J. Haxby Abbott

A Comparison of 3 Methodological Approaches to Defining Major Clinically Important Improvement of 4 Performance Measures in Patients With Hip Osteoarthritis

STUDY DESIGN Prospective cohort study. OBJECTIVES To establish the major clinically important improvement (MCII) of the timed up-and-go test (TUG), 40-meter self-paced walk test (40-m SPWT), 30-second chair stand (30 CST), and a 20-cm step test in patients with hip osteoarthritis (OA) undergoing physiotherapy treatment. As a secondary aim, a comparison of methods was employed to evaluate the effect of method on the reported MCII. BACKGROUND Minimal clinically important difference scores are commonly used by rehabilitation professionals to determine patient response following treatment. A gold standard for calculating MCII has yet to be determined, which has resulted in problems of interpretation due to varied results. METHODS As part of a randomized controlled trial, 65 patients were randomized into a physiotherapy treatment group for hip OA, in which they completed 4 physical performance measures at baseline and 9 weeks. Upon completion of physiotherapy, patients assessed their response to treatment on a 15-point global rating of change scale (GRCS). MCII was estimated using 3 variations of an anchor-based method, based on the patients opinion. RESULTS A comparison of 3 methods resulted in the following change scores being best associated with our definition of MCII: a reduction equal to or greater than 0.8, 1.4, and 1.2 seconds for the TUG; an increase equal to or greater than 0.2, 0.3, and 0.2 m/s for the 40-m SPWT; an increase equal to or greater than 2.0, 2.6, and 2.1 repetitions for the 30 CST; an increase equal to or greater than 5.0, 12.8, and 16.4 steps for the 20-cm step test. CONCLUSION The variation in methods provided very different results. This illustrates the importance of comparing methodologies and reporting a range of values associated with the MCII, as such values vary, depending upon the methodology chosen.

Patient characteristics that predict progression of knee osteoarthritis: A systematic review of prognostic studies

To identify, by systematic review, patient characteristics that can be used by health care practitioners to predict the likelihood of knee osteoarthritis (OA) progression.

Manual Physical Therapy and Exercise Versus Electrophysical Agents and Exercise in the Management of Plantar Heel Pain: A Multicenter Randomized Clinical Trial

STUDY DESIGN Randomized clinical trial. OBJECTIVE To compare the effectiveness of 2 different conservative management approaches in the treatment of plantar heel pain. BACKGROUND There is insufficient evidence to establish the optimal physical therapy management strategies for patients with heel pain, and little evidence of long-term effects. METHODS Patients with a primary report of plantar heel pain underwent a standard evaluation and completed a number of patient self-report questionnaires, including the Lower Extremity Functional Scale (LEFS), the Foot and Ankle Ability Measure (FAAM), and the Numeric Pain Rating Scale (NPRS). Patients were randomly assigned to be treated with either an electrophysical agents and exercise (EPAX) or a manual physical therapy and exercise (MTEX) approach. Outcomes of interest were captured at baseline and at 4-week and 6-month follow-ups. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance (ANOVA). The hypothesis of interest was the 2-way interaction (group by time). RESULTS Sixty subjects (mean [SD] age, 48.4 [8.7] years) satisfied the eligibility criteria, agreed to participate, and were randomized into the EPAX (n = 30) or MTEX group (n = 30). The overall group-by-time interaction for the ANOVA was statistically significant for the LEFS (P = .002), FAAM (P = .005), and pain (P = .043). Between-group differences favored the MTEX group at both 4-week (difference in LEFS, 13.5; 95% CI: 6.3, 20.8) and 6-month (9.9; 95% CI: 1.2, 18.6) follow-ups. CONCLUSION The results of this study provide evidence that MTEX is a superior management approach over an EPAX approach in the management of individuals with plantar heel pain at both the short- and long-term follow-ups. Future studies should examine the contribution of the different components of the exercise and manual physical therapy programs. LEVEL OF EVIDENCE Therapy, level 1b.

Variables Associated With the Progression of Hip Osteoarthritis: A Systematic Review

OBJECTIVE As populations age and the prevalence of hip osteoarthritis (OA) increases, health care providers must manage increasing demands for services. Evidence regarding the progression of hip OA can assist health care practitioners in determining expected patient prognosis and planning care. This systematic review of prospective cohort studies examines prognostic variables in patients with hip OA. METHODS Articles were selected following a comprehensive search of Medline, EMBase, CINAHL, and Allied and Complementary Medicine from database inception to October 2008 and hand searches of the reference lists of retrieved articles. Inclusion criteria involved 1) estimates of the association between prognostic variables and progression of OA, 2) prospective cohort design, 3) patients diagnosed with hip OA based on established criteria, 4) at least 1 year of followup, and 5) access to the full published text. Two independent reviewers assessed the methodologic quality of each study and the association between prognostic variables and OA progression. RESULTS Eighteen articles met the inclusion criteria; 17 were considered to be of high quality. Strong evidence of progression was associated with age, joint space width at entry, femoral head migration, femoral osteophytes, bony sclerosis, Kellgren/Lawrence hip grade 3, baseline hip pain, and Lequesne index score > or =10. Strong evidence of no association with progression was associated with acetabular osteophytes. Evidence was weak or inconclusive regarding associations between various other radiographic or clinical variables, molecular biomarkers, or use of nonsteroidal inflammatory drugs. CONCLUSION Overall, few variables were found to be strongly associated with the progression of hip OA, and a variety of other variables were weakly predictive of outcome.

Effect of Physical Therapy on Pain and Function in Patients With Hip Osteoarthritis: A Randomized Clinical Trial

IMPORTANCE There is limited evidence supporting use of physical therapy for hip osteoarthritis. OBJECTIVE To determine efficacy of physical therapy on pain and physical function in patients with hip osteoarthritis. DESIGN, SETTING, AND PARTICIPANTS Randomized, placebo-controlled, participant- and assessor-blinded trial involving 102 community volunteers with hip pain levels of 40 or higher on a visual analog scale of 100 mm (range, 0-100 mm; 100 indicates worst pain possible) and hip osteoarthritis confirmed by radiograph. Forty-nine patients in the active group and 53 in the sham group underwent 12 weeks of intervention and 24 weeks of follow-up (May 2010-February 2013) INTERVENTIONS: Participants attended 10 treatment sessions over 12 weeks. Active treatment included education and advice, manual therapy, home exercise, and gait aid if appropriate. Sham treatment included inactive ultrasound and inert gel. For 24 weeks after treatment, the active group continued unsupervised home exercise while the sham group self-applied gel 3 times weekly. MAIN OUTCOMES AND MEASURES Primary outcomes were average pain (0 mm, no pain; 100 mm, worst pain possible) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, 0 no difficulty to 68 extreme difficulty) at week 13. Secondary outcomes were these measures at week 36 and impairments, physical performance, global change, psychological status, and quality of life at weeks 13 and 36. RESULTS Ninety-six patients (94%) completed week 13 measurements and 83 (81%) completed week 36 measurements. The between-group differences for improvements in pain were not significant. For the active group, the baseline mean (SD) visual analog scale score was 58.8 mm (13.3) and the week-13 score was 40.1 mm (24.6); for the sham group, the baseline score was 58.0 mm (11.6) and the week-13 score was 35.2 mm (21.4). The mean difference was 6.9 mm favoring sham treatment (95% CI, -3.9 to 17.7). The function scores were not significantly different between groups. The baseline mean (SD) physical function score for the active group was 32.3 (9.2) and the week-13 score was 27.5 (12.9) units, whereas the baseline score for the sham treatment group was 32.4 (8.4) units and the week-13 score was 26.4 (11.3) units, for a mean difference of 1.4 units favoring sham (95% CI, -3.8 to 6.5) at week 13. There were no between-group differences in secondary outcomes (except greater week-13 improvement in the balance step test in the active group). Nineteen of 46 patients (41%) in the active group reported 26 mild adverse effects and 7 of 49 (14%) in the sham group reported 9 mild adverse events (P = .003). CONCLUSIONS AND RELEVANCE Among adults with painful hip osteoarthritis, physical therapy did not result in greater improvement in pain or function compared with sham treatment, raising questions about its value for these patients. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12610000439044.

Lumbar segmental instability: a criterion-related validity study of manual therapy assessment

BackgroundMusculoskeletal physiotherapists routinely assess lumbar segmental motion during the clinical examination of a patient with low back pain. The validity of manual assessment of segmental motion has not, however, been adequately investigated.MethodsIn this prospective, multi-centre, pragmatic, diagnostic validity study, 138 consecutive patients with recurrent or chronic low back pain (R/CLBP) were recruited. Physiotherapists with post-graduate training in manual therapy performed passive accessory intervertebral motion tests (PAIVMs) and passive physiological intervertebral motion tests (PPIVMs). Consenting patients were referred for flexion-extension radiographs. Sagittal angular rotation and sagittal translation of each lumbar spinal motion segment was measured from these radiographs, and compared to a reference range derived from a study of 30 asymptomatic volunteers. Motion beyond two standard deviations from the reference mean was considered diagnostic of rotational lumbar segmental instability (LSI) and translational LSI. Accuracy and validity of the clinical assessments were expressed using sensitivity, specificity, and likelihood ratio statistics with 95% confidence intervals (CI).ResultsOnly translation LSI was found to be significantly associated with R/CLBP (p < 0.05). PAIVMs were specific for the diagnosis of translation LSI (specificity 89%, CI 83–93%), but showed poor sensitivity (29%, CI 14–50%). A positive test results in a likelihood ratio (LR+) of 2.52 (95% CI 1.15–5.53). Flexion PPIVMs were highly specific for the diagnosis of translation LSI (specificity 99.5%; CI 97–100%), but showed very poor sensitivity (5%; CI 1–22%). Likelihood ratio statistics for flexion PPIVMs were not statistically significant. Extension PPIVMs performed better than flexion PPIVMs, with slightly higher sensitivity (16%; CI 6–38%) resulting in a likelihood ratio for a positive test of 7.1 (95% CI 1.7 to 29.2) for translation LSI.ConclusionThis study provides the first evidence reporting the concurrent validity of manual tests for the detection of abnormal sagittal planar motion. PAIVMs and PPIVMs are highly specific, but not sensitive, for the detection of translation LSI. Likelihood ratios resulting from positive test results were only moderate. This research indicates that manual clinical examination procedures have moderate validity for detecting segmental motion abnormality.

Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review.

OBJECTIVE To investigate the cost-effectiveness of nonpharmacological, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. METHODS We identified economic evaluations or cost studies associated with randomized or quasi-randomized controlled trials that assessed nonpharmacologic, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. Medline, Embase, PubMed, National Health Service Economic Evaluation Database, CENTRAL, EconLit, and OpenSIGLE were searched up to October 1, 2010. Study characteristics extracted include study population, health outcomes, and economic analysis elements. Economic analyses were assessed by using the Quality of Health Economic Studies instrument, and the methodological quality of the randomized controlled trials was graded by using an internal validity checklist. All costs were converted to 2008 US dollars. RESULTS Ten economic evaluations and one randomized controlled trial reporting health-care costs met our inclusion criteria. Interventions included exercise programs, acupuncture, rehabilitation programs, and lifestyle interventions. Six of the 11 studies exhibited high risks of bias for the cost and/or effect components of their cost-effectiveness estimate. Six studies used comparators of unknown cost-effectiveness. Four studies reported cost-effectiveness estimates lower than

Exercise therapy, manual therapy, or both, for osteoarthritis of the hip or knee: a factorial randomised controlled trial protocol

50,000 per quality-adjusted life-year. All studies evaluating exercise interventions found the programs to be cost saving. CONCLUSIONS There is only limited evidence for the cost-effectiveness of conservative treatments for the management of hip and/or knee osteoarthritis. More high-quality economic evaluations of conservative interventions are needed to further inform practice.

Lumbar segmental mobility disorders: comparison of two methods of defining abnormal displacement kinematics in a cohort of patients with non-specific mechanical low back pain

BackgroundNon-pharmacological, non-surgical interventions are recommended as the first line of treatment for osteoarthritis (OA) of the hip and knee. There is evidence that exercise therapy is effective for reducing pain and improving function in patients with knee OA, some evidence that exercise therapy is effective for hip OA, and early indications that manual therapy may be efficacious for hip and knee OA. There is little evidence as to which approach is more effective, if benefits endure, or if providing these therapies is cost-effective for the management of this disorder. The MOA Trial (Management of OsteoArthritis) aims to test the effectiveness of two physiotherapy interventions for improving disability and pain in adults with hip or knee OA in New Zealand. Specifically, our primary objectives are to investigate whether:1. Exercise therapy versus no exercise therapy improves disability at 12 months;2. Manual physiotherapy versus no manual therapy improves disability at 12 months;3. Providing physiotherapy programmes in addition to usual care is more cost-effective than usual care alone in the management of osteoarthritis at 24 months.MethodsThis is a 2 × 2 factorial randomised controlled trial. We plan to recruit 224 participants with hip or knee OA. Eligible participants will be randomly allocated to receive either: (a) a supervised multi-modal exercise therapy programme; (b) an individualised manual therapy programme; (c) both exercise therapy and manual therapy; or, (d) no trial physiotherapy. All participants will continue to receive usual medical care. The outcome assessors, orthopaedic surgeons, general medical practitioners, and statistician will be blind to group allocation until the statistical analysis is completed. The trial is funded by Health Research Council of New Zealand Project Grants (Project numbers 07/199, 07/200).DiscussionThe MOA Trial will be the first to investigate the effectiveness and cost-effectiveness of providing physiotherapy programmes of this kind, for the management of pain and disability in adults with hip or knee OA.Trial registrationAustralian New Zealand Clinical Trials Registry ref: ACTRN12608000130369.

Laser therapy in the treatment of achilles tendinopathy: a pilot study.

BackgroundLumbar segmental rigidity (LSR) and lumbar segmental instability (LSI) are believed to be associated with low back pain (LBP), and identification of these disorders is believed to be useful for directing intervention choices. Previous studies have focussed on lumbar segmental rotation and translation, but have used widely varying methodologies. Cut-off points for the diagnosis of LSR & LSI are largely arbitrary. Prevalence of these lumbar segmental mobility disorders (LSMDs) in a non-surgical, primary care LBP population has not been established.MethodsA cohort of 138 consecutive patients with recurrent or chronic low back pain (RCLBP) were recruited in this prospective, pragmatic, multi-centre study. Consenting patients completed pain and disability rating instruments, and were referred for flexion-extension radiographs. Sagittal angular rotation and sagittal translation of each lumbar spinal motion segment was measured from the radiographs, and compared to a reference range derived from a study of 30 asymptomatic volunteers. In order to define reference intervals for normal motion, and define LSR and LSI, we approached the kinematic data using two different models. The first model used a conventional Gaussian definition, with motion beyond two standard deviations (2sd) from the reference mean at each segment considered diagnostic of rotational LSMD and translational LSMD. The second model used a novel normalised within-subjects approach, based on mean normalised contribution-to-total-lumbar-motion. An LSMD was then defined as present in any segment that contributed motion beyond 2sd from the reference mean contribution-to-normalised-total-lumbar-motion. We described reference intervals for normal segmental mobility, prevalence of LSMDs under each model, and the association of LSMDs with pain and disability.ResultsWith the exception of the conventional Gaussian definition of rotational LSI, LSMDs were found in statistically significant prevalences in patients with RCLBP. Prevalences at both the segmental and patient level were generally higher using the normalised within-subjects model (2.8 to 16.8% of segments; 23.3 to 35.5% of individuals) compared to the conventional Gaussian model (0 to 15.8%; 4.7 to 19.6%). LSMDs are associated with presence of LBP, however LSMDs do not appear to be strongly associated with higher levels of pain or disability compared to other forms of non-specific LBP.ConclusionLSMDs are a valid means of defining sub-groups within non-specific LBP, in a conservative care population of patients with RCLBP. Prevalence was higher using the normalised within-subjects contribution-to-total-lumbar-motion approach.