Lessons from the World Congress of Physical Therapy (WCPT).
In April I had the privilege of being part of the WCPT held
in Amsterdam, Netherlands. The theme of this year's world congress was
"Moving Physical Therapy Forward" and it truly did so with over 100
presentations and 1500 poster presentations.
As you can appreciate, it is
impossible to attend every session. Hence in this article I have summarized a
number of presentations that I attended based on the area of interest and its
direct application to clinical practice.
Should you have any questions regarding any particular summary, do not hesitate to contact me (swapnil_rege@hotmail.com). I have included references where appropriate (majority of the studies have not been published till date).
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Developing an Audit Tool to Determine the Clinical Diagnostic Accuracy when requesting Magnetic Resonance Imaging and Ultrasound Scans
Purpose: To provide a measurement of clinical accuracy in diagnosing against the results of MRI and US scans. The clinical accuracy, hence, would also give an indication of the clinical expertise of the physiotherapy team and if diagnostic imaging referrals were being used appropriately.
Subjects: Of the 1,842 new patients seen between April 2009 and March 2010, 308 individuals were referred for investigations (219 MRI, 91 US). Analysis used a 0-3 scoring system or “not applicable” (N/A). If the diagnosis scored 2 or more the scan was deemed justified and accurate.
For example: Request: cervical spine MRI scan, history of left arm weakness for 16 weeks, probable C6/7 nerve root compression. Actual results were: C5-7 stenosis, C4/5/6 osteophyte formation extending into left exit foramen C4/5/6, diagnosis C6 nerve root. Score = 3 (very appropriate)
Results: The results of their study suggest that investigations requested by the team were appropriate in the majority of cases. The authors showed that in cases where lumbar spine were referred for further investigations, 54% of the referrals were deemed very accurate/appropriate, and 40% were deemed appropriate. Ultrasounds were not used unless there was suspicion of a tumor.
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The Development of a Cumulative Psychosocial Risk Index for Problematic Recovery following Physical Therapy for Work-Related Musculoskeletal Injuries
Purpose: It is well-established that work-related musculoskeletal injuries are a major contributor to healthcare costs and personal suffering. It has been shown that even after controlling for pain, factors such as depression, fear of movement and pain catastrophizing are significant predictors of pain-related outcomes. Despite the established importance of each of these factors, there is a minimal research exploring their cumulative effect on level of risk for problematic recovery. Hence the authors are conducting research to determine the relationship between patients' total number of psychosocial risk factors and their likelihood of experiencing a prolonged, problematic recovery.
Subjects: 202 individuals with sub-acute, work-related musculoskeletal injuries were included in the study. All participants received seven-weeks of physical therapy and were off work at treatment onset. Testing was conducted at the onset of physical therapy and one-year later. The authors used self-report measurements tools such as pain intensity (pain numerical rating scale), depression (Beck Depression Index), fear of movement (Tampa Scale of Kinesiophobia), and pain catastrophizing (Pain Catastrophizing Scale). The authors used a 0-3 point scale to code each individual. They used cut-off scores for the self-report measures to determine the scoring system.
Results: It was shown that individuals with higher scores had increased pain at one year, increased medication usage and increased likelihood of not returning to work. These results suggest that the number of psychosocial risk factors is a significant predictor of long-term recovery from musculoskeletal injury.
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Long-term Effect of Exercise Therapy in Patients with Osteoarthritis: A Randomized Controlled Trial Comparing Two Different Physiotherapy Interventions
Purpose: It is often seen that the positive effects of exercise therapy with patients with OA decline over time after discharge. This is partly due to poor adherence rates with exercise. It has been shown that behavioural graded activity results in better exercise adherence and a more physically active lifestyle. Hence, the authors wanted to compare the effectiveness of behavioural graded activity vs. usual exercise therapy in patients with OA of the hip or knee.
Subjects: 149 patients with osteoarthritis of the hip and/or knee were followed until 60 months follow-up. Primary outcome measures were pain, physical function, and patient global assessment. Furthermore, patient oriented physical function, physical performance, health care utilization and the number of joint replacement surgeries were assessed. Assessments took place at 3, 9, 15 and 60 months follow-up.
Results: Both treatments showed beneficial within-groups effects in the long-term. In patients with knee OA no differences between treatments were found on the short-, mid-long and long-term. In patients with hip OA significant differences in favour of BGA were found at 3 months (pain and physical performance) and 9 months follow-up (pain, physical function, patients global assessment and patient oriented physical function). Furthermore, exercise therapy resulted in patients with hip OA in more joint replacement surgeries compared to BGA.
References
1. Veenhof C, Koke A, Dekker J, Oosterndorp R, Bijlsma J, Maurits W, Ende C. Effectiveness of Behavioral Graded Activity in Patients With Osteoarthritis of the Hip and/or Knee: A Randomized Clinical Trial. Arthritis & Rheumatism 2006; 55 (6): 925–934.
2. Pisters M, Veenhof C, Schellevis F, De Bakker D, Dekker J. Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized controlled trial comparing two different physical therapy interventions. Osteoarthritis & Cartilage 2010; 18 (8): 1019-26.
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The Effectiveness of Exercise with and without Manual Therapy for Hip Osteoarthritis: Preliminary Results of a Multi-Centre Randomized Controlled Trial
Purpose: Recent clinical guidelines published in Australia and UK only recommend manual therapy (MT) to be used as an adjunct to exercise therapy (ET) when treating individuals with hip OA. In this study, the authors wanted to determine the effectiveness of exercise therapy with and without manual therapy for individuals with hip OA. Their secondary aim was to assess the effect of an 8 week waiting period on outcomes.
Subjects: A total of 131 men and women with a diagnosis of hip OA were recruited in four different centres. The participants were randomized into three groups: ET (n = 45), ET and MT (n = 43) and wait list (n = 43). The treatment groups underwent individualized ET or ET+MT for a total of 8 weeks. The wait-list control were then randomized into one of the two treatment groups after an 9-week follow-up and pooled into original treatment groups (ET n = 66, ET + MT n = 65). All participants were followed up at 9 and 18 weeks and the control group was reassessed at 27 weeks (18 weeks post-treatment). Primary outcome measures were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), sit-to-stand test, 50 foot walk test, pain severity with activity and at night, hip range of motion (HROM) and quality of life (Short Form-36).
Results: There was a significant difference between the ET and control group in WOMAC pain outcome at 9 weeks (p=0.04). Although there was no significant difference between the three groups in any other outcomes, there were trends towards increased pain severity and a deterioration in physical function in the control group, compared to the two intervention groups. Both ET and ET+MT groups showed beneficial within-group effects in WOMAC physical function, pain with activity, night pain and HROM, both at 9 weeks and 18 weeks. There was a significant improvement in sit-to-stand test at 18 weeks. There was no significant difference between the two intervention groups for any of the measures.
Discussion: The authors suggest that the focus should be primarily on an individualized exercise program and the addition of manual therapy may actually hinder self-management. They concluded by calling into question the recommendation of the clinical guidelines that suggest that manual therapy should be used as an adjunct to exercise therapy in the treatment of hip OA.
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The Efficacy of Mobilizations with Movement Treatment on Musculoskeletal Pain: A Systematic Review and Meta-Analysis
Purpose: Mobilization with movement (MWM) is a common technique used in the treatment of musculoskeletal pain to increase range of motion, decrease pain and enhance muscle function. However, no systematic review has been conducted till date to determine the efficacy of the treatment technique.
Method: Selected studies included participants with a diagnosis of a musculoskeletal condition who were treated with a MWM technique, and which included clinically relevant outcome measures.
Results: A total of 38 studies were included, with designs ranging from randomized controlled trials to single case reports across a number of body regions. The following results were obtained:
Tennis Elbow
(a) Pooled data from two studies showed immediate effects of MWM for tennis elbow on pain free grip strength and pressure pain threshold were superior to control.
(b) One high quality RCT showed MWM in combination with exercise was superior to control at 6 weeks and superior to corticosteroid injection at 52 weeks for people with tennis elbow.
Recurrent Ankle Sprains
(a) Pooled data found a positive immediate effect on ankle dorsiflexion compared with control.
Cervicogenic Headaches
(a) Cervical MWM (SNAG) was shown to be efficacious in managing cervicogenic head symptoms (headache, dizziness) in separate RCTs.
Shoulder, wrist/hand, spine, hip and knee
(a) Due to the limited number of studies available, there is insufficient published evidence to support or refute the use of MWM.
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Focused Symposium
Spinal Manipulation - evidence for physiotherapist delivery of effective procedures
Purpose: Spinal manipulation has become an integral part of a physiotherapists repertoire. The current evidence for the safety and efficacy is variable but is growing. Some areas such as the cervical spine continue to pose an element of risk associated with the delivery of spinal manipulation. Hence debates continue about whether there is enough evidence for the effectiveness of spinal manipulation to warrant its continued usage. The purpose of this symposium was to provide information on the current efficacy of spinal manipulation, current screening procedures to reduce risk and current trends in the delivery of such techniques in undergraduate and postgraduate curricula.
Discussion:
Efficacy for spinal manipulation in lumbar spine
The UK Beam trial1 conducted in 2004 showed that "relative to “best care” in general practice, manipulation followed by exercise achieved a moderate benefit at three months and a small benefit at 12 months". It also demonstrated that "spinal manipulation achieved a small to moderate benefit at three months and a small benefit at 12 months and exercise achieved a small benefit at three months but not 12 months".
Another study conducted in 2004, showed that outcomes for low back pain were similar for individuals who received spinal manipulation plus exercise as compared to those who received exercise only. However, the study demonstrated that some patients did respond to spinal manipulation and that certain criterion may be helpful for doctors to be able to identify such patients. The authors of this study developed the spinal manipulation clinical prediction rule. Individuals who meet 4 out of the 5 criteria listed below are considered good candidates for spinal manipulation:
· Duration of current episode of low back pain: less than 16 days
· Extent of distal symptoms: Not having symptoms distal to the knee
· FABQ work subscale score: less than 19 points
· Segmental mobility testing: greater than or equal to 1 hypomobile segment in the lumbar spine
·
Hip internal rotation range of motion: greater than or equal to 1 hip with greater than 35 degrees of internal range of motion
The authors also stated that if individuals showed two factors (recent onset < 16 days and no symptoms distal to the knee), there was a 91% chance of pain reduction with the use of spinal manipulation. Hence, their conclusion was that if you are treating the lumbar spine, then use spinal manipulation. If you are not using spinal manipulation, then refer to someone who does!
Efficacy for spinal manipulation in cervical spine
Recent blood flow studies of vertebral artery has been variable and no conclusive numbers have been presented. It has been shown that younger individuals (less than 45 years of age) have a greater risk of having an adverse event within one week of spinal manipulation3 (5 times more likely than controls to have had CMT within 1 week of the event date). They did not find any significant associations were found for those greater than or equal to 45 years of age. They state that the best available estimate of incidence is approximately 1.3 cases of VAD or occlusion attributable to CMT for every 100,000 persons less than 45 years of age receiving CMT within 1 week of manipulative therapy.
The presenters suggested that a comprehensive examination precede any treatment that involves manipulation of the cervical spine. The integral part of the clinical examination involves asking for the presence of the 5 D's (diploplia, dysarthria, dysphagia, drop attacks, and dizziness) and 3 N's (nausea, numbness, and nystagmus). In addition, they stressed the importance of conducting a thorough cranial exam, especially with individuals who present with headaches.
At present, the evidence is scarce to suggest that cervical manipulation is effective in the treatment of cervical spine pain. A systematic review of the literature conducted in 1996 demonstrated that cervical spine manipulation and mobilization may provide at least short-term benefits for some patients with neck pain and headaches. They showed that the rate of complications for cervical spine manipulation was estimated to be between 5 and 10 per 10 million manipulations. They concluded that although the risk was small the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death. In addition, a study conducted in 20104 demonstrated that neck manipulation was not more effective than mobilization and hence its use cannot be justified.
The panel concluded that cervical spine pain can be treated without the use of manipulation. However, they suggested that if cervical manipulation is used as a treatment option, then a consent discussion is a must. This includes giving the individual information on risks, odds of having an adverse event, uncertainty of the efficacy and alternate treatment options. Lastly, they recommend that the physiotherapist wait a week to perform any manipulation to decrease the chance of an adverse event.
Conclusion:
· Use spinal manipulation for treatment of lumbar spine pain
· Use your discretion when using spinal manipulation for treatment of cervical spine pain
· Conduct a thorough subjective and objective examination prior to performing spinal manipulation
· Discuss consent prior to spinal manipulation
References
1. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. 2004. BMJ 329 : 1377
3. Miley M, Wellik K, Wingerchuk D, Demaerschalk B. Does Cervical Manipulative Therapy Cause Vertebral Artery Dissection and Stroke? The Neurologist 2008; 14: 66–73.
4. Leaver A, Maher C, Herbert R, Latimer J. A Randomized Controlled Trial Comparing Manipulation with Mobilization for Recent Onset Neck Pain. Archives of Physical Medicine and Rehabilitation 2010; 91 (9) 1313-18.
