic headache among patients with recurrent headaches. The pattern’s validity has not been tested against the ‘gold standard’ of controlled diagnostic blocks. This study assessed the validity of this pattern of cervical musculoskeletal signs to identify a cervical source of headache and neck pain, against controlled diagnostic blocks, in patients with headache and neck pain.DesignProspective concurrent validity study that employed a diagnostic model building approach to analysis.SettingHospital-based multidisciplinary outpatient clinic in Joliet, Illinois.ParticipantsA convenience sample of participants who presented to a headache clinic with recurrent headaches associated with neck pain. Sixty participants were enrolled and thirty were included in the analysis.Outcome measuresParticipants underwent a clinical examination consisting of relevant tests of cervical musculoskeletal dysfunction. Controlled diagnostic blocks of C2/C3–C3/C4 established a cervical source of neck pain. Penalised logistic regression identified clinical signs to be included in a diagnostic model that best predicted participants’ responses to diagnostic blocks.ResultsTen of thirty participants responded to diagnostic blocks. The full pattern of cervical musculoskeletal signs best predicted participants’ responses (expected prediction error = 0.57) and accounted for 65% of the variance in responses.ConclusionsThis study confirmed the validity of the musculoskeletal pattern to identify a cervical source of headache and neck pain. Adopting this criterion pattern may strengthen cervicogenic headache diagnosis and inform differential diagnosis of neck pain accompanying migraine and tension-type headache.
STUDY DESIGN.A population based cross-sectional study.
OBJECTIVE.To clarify relative constituents of viable muscle in 2-dimensional cross-sectional area (CSA) measures of ventral and dorsal cervical ...muscles in patients with chronic whiplash-associated disorders (WAD), idiopathic neck pain, and healthy controls.
SUMMARY OF BACKGROUND DATA.Previous data using T1-weighted magnetic resonance image demonstrated large amounts of neck muscle fat infiltration and increased neck muscle CSA in patients with chronic WAD but not in idiopathic neck pain or healthy controls.
METHODS.Magnetic resonance images were obtained for 14 cervical muscle regions in 136 females, including 79 with chronic whiplash, 23 with chronic idiopathic neck pain, and 34 healthy controls.
RESULTS.Without fat removed, relative CSA of 7 of 14 muscle regions in the participants with chronic WAD was larger, 3 of 14 smaller and 4 of 14 similar to healthy individuals. When T1-weighted signal representing the lipid content of these muscles was removed, 8 of 14 relative muscle CSA in patients with whiplash were similar, 5 of 14 were smaller and only 1 of 14 was larger than those observed in healthy controls. Removal of fat from the relative CSA measurement did not alter findings between participants with idiopathic neck pain and healthy controls.
CONCLUSION.These findings clarify that previous reports of increased relative CSA in patients with chronic whiplash represent cervical muscle pseudohypertrophy. Relative muscle CSA measures reveal atrophy in several muscles in both patients with WAD and idiopathic neck pain, which supports inclusion of muscle conditioning in the total management of these patients.Level of Evidence3
The validity of upper-limb neurodynamic tests (ULNTs) for detecting peripheral neuropathic pain (PNP) was assessed by reviewing the evidence on plausibility, the definition of a positive test, ...reliability, and concurrent validity. Evidence was identified by a structured search for peer-reviewed articles published in English before May 2011. The quality of concurrent validity studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool, where appropriate. Biomechanical and experimental pain data support the plausibility of ULNTs. Evidence suggests that a positive ULNT should at least partially reproduce the patient's symptoms and that structural differentiation should change these symptoms. Data indicate that this definition of a positive ULNT is reliable when used clinically. Limited evidence suggests that the median nerve test, but not the radial nerve test, helps determine whether a patient has cervical radiculopathy. The median nerve test does not help diagnose carpal tunnel syndrome. These findings should be interpreted cautiously, because diagnostic accuracy might have been distorted by the investigators' definitions of a positive ULNT. Furthermore, patients with PNP who presented with increased nerve mechanosensitivity rather than conduction loss might have been incorrectly classified by electrophysiological reference standards as not having PNP. The only evidence for concurrent validity of the ulnar nerve test was a case study on cubital tunnel syndrome. We recommend that researchers develop more comprehensive reference standards for PNP to accurately assess the concurrent validity of ULNTs and continue investigating the predictive validity of ULNTs for prognosis or treatment response.
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