Keith G. Avin

Patellar taping and bracing for the treatment of chronic knee pain: A systematic review and meta‐analysis

OBJECTIVE To evaluate the evidence for patellar taping and bracing in the management of chronic knee pain. METHODS Randomized or quasi-randomized studies assessing patellar taping or bracing effects on chronic knee pain were sourced from 7 electronic databases (to November 2006), and assessed using the Physiotherapy Evidence Database scale. Weighted mean differences were determined, and pooled estimates of taping and bracing effects were obtained using random-effects models. RESULTS Of 16 eligible trials, 13 investigated patellar taping or bracing effects in individuals with anterior knee pain, and 3 investigated taping effects in individuals with knee osteoarthritis (OA). The methodologic quality of the taping studies was significantly higher than the bracing studies (mean+/-SD 4.8+/-2.1 versus 2.8+/-0.8; P<0.05). On a 100-mm scale, tape applied to exert a medially-directed force on the patella decreased chronic knee pain compared with no tape by 16.1 mm (95% confidence interval [95% CI] -22.2, -10.0; P<0.001) and sham tape by 10.9 mm (95% CI -18.4, -3.4; P<0.001). For anterior knee pain and OA, medially-directed tape decreased pain compared with no tape by 14.7 mm (95% CI -22.8, -6.9; P<0.001) and 20.1 mm (95% CI -26.0, -14.3; P<0.001), respectively. There was disputable evidence from low-quality studies for patellar bracing benefits. CONCLUSION There was evidence that tape applied to exert a medially-directed force on the patella produces a clinically meaningful change in chronic knee pain. There was limited evidence to demonstrate the efficacy of patellar bracing. These outcomes were limited by the presence of high heterogeneity between study outcomes and significant publication bias.

Low-Intensity Pulsed Ultrasound Accelerates and a Nonsteroidal Anti-inflammatory Drug Delays Knee Ligament Healing

Background Low-intensity pulsed ultrasound and nonsteroidal anti-inflammatory drugs are used to treat ligament injuries; however, their individual and combined effects are not established. Hypotheses Low-intensity pulsed ultrasound accelerates ligament healing, a nonsteroidal anti-inflammatory drug delays healing, and the nonsteroidal anti-inflammatory drug inhibits the beneficial effect of low-intensity pulsed ultrasound. Study Design Controlled laboratory study. Methods Sixty adult rats underwent bilateral transection of their knee medial collateral ligaments. Animals were divided into 2 drug groups and treated 5 d/wk with celecoxib (5 mg/kg) mixed in a vehicle solution (NSAID group) or vehicle alone (VEH group). One to 3 hours after drug administration, all animals were treated with unilateral active low-intensity pulsed ultrasound and contralateral inactive low-intensity pulsed ultrasound. Equal numbers of animals from each drug group were mechanically tested at 2 weeks (n = 14/group), 4 weeks (n = 8/group), and 12 weeks (n = 8/group) after injury. Results Ultrasound and drug intervention did not interact to influence ligament mechanical properties at any time point. After 2 weeks of intervention, ligaments treated with active low-intensity pulsed ultrasound were 34.2% stronger, 27.0% stiffer, and could absorb 54.4% more energy before failure than could ligaments treated with inactive low-intensity pulsed ultrasound, whereas ligaments from the NSAID group could absorb 33.3% less energy than could ligaments from the VEH group. There were no ultrasound or drug effects after 4 and 12 weeks of intervention. Conclusions Low-intensity pulsed ultrasound accelerated but did not improve ligament healing, whereas the nonsteroidal anti-inflammatory drug delayed but did not impair healing. When used in combination, the beneficial low-intensity pulsed ultrasound effect was cancelled by the detrimental nonsteroidal anti-inflammatory drug effect. Clinical Relevance Low-intensity pulsed ultrasound after ligament injury may facilitate earlier return to activity, whereas nonsteroidal anti-inflammatory drugs may elevate early reinjury risk.

Management of Falls in Community-Dwelling Older Adults: Clinical Guidance Statement From the Academy of Geriatric Physical Therapy of the American Physical Therapy Association

Background Falls in older adults are a major public health concern due to high prevalence, impact on health outcomes and quality of life, and treatment costs. Physical therapists can play a major role in reducing fall risk for older adults; however, existing clinical practice guidelines (CPGs) related to fall prevention and management are not targeted to physical therapists. Objective The purpose of this clinical guidance statement (CGS) is to provide recommendations to physical therapists to help improve outcomes in the identification and management of fall risk in community-dwelling older adults. Design and Methods The Subcommittee on Evidence-Based Documents of the Practice Committee of the Academy of Geriatric Physical Therapy developed this CGS. Existing CPGs were identified by systematic search and critically appraised using the Appraisal of Guidelines, Research, and Evaluation in Europe II (AGREE II) tool. Through this process, 3 CPGs were recommended for inclusion in the CGS and were synthesized and summarized. Results Screening recommendations include asking all older adults in contact with a health care provider whether they have fallen in the previous year or have concerns about balance or walking. Follow-up should include screening for balance and mobility impairments. Older adults who screen positive should have a targeted multifactorial assessment and targeted intervention. The components of this assessment and intervention are reviewed in this CGS, and barriers and issues related to implementation are discussed. Limitations A gap analysis supports the need for the development of a physical therapy–specific CPG to provide more precise recommendations for screening and assessment measures, exercise parameters, and delivery models. Conclusion This CGS provides recommendations to assist physical therapists in the identification and management of fall risk in older community-dwelling adults.

Ultrasound Produced by a Conventional Therapeutic Ultrasound Unit Accelerates Fracture Repair: 686

BACKGROUND AND PURPOSE A recent novel application of ultrasound therapy is the treatment of bone fractures. The aim of this study was to investigate the effect on fracture repair of ultrasound produced by a conventional therapeutic ultrasound unit as used by physical therapists. SUBJECTS AND METHODS Bilateral midshaft femur fractures were created in 30 adult male Long-Evans rats. Ultrasound therapy was commenced on the first day after fracture and introduced 5 days a week for 20 minutes a day. Each animal was treated unilaterally with active ultrasound and contralaterally with inactive ultrasound. Active ultrasound involved a 2-millisecond burst of 1.0-MHz sine waves repeating at 100 Hz. The spatially averaged, temporally averaged intensity was set at 0.1 W/cm2. Animals were killed at 25 and 40 days after fracture induction, and the fractures were assessed for bone mass and strength. RESULTS There were no differences between fractures treated with active ultrasound and fractures treated with inactive ultrasound at 25 days. However, at 40 days, active ultrasound-treated fractures had 16.9% greater bone mineral content at the fracture site than inactive ultrasound-treated fractures. This change resulted in a 25.8% increase in bone size, as opposed to an increase in bone density, and contributed to active ultrasound-treated fractures having 81.3% greater mechanical strength than inactive ultrasound-treated fractures. DISCUSSION AND CONCLUSION These data indicate that ultrasound produced by a conventional therapeutic ultrasound unit as traditionally used by physical therapists may be used to facilitate fracture repair. However, careful interpretation of this controlled laboratory study is warranted until its findings are confirmed by clinical trials.

Biomechanical aspects of the muscle-bone interaction.

There is growing interest in the interaction between skeletal muscle and bone, particularly at the genetic and molecular levels. However, the genetic and molecular linkages between muscle and bone are achieved only within the context of the essential mechanical coupling of the tissues. This biomechanical and physiological linkage is readily evident as muscles attach to bone and induce exposure to varied mechanical stimuli via functional activity. The responsiveness of bone cells to mechanical stimuli, or their absence, is well established. However, questions remain regarding how muscle forces applied to bone serve to modulate bone homeostasis and adaptation. Similarly, the contributions of varied, but unique, stimuli generated by muscle to bone (such as low-magnitude, high-frequency stimuli) remains to be established. The current article focuses upon the mechanical relationship between muscle and bone. In doing so, we explore the stimuli that muscle imparts upon bone, models that enable investigation of this relationship, and recent data generated by these models.

Bone is Not Alone: the Effects of Skeletal Muscle Dysfunction in Chronic Kidney Disease

Chronic kidney disease (CKD) is associated with a decline in muscle mass, strength, and function, collectively called “sarcopenia.” Sarcopenia is associated with hospitalizations and mortality in CKD and is therefore important to understand and characterize. While the focus of skeletal health in CKD has traditionally focused on bone and mineral aberrations, it is now recognized that sarcopenia must also play a role in poor musculoskeletal health in this population. In this paper, we present an overview of skeletal muscle changes in CKD, including defects in skeletal muscle catabolism and anabolism in uremic tissue. There are many gaps in knowledge in this field that should be the focus for future research to unravel pathogenesis and therapies for musculoskeletal health in CKD.

Clinical relevance of sarcopenia in chronic kidney disease.

Purpose of review In this article, we review sarcopenia in chronic kidney disease (CKD). We aim to present how definitions of sarcopenia from the general population may pertain to those with CKD, its assessment by clinicians and emerging therapies for sarcopenia in CKD. For this review, we limit our description and recommendations to patients with CKD who are not on dialysis. Recent findings Poorer parameters of lean mass, strength and physical function are associated with worsening patient-centered outcomes such as limiting mobility, falls and mortality in CKD; however, the magnitude of these associations are different in those with and without CKD. Sarcopenia in CKD is a balance between skeletal muscle regeneration and catabolism, which are both altered in the uremic environment. Multiple pathways are involved in these derangements, which are briefly reviewed. Differences between commonly used terms cachexia, frailty, protein-energy wasting, dynapenia and sarcopenia are described. Therapeutic options in predialysis CKD are not well studied; therefore, we review exercise options and emerging pharmacological therapies. Summary Sarcopenia, now with its own International Classification of Diseases, 10th Revision (ICD-10) code, is of importance clinically and should be accounted for in research studies in patients with CKD. Multiple therapies for sarcopenia are in development and will hopefully be available for our patients in the future.

Peripheral Quantitative Computed Tomography Predicts Humeral Diaphysis Torsional Mechanical Properties With Good Short-Term Precision

Peripheral quantitative computed tomography (pQCT) is a popular tool for noninvasively estimating bone mechanical properties. Previous studies have demonstrated that pQCT provides precise estimates that are good predictors of actual bone mechanical properties at popular distal imaging sites (tibia and radius). The predictive ability and precision of pQCT at more proximal sites remain unknown. The aim of the present study was to explore the predictive ability and short-term precision of pQCT estimates of mechanical properties of the midshaft humerus, a site gaining popularity for exploring the skeletal benefits of exercise. Predictive ability was determined ex vivo by assessing the ability of pQCT-derived estimates of torsional mechanical properties in cadaver humeri (density-weighted polar moment of inertia [I(P)] and polar strength-strain index [SSI(P)]) to predict actual torsional properties. Short-term precision was assessed in vivo by performing 6 repeat pQCT scans at the level of the midshaft humerus in 30 young, healthy individuals (degrees of freedom = 150), with repeat scans performed by the same and different testers and on the same and different days to explore the influences of different testers and time between repeat scans on precision errors. IP and SSI(P) both independently predicted at least 90% of the variance in ex vivo midshaft humerus mechanical properties in cadaveric bones. Overall values for relative precision error (root mean squared coefficients of variation) for in vivo measures of IP and SSI(P) at the midshaft humerus were <1.5% and were not influenced by pQCT assessments being performed by different testers or on different days. These data indicate that pQCT provides very good prediction of midshaft humerus mechanical properties with good short-term precision, with measures being robust against the influences of different testers and time between repeat scans.

Electroacupuncture Promotes Central Nervous System-Dependent Release of Mesenchymal Stem Cells

Electroacupuncture (EA) performed in rats and humans using limb acupuncture sites, LI‐4 and LI‐11, and GV‐14 and GV‐20 (humans) and Bai‐hui (rats) increased functional connectivity between the anterior hypothalamus and the amygdala and mobilized mesenchymal stem cells (MSCs) into the systemic circulation. In human subjects, the source of the MSC was found to be primarily adipose tissue, whereas in rodents the tissue sources were considered more heterogeneous. Pharmacological disinhibition of rat hypothalamus enhanced sympathetic nervous system (SNS) activation and similarly resulted in a release of MSC into the circulation. EA‐mediated SNS activation was further supported by browning of white adipose tissue in rats. EA treatment of rats undergoing partial rupture of the Achilles tendon resulted in reduced mechanical hyperalgesia, increased serum interleukin‐10 levels and tendon remodeling, effects blocked in propranolol‐treated rodents. To distinguish the afferent role of the peripheral nervous system, phosphoinositide‐interacting regulator of transient receptor potential channels (Pirt)‐GCaMP3 (genetically encoded calcium sensor) mice were treated with EA acupuncture points, ST‐36 and LIV‐3, and GV‐14 and Bai‐hui and resulted in a rapid activation of primary sensory neurons. EA activated sensory ganglia and SNS centers to mediate the release of MSC that can enhance tissue repair, increase anti‐inflammatory cytokine production and provide pronounced analgesic relief. Stem Cells 2017;35:1303–1315

Electroacupuncture Promotes CNS-Dependent Release of Mesenchymal Stem Cells.

Electroacupuncture (EA) performed in rats and humans using limb acupuncture sites, LI‐4 and LI‐11, and GV‐14 and GV‐20 (humans) and Bai‐hui (rats) increased functional connectivity between the anterior hypothalamus and the amygdala and mobilized mesenchymal stem cells (MSCs) into the systemic circulation. In human subjects, the source of the MSC was found to be primarily adipose tissue, whereas in rodents the tissue sources were considered more heterogeneous. Pharmacological disinhibition of rat hypothalamus enhanced sympathetic nervous system (SNS) activation and similarly resulted in a release of MSC into the circulation. EA‐mediated SNS activation was further supported by browning of white adipose tissue in rats. EA treatment of rats undergoing partial rupture of the Achilles tendon resulted in reduced mechanical hyperalgesia, increased serum interleukin‐10 levels and tendon remodeling, effects blocked in propranolol‐treated rodents. To distinguish the afferent role of the peripheral nervous system, phosphoinositide‐interacting regulator of transient receptor potential channels (Pirt)‐GCaMP3 (genetically encoded calcium sensor) mice were treated with EA acupuncture points, ST‐36 and LIV‐3, and GV‐14 and Bai‐hui and resulted in a rapid activation of primary sensory neurons. EA activated sensory ganglia and SNS centers to mediate the release of MSC that can enhance tissue repair, increase anti‐inflammatory cytokine production and provide pronounced analgesic relief. Stem Cells 2017;35:1303–1315