Amy W. McDevitt

Manual Physical Therapy and Exercise Versus Supervised Home Exercise in the Management of Patients With Inversion Ankle Sprain: A Multicenter Randomized Clinical Trial

STUDY DESIGN Randomized clinical trial. OBJECTIVE To compare the effectiveness of manual therapy and exercise (MTEX) to a home exercise program (HEP) in the management of individuals with an inversion ankle sprain. BACKGROUND An in-clinic exercise program has been found to yield similar outcomes as an HEP for individuals with an inversion ankle sprain. However, no studies have compared an MTEX approach to an HEP. METHODS Patients with an inversion ankle sprain completed the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, the FAAM sports subscale, the Lower Extremity Functional Scale, and the numeric pain rating scale. Patients were randomly assigned to either an MTEX or an HEP treatment group. Outcomes were collected at baseline, 4 weeks, and 6 months. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance. The hypothesis of interest was the 2-way interaction (group by time). RESULTS Seventy-four patients (mean ± SD age, 35.1 ± 11.0 years; 48.6% female) were randomized into the MTEX group (n = 37) or the HEP group (n = 37). The overall group-by-time interaction for the mixed-model analysis of variance was statistically significant for the FAAM activities of daily living subscale (P<.001), FAAM sports subscale (P<.001), Lower Extremity Functional Scale (P<.001), and pain (P ≤.001). Improvements in all functional outcome measures and pain were significantly greater at both the 4-week and 6-month follow-up periods in favor of the MTEX group. CONCLUSION The results suggest that an MTEX approach is superior to an HEP in the treatment of inversion ankle sprains. Registered at clinicaltrials.gov (NCT00797368). LEVEL OF EVIDENCE Therapy, level 1b-.

Regional interdependence and manual therapy directed at the thoracic spine.

Abstract Thoracic spine manipulation is commonly used by physical therapists for the management of patients with upper quarter pain syndromes. The theoretical construct for using thoracic manipulation for upper quarter conditions is a mainstay of a regional interdependence (RI) approach. The RI concept is likely much more complex and is perhaps driven by a neurophysiological response including those related to peripheral, spinal cord and supraspinal mechanisms. Recent evidence suggests that thoracic spine manipulation results in neurophysiological changes, which may lead to improved pain and outcomes in individuals with musculoskeletal disorders. The intent of this narrative review is to describe the research supporting the RI concept and its application to the treatment of individuals with neck and/or shoulder pain. Treatment utilizing both thrust and non-thrust thoracic manipulation has been shown to result in improvements in pain, range of motion and disability in patients with upper quarter conditions. Research has yet to determine optimal dosage, techniques or patient populations to which the RI approach should be applied; however, emerging evidence supporting a neurophysiological effect for thoracic spine manipulation may negate the need to fully answer this question. Certainly, there is a need for further research examining both the clinical efficacy and effectiveness of manual therapy interventions utilized in the RI model as well as the neurophysiological effects resulting from this intervention.

Cervicothoracic Manual Therapy Plus Exercise Therapy Versus Exercise Therapy Alone in the Management of Individuals With Shoulder Pain: A Multicenter Randomized Controlled Trial

Study Design Multicenter randomized controlled trial. Background Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain, but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a randomized controlled trial. Objectives To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain. Methods Individuals (n = 140) with shoulder pain were randomly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy (manual therapy plus exercise). Pain and disability were assessed at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group by time) was examined using linear mixed-model analyses and the repeated measure of time for the Shoulder Pain and Disability Index (SPADI), the numeric pain-rating scale, and the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Patient-perceived success was assessed and analyzed using the global rating of change (GROC) and the Patient Acceptable Symptom State (PASS), using chi-square tests of independence. Results There were no significant 2-way interactions of group by time or main effects by group for pain or disability. Both groups improved significantly on the SPADI, numeric pain-rating scale, and QuickDASH. Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks (P = .03 and P<.01, respectively) and on the GROC at 6 months (P = .04). Conclusion Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks. More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain. Level of Evidence Therapy, level 1b. Prospectively registered March 30, 2012 at www.ClinicalTrials.gov (NCT01571674). J Orthop Sports Phys Ther 2016;46(8):617-628. doi:10.2519/jospt.2016.6319.

Examination of the Validity of a Clinical Prediction Rule to Identify Patients With Shoulder Pain Likely to Benefit From Cervicothoracic Manipulation

• STUDY DESIGN: Secondary analysis of a randomized controlled trial. • BACKGROUND: Prognostic variables identifying patients with shoulder pain who are likely to respond to cervicothoracic manipulation have been reported; however, they have yet to be validated. • OBJECTIVE: To examine the validity of previously reported prognostic variables in predicting which patients with shoulder pain will respond to cervicothoracic manipulation. • METHODS: Participants (n = 140) with a report of shoulder pain were randomly assigned to receive either 2 sessions of range‐of‐motion exercises plus 6 sessions of stretching and strengthening exercises (exercise group), or 2 sessions of cervicothoracic manipulation and range‐of‐motion exercises followed by 6 sessions of stretching and strengthening exercise (manipulative‐therapy‐plus‐exercise group). Outcomes of disability (Shoulder Pain and Disability Index, shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire) and pain (numeric pain‐rating scale) were collected at baseline, 1 week, 4 weeks, and 6 months. Time, treatment group, status of predictor variables, and 2‐way and 3‐way interactions were analyzed using linear mixed models with repeated measures. • RESULTS: There were no significant 3‐way interactions for either disability (P = .27) or pain scores (P = .70) for time, group, and predictor status for any of the predictor variables. • CONCLUSION: The results of the current study did not validate the previously identified prognostic variables; therefore, we cannot support using these in clinical practice. Further updating of the existing prediction rule may be warranted and could potentially result in new prognostic variables and improved generalizability. Limitations of the study were a mean duration of symptoms of greater than 2 years and a loss to follow‐up of 19% at 6 months. • LEVEL OF EVIDENCE: Prognosis, level 1b. Trial prospectively registered March 30, 2012 at www.clinicaltrials.gov (NCT01571674).

Treatment of individuals with chronic bicipital tendinopathy using dry needling, eccentric-concentric exercise and stretching; a case series

ABSTRACT Objectives: To describe the outcomes of 10 patients with chronic biceps tendinopathy treated by physical therapy with the novel approach of dry needling (DN), eccentric-concentric exercise (ECE), and stretching of the long head of the biceps tendon (LHBT). Methods: Ten individuals reporting chronic anterior shoulder symptoms (> 3 months), pain with palpation of the LHBT, and positive results on a combination of tests including active shoulder flexion, Speed’s, Hawkins Kennedy, Neer, and Yergason’s tests participated in this case series. Validated self-reported outcome measures including the mean numeric pain rating scale (NPRS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) were taken at baseline. Participants were treated with two to eight sessions of DN to the LHBT and an ECE program and stretching of the biceps muscle. At discharge, patients completed the global rating of change (GROC), QuickDASH and NPRS. Results: Patients had an improved mean NPRS of 3.9 (SD, 1.3; p < 0.001), QuickDASH of 19.01% (SD, 10.8; p < 0.02) and GROC +5.4 (SD, 1.3). Conclusion: Findings from this case series suggest that DN and ECE may be beneficial for the management of patients with chronic LHBT tendinopathy. Further research on the efficacy of this novel treatment approach is warranted.

Impact of expectations on functional recovery in individuals with chronic shoulder pain

Abstract Study Design Retrospective cohort Objectives To examine general expectations for treatment by physical therapists and specific expectations for common interventions in patients with shoulder pain. A secondary objective was to assess the extent to which patients’ general and specific expectations for treatment affect clinical outcomes. Methods We performed a secondary analysis of data from a clinical trial of interventions for shoulder pain. Prior to beginning treatment for shoulder pain, 140 patients were asked their general expectations of benefit and their specific expectations for individual interventions. Next we examined how these expectations related to the patients’ ratings of the success of treatment at one and six months after treatment. Results Patients had positive general expectations for treatment by a physical therapist. Specific manual therapy interventions of range of motion and strengthening had the highest proportion of patients who expected these interventions to significantly improve shoulder pain. Seventy-two patients (58%) reported themselves to be improved using the global rating of change (GROC) at one month and six months. In the full model predicting one-month GROC, only the expectation of moderate relief (p = 0.012) and body mass index (BMI) (p = 0.013) had significant effects. Overall, the Shoulder Pain and Disability Index (SPADI) significantly decreased over time (p = 0.004); however, a significant interaction did occur between time and BMI (p = 0.021). Discussion Patients expect common interventions used by physical therapists to be effective to manage shoulder pain. In conclusion, patients with shoulder pain had high general expectations for physical therapy. Level of Evidence: Prognosis, level 2b

Use of Pain Neuroscience Education, Tactile Discrimination, and Graded Motor Imagery in an Individual With Frozen Shoulder

STUDY DESIGN: Case report. BACKGROUND: Aggressive physical therapy in the freezing stage of frozen shoulder may prolong the course of recovery. Central sensitization may play a role in the early stages of frozen shoulder. Pain neuroscience education, tactile discrimination, and graded motor imagery have been used in a number of conditions with central sensitization. The purpose of this case report was to describe the examination and treatment of a patient in the freezing stage of frozen shoulder using pain neuroscience education, tactile discrimination, and graded motor imagery. CASE DESCRIPTION: A 54‐year‐old woman with a diagnosis of frozen shoulder was referred by an orthopaedic surgeon following lack of progress after 4 weeks of intensive daily physical therapy. Pain at rest was 7/10, and her Shoulder Pain and Disability Index score was 64%. She had painful and limited active range of motion and elevated fear‐avoidance beliefs. Tactile discrimination and limb laterality were impaired, with signs of central sensitization. A “top‐down” approach using pain neuroscience education, tactile discrimination, and graded motor imagery was used for the first 6 weeks, followed by a “bottom‐up” impairmentbased approach. OUTCOMES: The patient was seen for 20 sessions over 12 weeks. At discharge, her Shoulder Pain and Disability Index score was 22%, resting pain was 0/10, and fear‐avoidance beliefs improved. Improvements in active range of motion, laterality, and tactile discrimination were also noted. DISCUSSION: Intensive physical therapy in the freezing stage of frozen shoulder may be detrimental to long‐term outcomes. This case report suggests that a top‐down approach may allow a quicker transition through the freezing stage of frozen shoulder. LEVEL OF EVIDENCE: Therapy, level 5.