Klaas Postema

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain: A Randomized, Controlled Trial

Context Shoulder pain in the absence of trauma, fracture, rupture, or dislocation can lead to substantial functional limitations and can be a difficult condition to treat. Contribution In this randomized, controlled trial, patients with shoulder pain and shoulder girdle dysfunction assigned to receive manipulative therapy in addition to usual general practitioner care had more rapid improvement in symptoms and fewer shoulder symptoms at 12 weeks than patients assigned to usual care alone. Implications Manipulative therapy appears to be an effective treatment option for patients with shoulder pain and shoulder girdle dysfunction that are not due to trauma, fracture, rupture, or dislocation. The Editors Shoulder disorders are a widely recognized medical, social, and economic problem (1). They are characterized by functional disability due to pain in the shoulder at rest or during movement or by functional disability due to restricted range of motion. The annual incidence of shoulder symptoms in Dutch general medical practices is estimated to be 10 to 25 per 1000 enrolled patients (2-4). In the Netherlands, shoulder disorders are treated according to the Guidelines for Shoulder Complaints of the Dutch College of General Practitioners (5, 6). Initial treatment during the first 2 weeks includes informing patients about the nature and course of shoulder symptoms and advising them on how to use the affected shoulder during daily living. Patients can also be prescribed analgesics or nonsteroidal anti-inflammatory drugs if necessary. If this initial treatment is not effective, up to 3 corticosteroid injections (in the subacromial space or glenohumeral joint) can be given. Referral for physiotherapy is considered only for patients whose symptoms persist for 6 weeks or more. This treatment regimen, according to the guidelines, provides short-term benefit for many patients but cannot prevent the often unfavorable long-term course of the symptoms. Indeed, only 50% of all new episodes of shoulder disorders resolve within 6 months, while at 12 months more than 40% of all patients are still disabled during work and leisure time (4, 7). Pain or dysfunction of the cervicothoracic spine and the adjacent ribs (also called the shoulder girdle) often accompanies shoulder symptoms (8). A considerable proportion of patients with shoulder symptoms (approximately 20%) but no shoulder joint disorders may be found to have dysfunction of the shoulder girdle on further physical examination (9). Moreover, dysfunction of the shoulder girdle triples the risk for shoulder complications (10) and also predicts poor outcome of shoulder disorders (10-12). In clinical practice, dysfunction of the shoulder girdle can be treated with manipulative therapy, which aims to restore normal function. Winters and colleagues (13) found that manipulative therapy accelerated recovery and improved symptoms compared with physiotherapy in a relatively small subgroup of patients with both shoulder symptoms and shoulder girdle dysfunction. These effects were not sustained on long-term follow-up, possibly because of high attrition rates (14). Evidence showing that manipulative therapy for the shoulder girdle effectively treats shoulder symptoms is scarce; Winters and colleagues have performed the only randomized trial (13, 14) to date. Our objective was to study the effectiveness of manipulative therapy for the shoulder girdle in addition to usual medical care by a general practitioner. The study design has been described elsewhere (15), and the trial was designed and reported accord ing to the Consolidated Standards of Reporting Trials (CONSORT) statement (16). We report the effects of the use of additional manipulative therapy for the shoulder girdle to treat shoulder symptoms. Methods Participants Potential eligible participants with shoulder symptoms (pain and dysfunction) were recruited in 50 general practices in Groningen, the Netherlands. General practitioners started initial treatment (usual medical care) at presentation, assessed eligibility criteria, and told the conducting researcher about each eligible patient. The general practitioner used a standardized eligibility checklist and a physical examination as recommended by the Dutch College of General Practitioners (5, 6). A baseline assessment at the research center was scheduled within 2 weeks of presentation. Shoulder symptoms were defined as pain between the neck and the elbow at rest or during movement of the upper arm (Figure 1). Pain radiating to the neck region or to the lower part of the arm was not used as an exclusion criterion. The physical examination established the presence of both shoulder symptoms and dysfunction of the cervicothoracic spine and the adjacent ribs with accompanying pain or restricted movement. Eligible patients were 18 years of age or older and had had no consultation or treatment for shoulder symptoms in the past 3 months. No limits were placed on duration of symptoms before the first consultation. Figure 1. Location of shoulder symptoms. Reasons for exclusion were acute severe trauma, such as fractures, ruptures, or dislocation in the shoulder region; previous orthopedic surgery; clear treatment preference deviating from the study protocol; contraindications to manipulative therapy (for example, hypermobility, instability, or severe arthrosis of the cervicothoracic spine); signs of cervical nerve root compression; presence of specific rheumatic disorders; presence of dementia or other severe psychiatric, emotional, or behavioral disorders; shoulder disorders due to general internal disease of thoracic and abdominal organs; and inability to complete Dutch-language written questionnaires. Eligibility and exclusion criteria were verified before randomization by using a structured medical history and physical assessment. Randomization Patients were evenly allocated to receive manipulative therapy plus usual medical care or usual medical care alone. An independent statistician not involved in recruitment of patients generated a random list that was stratified for general practitioner by permutation of randomized blocks, with a block size of 6. After eligibility was verified, written informed consent was obtained. A researcher opened preprepared numbered, opaque sealed envelopes containing the treatment allocation codes and made appointments with manual therapists when applicable. Interventions Usual Medical Care All patients received usual medical care from their general practitioners. Usual medical care was similar to that outlined by the Dutch College of General Practitioners (5, 6) and included information, advice, and therapy. During the first 2 weeks, patients were given information about the nature and course of shoulder symptoms, along with advice on daily use of the affected shoulder. Patients were prescribed oral analgesics or nonsteroidal anti-inflammatory drugs if necessary. The Dutch College of General Practitioners recommends 2 weeks of treatment with paracetamol, 4 times daily (maximum dosage, 4000 mg/d), or nonsteroidal anti-inflammatory drugs such as ibuprofen, 3 times daily (maximum dosage, 2400 mg/d); diclofenac, 3 times daily (maximum dosage, 150 mg/d); or naproxen, twice daily (maximum dosage, 1000 mg/d) (5, 6). If patients did improve, drug treatment could be extended for another 2 weeks. If this approach was ineffective, up to 3 corticosteroid injections could be given in either the subacromial space or the glenohumeral joint. For injections in either location, physicians used triamcinolone acetonide, 40 mg suspended in a 1-mL vehicle, if necessary, combined with lidocaine, 10 mg suspended in a 5- to 10-mL vehicle. If improvement remained insufficient 2 weeks after injections were given, injections could be repeated. Further corticosteroid treatment was not considered appropriate if patients did not improve after the second series of injections. For symptoms persisting at least 6 weeks, physiotherapy consisting of shoulder exercises, massage, and physical applications was considered. Other referrals during the intervention and follow-up periods (for example, to a rheumatology consultant or orthopedic surgeon) were discouraged but were documented if they occurred. Manipulative Therapy According to the International Federation of Orthopedic Manipulative Therapists, orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities. Our approach to manipulative therapy focused on manual manipulation and mobilization techniques used in western Europe, North America, and Australia, including those described by Cyriax (17), Greenman (18), and Lewit (19). In our trial, manipulative therapy included specific manipulations (low-amplitude, high-velocity thrust techniques) and specific mobilizations (high-amplitude, low-velocity thrust techniques) to improve overall joint function and decrease any restrictions in movement at single or multiple segmental levels in the cervical spine and upper thoracic spine and adjacent ribs. The manual therapist chose the applied techniques on the basis of the location of the dysfunction and the therapists technique preferences. Within the boundaries of the protocol, treatment could be reassessed and adapted to the patients condition. A maximum of 6 treatment sessions could be given over a 12-week period. Eight experienced physiotherapists who were members of the Dutch Association of Manual Therapy and registered by the Royal Dutch Society for Physical Therapy (a member of the International Federation of Orthopedic Manipulative Therapists) provided the manual therapy. To minimize variations in manipulative therapy, therapists received a special training session to familiarize them with the protocols mobilization and manipulation techniques for treatment of the cervico

Depressive Symptoms as Predictors of Mortality in Patients With COPD

OBJECTIVE Prognostic studies of mortality in patients with COPD have mostly focused on physiologic variables, with little attention to depressive symptoms. This stands in sharp contrast to the attention that depressive symptoms have been given in the outcomes of patients with other chronic health conditions. The present study investigated the independent association of depressive symptoms in stable patients with COPD with all-cause mortality. METHODS The baseline characteristics of 121 COPD patients (78 men and 43 women; mean [+/- SD] age, 61.5 +/- 9.1 years; and mean FEV(1), 36.9 +/- 15.5% predicted) were collected on hospital admission to a pulmonary rehabilitation center. The data included demographic variables, body mass index (BMI), post-bronchodilator therapy FEV(1), and Wpeak (peak workload [Wpeak]). Depressive symptoms were assessed using the Beck depression inventory. The vital status was ascertained using municipal registrations. In 8.5 years of follow-up, 76 deaths occurred (mortality rate, 63%). Survival time ranged from 88 days to 8.5 years (median survival time, 5.3 years). The Cox proportional hazard model was used to quantify the association of the baseline characteristics (ie, age, sex, marital status, smoking behavior, FEV(1), BMI, Wpeak, and depressive symptoms) with mortality. RESULTS Depressive symptoms (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.12 to 3.33) were associated with mortality in patients with COPD, independent of other factors including male sex (OR, 1.73; 95% CI, 1.03 to 2.92), older age (OR, 1.05; 95% CI, 1.02 to 1.08), and lower Wpeak (OR, 0.98; 95% CI, 0.97 to 0.99). CONCLUSIONS This study provides evidence that depressive symptoms assessed in stable patients with COPD are associated with their subsequent all-cause mortality.

Exergaming for balance training of elderly: state of the art and future developments

Fall injuries are responsible for physical dysfunction, significant disability, and loss of independence among elderly. Poor postural control is one of the major risk factors for falling but can be trained in fall prevention programs. These however suffer from low therapy adherence, particularly if prevention is the goal. To provide a fun and motivating training environment for elderly, exercise games, or exergames, have been studied as balance training tools in the past years. The present paper reviews the effects of exergame training programs on postural control of elderly reported so far. Additionally we aim to provide an in-depth discussion of technologies and outcome measures utilized in exergame studies. Thirteen papers were included in the analysis. Most of the reviewed studies reported positive results with respect to improvements in balance ability after a training period, yet few reached significant levels. Outcome measures for quantification of postural control are under continuous dispute and no gold standard is present. Clinical measures used in the studies reviewed are well validated yet only give a global indication of balance ability. Instrumented measures were unable to detect small changes in balance ability as they are mainly based on calculating summary statistics, thereby ignoring the time-varying structure of the signals. Both methods only allow for measuring balance after the exergame intervention program. Current developments in sensor technology allow for accurate registration of movements and rapid analysis of signals. We propose to quantify the time-varying structure of postural control during gameplay using low-cost sensor systems. Continuous monitoring of balance ability leaves the user unaware of the measurements and allows for generating user-specific exergame training programs and feedback, both during one game and in timeframes of weeks or months. This approach is unique and unlocks the as of yet untapped potential of exergames as balance training tools for community dwelling elderly.

Gait analysis in prosthetics: opinions, ideas and conclusions.

A review was performed of the literature of the last eleven years (1990–2000) with the topic: “clinical use of instrumented gait analysis in patients wearing a prosthesis of the lower limb”. To this end a literature search was performed in Embase, Medline and Recal. Forty-five (45) articles were identified for study from which 34 were reviewed. The reviews were divided into five subtopics: 1) adaptive strategies in gait (12 studies); 2) the influence of different parts of the prosthesis on gait (12 studies); 3) pressure measurements in the socket in gait studies (4 studies); 4) the influence of the mass of the prostheses on gait (5 studies); 5) energy considerations in gait (2 studies). A considerable part of the studies concerned the adaptive strategies of the amputee in walking and running and the evaluation of different prosthetic feet. All aspects and outcomes were reviewed concerning the clinical relevance.

Abnormal landing strategies after ACL reconstruction

The objective was to analyze muscle activity and movement patterns during landing of a single leg hop for distance after anterior cruciate ligament (ACL) reconstruction. Nine (six males, three females) ACL‐reconstructed patients 6 months after surgery and 11 (eight males, three females) healthy control subjects performed the hop task. Electromyographic signals from lower limb muscles were analyzed to determine onset time before landing. Biomechanical data were collected using an Optotrak Motion Analysis System and force plate. Matlab was used to calculate kinetics and joint kinematics. Side‐to‐side differences in ACL‐reconstructed patients and healthy subjects as well as differences between the patients and control group were analyzed. In ACL‐reconstructed limbs, significantly earlier onset times were found for all muscles, except vastus medialis, compared with the uninvolved side. The involved limbs had significantly reduced knee flexion during the take‐off and increased plantarflexion at initial contact. The knee extension moment was significantly lower in the involved limb. In the control group, significantly earlier onset times were found for the semitendinosus, vastus lateralis and medial gastrocnemius of the non‐dominant side compared with the dominant side. Muscle onset times are earlier and movement patterns are altered in the involved limb 6 months after ACL reconstruction.

Balance control on a moving platform in unilateral lower limb amputees

OBJECTIVE To study balance control on a moving platform in lower limb amputees. DESIGN Observational cohort study. PARTICIPANTS Unilateral transfemoral and transtibial amputees and able-bodied control subjects. INTERVENTIONS Balance control on a platform that moved in the anteroposterior direction was tested with eyes open, blindfolded and while performing a dual task. MAIN OUTCOME MEASURES Weight bearing symmetry, anteroposterior ground reaction force and centre of pressure shift. RESULTS Compared to able-bodied subjects, in amputees the anteroposterior ground reaction force was larger in the prosthetic and non-affected limb, and the centre of pressure displacement was increased in the non-affected limb and decreased in the prosthetic limb. In amputees body weight was loaded more on the non-affected limb. Blindfolding or adding a dual task did not influence the outcome measures importantly. CONCLUSION The results of this study indicate that experienced unilateral amputees with a high activity level compensate for the loss of ankle strategy by increasing movements and loading in the non-affected limb. The ability to cope with balance perturbations is limited in the prosthetic limb. To enable amputees to manage all possible balance disturbances in real life in a safe manner, we recommend to improve muscle strength and control in the non-affected limb and to train complex balance tasks in challenging environments during rehabilitation.

Uphill and downhill walking in unilateral lower limb amputees

OBJECTIVE To study adjustment strategies in unilateral amputees in uphill and downhill walking. DESIGN Observational cohort study. SUBJECTS Seven transfemoral, 12 transtibial unilateral amputees and 10 able-bodied subjects. METHODS In a motion analysis laboratory the subjects walked over a level surface and an uphill and downhill slope. Gait velocity and lower limb joint angles were measured. RESULTS In uphill walking hip and knee flexion at initial contact and hip flexion in swing were increased in the prosthetic limb of transtibial amputees. In downhill walking transtibial amputees showed more knee flexion on the prosthetic side in late stance and swing. Transfemoral amputees were not able to increase prosthetic knee flexion in uphill and downhill walking. An important adjustment strategy in both amputee groups was a smaller hip extension in late stance in uphill and downhill walking, probably related with a shorter step length. In addition, amputees increased knee flexion in early stance in the non-affected limb in uphill walking to compensate for the shorter prosthetic limb length. In downhill walking fewer adjustments were necessary, since the shorter prosthetic limb already resulted in lowering of the body. CONCLUSION Uphill and downhill walking can be trained in rehabilitation, which may improve safety and confidence of amputees. Prosthetic design should focus on better control of prosthetic knee flexion abilities without reducing stability.

Short and Long Term Mortality Rates after a Lower Limb Amputation

OBJECTIVE To determine mortality rates after a first lower limb amputation and explore the rates for different subpopulations. METHODS Retrospective cohort study of all people who underwent a first amputation at or proximal to transtibial level, in an area of 1.7 million people. Analysis with Kaplan-Meier curves and Log Rank tests for univariate associations of psycho-social and health variables. Logistic regression for odds of death at 30-days, 1-year and 5-years. RESULTS 299 people were included. Median time to death was 20.3 months (95%CI: 13.1; 27.5). 30-day mortality = 22%; odds of death 2.3 times higher in people with history of cerebrovascular disease (95%CI: 1.2; 4.7, P = 0.016). 1 year mortality = 44%; odds of death 3.5 times higher for people with renal disease (95%CI: 1.8; 7.0, P < 0.001). 5-years mortality = 77%; odds of death 5.4 times higher for people with renal disease (95%CI: 1.8; 16.0,P = 0.003). Variation in mortality rates was most apparent in different age groups; people 75-84 years having better short term outcomes than those younger and older. CONCLUSIONS Mortality rates demonstrated the frailty of this population, with almost one quarter of people dying within 30-days, and almost half at 1 year. People with cerebrovascular had higher odds of death at 30 days, and those with renal disease and 1 and 5 years, respectively.

Proprioceptive deficits after ACL injury: are they clinically relevant?

Objective To establish the clinical relevance of proprioceptive deficits reported after anterior cruciate ligament (ACL) injury. Material and methods A literature search was done in electronic databases from January 1990 to June 2009. Inclusion criteria for studies were ACL deficient (ACL-D) and ACL reconstruction (ACL-R) articles written in English, Dutch or German and calculation of correlation(s) between proprioception tests and clinical outcome measures. Clinical outcome measures were muscle strength, laxity, hop test, balance, patient-reported outcome, objective knee score rating, patient satisfaction or return to sports. Studies included in the review were assessed on their methodological quality. Results In total 1161 studies were identified of which 24 met the inclusion criteria. Pooling of all data was not possible due to substantial differences in measurement techniques and data analysis. Most studies failed to perform reliability measurements of the test device used. In general, the correlation between proprioception and laxity, balance, hop tests and patient outcome was low. Four studies reported a moderate correlation between proprioception, strength, balance or hop test. Conclusion There is limited evidence that proprioceptive deficits as detected by commonly used tests adversely affect function in ACL-D and ACL-R patients. Development of new tests to determine the relevant role of the sensorimotor system is needed. These tests should ideally be used as screening tests for primary and secondary prevention of ACL injury.

Determinants of return to work in patients with hand disorders and hand Injuries

Introduction Return to work (RTW) in patients with hand disorders and hand injuries is determined by several determinants not directly related to the physical situation. Besides biomedical determinants, work-related and psychosocial determinants may influence RTW as well. This study is conducted to investigate the influence of these potential determinants on RTW in patients with hand disorders and hand injuries. Methods Included 91 patients who were operatively treated for a hand disorder or a hand injury, and who were employed prior to surgery. Patients answered several questionnaires on the aforementioned categories. Potential determinants significantly related to RTW in a univariate analysis were entered in a logistic regression for the total group and the acutely injured patients separately. Results Pain, accident location, job independence and symptoms of post-traumatic stress disorder (PTSD) were univariately associated with RTW. Pain was a determinant for late RTW in the total group and accident location and symptoms of PTSD in the acutely injured group. Conclusion Pain, accident location and symptoms of PTSD were most important in resuming work in hand injured patients or in patients with a hand disorder. These findings may indicate that attention should be paid to the treatment of pain, and to the development of symptoms of PTSD during rehabilitation. It may be necessary to make extra efforts aimed at RTW in patients who sustained their injury on the job.