Robyn E. Fary

The Effectiveness of Pulsed Electrical Stimulation in the Management of Osteoarthritis of the Knee: Results of a Double-Blind, Randomized, Placebo-Controlled, Repeated-Measures Trial

OBJECTIVE To determine the effectiveness of subsensory, pulsed electrical stimulation (PES) in the symptomatic management of osteoarthritis (OA) of the knee. METHODS This was a double-blind, randomized, placebo-controlled, repeated-measures trial in 70 participants with clinical and radiographically diagnosed OA of the knee who were randomized to either PES or placebo. The primary outcome was change in pain score over 26 weeks measured on a 100-mm visual analog scale (VAS). Other measures included pain on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), function on the WOMAC, patients global assessment of disease activity (on a 100-mm VAS), joint stiffness on the WOMAC, quality of life on the Medical Outcomes Study Short-Form 36 (SF-36) health survey, physical activity (using the Human Activity Profile and an accelerometer), and global perceived effect (on an 11-point scale). RESULTS Thirty-four participants were randomized to PES and 36 to placebo. Intent-to-treat analysis showed a statistically significant improvement in VAS pain score over 26 weeks in both groups, but no difference between groups (mean change difference 0.9 mm [95% confidence interval -11.7, 13.4]). Similarly, there were no differences between groups for changes in WOMAC pain, function, and stiffness scores (-5.6 [95% confidence interval -14.9, 3.6], -1.9 [95% confidence interval -9.7, 5.9], and 3.7 [95% confidence interval -6.0, 13.5], respectively), SF-36 physical and mental component summary scores (1.7 [95% confidence interval -1.5, 4.8] and 1.2 [95% confidence interval -2.9, 5.4], respectively), patients global assessment of disease activity (-2.8 [95% confidence interval -13.9, 8.4]), or activity measures. Fifty-six percent of the PES-treated group achieved a clinically relevant 20-mm improvement in VAS pain score at 26 weeks compared with 44% of controls (12% [95% confidence interval -11%, 33%]). CONCLUSION In this sample of subjects with mild-to-moderate symptoms and moderate-to-severe radiographic OA of the knee, 26 weeks of PES was no more effective than placebo.

Disease‐specific knowledge and clinical skills required by community‐based physiotherapists to co‐manage patients with rheumatoid arthritis

While strong evidence supports the role of physiotherapy in the co‐management of patients with rheumatoid arthritis (RA), it remains unclear what constitutes the essential disease‐specific knowledge and clinical skills required by community‐based physiotherapists to effectively and safely deliver recommended care. This study aimed to identify essential disease‐specific knowledge and skills, link these with evidence from clinical guidelines, and broadly determine the professional development (PD) needs and confidence related to the management of RA among physiotherapists.

Prevalence and Predictors of Adolescent Idiopathic Scoliosis in Adolescent Ballet Dancers

OBJECTIVE To determine any differences between the prevalence of adolescent idiopathic scoliosis in ballet dancers who are girls compared with age-matched nondancers, and to establish if any relations exist between the presence of scoliosis and generalized joint hypermobility, age of menarche, body mass index (BMI), and the number of hours of dance training per week. DESIGN Cross-sectional, matched pair study. SETTING Dance school. PARTICIPANTS Dancers (n=30) between the ages of 9 and 16 years were recruited from a certified dance school in Western Australia; each dancer provided a consenting age-matched nondancer (n=30). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Measurements were taken for angle of trunk rotation using a scoliometer (presence of scoliosis) and for height and weight to produce generalized joint hypermobility using Beighton criteria and an age-adjusted BMI, respectively. A subjective questionnaire regarding age of menarche and participation in dance and other sports was completed. RESULTS Thirty percent of dancers tested positive for scoliosis compared with 3% of nondancers. Odds ratio calculations suggest that dancers were 12.4 times more likely to have scoliosis than nondancers of the same age. There was a higher rate of hypermobility in the dancer group (70%) compared with the nondancers (3%); however, there were no statistically significant relations between scoliosis and hypermobility, age of menarche, BMI, or hours of dance per week. CONCLUSIONS Adolescent dancers, similar to adult dancers, are at significantly higher risk of developing scoliosis than nondancers of the same age. Vigilant screening and improved education of dance teachers and parents of dance students may be beneficial in earlier detection and, consequently, reducing the risk of requiring surgical intervention.

Translating Policy into Practice for Community-Based Management of Rheumatoid Arthritis: Targeting Professional Development Needs among Physiotherapists

Introduction. Contemporary health policy promotes delivery of community-based health services to people with musculoskeletal conditions, including rheumatoid arthritis (RA). This emphasis requires a skilled workforce to deliver safe, effective care. We aimed to explore physiotherapy workforce readiness to co-manage consumers with RA by determining the RA-specific professional development (PD) needs in relation to work and educational characteristics of physiotherapists in Western Australia (WA). Methods. An e-survey was sent to physiotherapists regarding their confidence in co-managing people with RA and their PD needs. Data including years of clinical experience, current RA clinical caseload, professional qualifications, and primary clinical area of practice were collected. Results. 273 physiotherapists completed the survey. Overall confidence in managing people with RA was low (22.7–58.2%) and need for PD was high (45.1–95.2%). Physiotherapists with greater years of clinical experience, a caseload of consumers with RA, postgraduate qualifications in musculoskeletal physiotherapy, or who worked in the musculoskeletal area were more confident in managing people with RA and less likely to need PD. Online and face-to-face formats were preferred modes of PD delivery. Discussion. To enable community-based RA service delivery to be effectively established, subgroups within the current physiotherapy workforce require upskilling in the evidence-based management of consumers with RA.

The effectiveness of pulsed electrical stimulation (E-PES) in the management of osteoarthritis of the knee : a protocol for a randomised controlled trial

BackgroundOsteoarthritis (OA) of the knee is one of the main causes of musculoskeletal disability in the western world. Current available management options provide symptomatic relief (exercise and self-management, medication and surgery) but do not, in general, address the disease process itself. Moreover, adverse effects and complications with some of these interventions (medication and surgery) and the presence of co-morbidities commonly restrict their use. There is clearly a need to investigate treatments that are more widely applicable for symptom management and which may also directly address the disease process itself.In two randomised controlled trials of four and 12 weeks duration, pulsed electrical stimulation was shown to be effective in managing the symptoms of OA of the knee. Laboratory and animal studies demonstrate the capacity of externally applied electric and electromagnetic fields to positively affect chondrocyte proliferation and extracellular matrix protein production. This latter evidence provides strong theoretical support for the use of electrical stimulation to maintain and repair cartilage in the clinical setting and highlights its potential as a disease-modifying modality.Methods/DesignA double-blind, randomised, placebo-controlled, repeated measures trial to examine the effectiveness of pulsed electrical stimulation in providing symptomatic relief for people with OA of the knee over 26 weeks.Seventy people will be recruited and information regarding age, gender, body mass index and medication use will be recorded. The population will be stratified for age, gender and baseline pain levels.Outcome measures will include pain (100 mm VAS and WOMAC 3.1), function (WOMAC 3.1), stiffness (WOMAC 3.1), patient global assessment (100 mm VAS) and quality of life (SF-36). These outcomes will be measured at baseline, four, 16 and 26 weeks. Activity levels will be measured at baseline and 16 weeks using accelerometers and the Human Activity Profile questionnaire. A patient global perceived effect scale (11-point Likert) will be completed at 16 and 26 weeks.DiscussionThis paper describes the protocol for a randomised, double-blind, placebo-controlled trial that will contribute to the evidence regarding the use of sub-sensory pulsed electrical stimulation in the management of OA of the knee.Trial registrationAustralian Clinical Trials Registry ACTRN12607000492459.

Policy-into-practice for rheumatoid arthritis: Randomized controlled trial and cohort study of E-learning targeting improved physiotherapy management

To examine the effectiveness of a physiotherapy‐specific, web‐based e‐learning platform, “RAP‐el,” in best‐practice management of rheumatoid arthritis (RA) using a single‐blind, randomized controlled trial (RCT) and prospective cohort study.

Monophasic electrical stimulation produces high rates of adverse skin reactions in healthy subjects

Monophasic pulsed electrical stimulation (PES) has been reported to improve pain and function in osteoarthritis of the knee with few side effects. This use of monophasic current is contrary to conventional thinking where it is often associated with adverse skin reactions. The objectives of this study were to compare the rates of adverse skin reactions, using independently developed subsensory monophasic PES in healthy subjects, with those described in previous studies and compare the rate of adverse skin reactions after using the monophasic PES with that after using the same shaped electrical waveform that is asymmetrically biphasic. Healthy subjects (n=25) with no contraindications to electrical stimulation were administered subsensory, monophasic, and biphasic PES sequentially to the knee region for approximately 10 minutes each. Stimulation intensities; duration of stimulation; description of sensation reported; skin condition after intervention; and duration of skin reaction were all recorded. Fifty-two percent of subjects experienced adverse skin reactions using monophasic PES. This was significantly different from the reported rates in three of the four previous studies (p<0.04). Only one subject (4%) using the biphasic current demonstrated an adverse skin reaction. Results support the caution advised in the electrotherapy literature when using monophasic electrical stimulation.

Upper cervical instability associated with rheumatoid arthritis: What to ‘know’ and what to ‘do’

This case report describes a patient who presented with cervical spinal pain and headaches associated with atlanto-axial subluxation (AAS) secondary to rheumatoid arthritis (RA). For physiotherapists, especially less experienced clinicians, the significant risks associated with using manual assessment and treatment techniques in such a patient require careful consideration right at the start of a consultation. The focus of the case is therefore on the recognition of AAS in this patient with RA, highlighting the clinical findings that alert clinicians to this possibility and explaining the requisite knowledge and skills required to safely and effectively manage this patient. The use of screening tools to help clinicians identify possible RA in its pre-diagnosis stage and the clinical signs and symptoms that raise the index of suspicion for AAS, are discussed. The relevant contraindications and precautions associated with manual treatments directed at the upper cervical spine, and which may have potentially serious negative consequences, including quadriplegia and mortality, are addressed. Finally, the implications for the use of manual assessment and treatment of patients with RA and co-morbid AAS are addressed.

Physiotherapy co-management of rheumatoid arthritis: Identification of red flags, significance to clinical practice and management pathways

Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune disease. Physiotherapy interventions for people with RA are predominantly targeted at ameliorating disability resulting from articular and peri-articular manifestations of the disease and providing advice and education to improve functional capacity and quality of life. To ensure safe and effective care, it is critical that physiotherapists are able to identify potentially serious articular and peri-articular manifestations of RA, such as instability of the cervical spine. Additionally, as primary contact professionals, it is essential that physiotherapists are aware of the potentially serious extra-articular manifestations of RA. This paper provides an overview of the practice-relevant manifestations associated with RA that might warrant further investigation by a medical practitioner (red flags), their relevance to physiotherapy practice, and recommended management pathways.

Effectiveness of pulsed electrical stimulation in the management of osteoarthritis of the knee: Three case reports

This report examines the symptomatic and functional changes associated with subsensory threshold, pulsed electrical stimulation (PES) treatment for osteoarthritis of the knee in three patients. Two females and one male over age 60, with radiologically diagnosed osteoarthritis of the knee, were treated with PES. The intervention was delivered for eight hours daily at home using a portable, battery-operated unit over 16 weeks. Treatment outcome data were collected at three time points with results plotted for visual examination. Pain, function, patient global assessment, quality of life, global perceived effectiveness, and ambulatory activity levels were measured. The device was well tolerated with adherence levels of 63%, 83%, and 102% of target dose. Perceived global effectiveness of treatment was high for two of the three patients (+3 and +4.5 out of 5), but the third patient reported no change. Scores for pain, global assessment, function, and ambulation were internally consistent with global treatment effect. It is concluded that the PES device was well tolerated, and subsensory PES may provide an effective nonpharmaceutical, noninvasive addition to the management of osteoarthritis of the knee over 16 weeks.