Steve Tumilty

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

OBJECTIVE To test the feasibility of a randomized controlled trial to assess the clinical effectiveness of low-level laser therapy (LLLT) when used in addition to eccentric exercise in the management of Achilles tendinopathy. BACKGROUND DATA LLLT has emerged as a possible treatment modality for tendon injuries. Over the past 20 years only three human studies have investigated LLLT for Achilles tendinopathy. MATERIALS AND METHODS Twenty patients were randomized into an active laser or placebo group; all patients, therapists, and investigators were blinded to allocation. All patients were given a 12-week eccentric exercise program and irradiated three times per week for 4 wk with either an active or placebo laser at standardized points over the affected tendons. Irradiation parameters in the active treatment group were: 810 nm, 100 mW, applied to six points on the tendon for 30 s, for a total dose of 3 J per point and 18 J per session. Outcome measures were the VISA-A questionnaire, pain, and isokinetic strength. Patients were measured before treatment and at 4 and 12 wk. Analysis of covariance was used to analyze data, using the effects of baseline measurements as a covariate. RESULTS Within groups, there were significant improvements (p < 0.05) at 4 and 12 wk for all outcome measures, except eccentric strength for the placebo group at 4 wk (p = 0.11). Based on the results of the current study, recruitment of 20 subjects per group would be required to perform an adequately powered study based on minimally important clinical differences in VISA-A scale. CONCLUSION This study has demonstrated the feasibility of undertaking a randomized controlled trial of LLLT for Achilles tendinopathy. Conclusions regarding effectiveness cannot be made due to the low statistical power of this pilot study.

Eccentric exercise protocols for chronic non-insertional Achilles tendinopathy: how much is enough?

Eccentric exercises for the calf muscles have been shown to be effective for chronic non‐insertional Achilles tendinopathy (AT). However, the relative effectiveness of various dosages is unknown. A systematic review of randomized‐controlled trials (RCTs) was designed to determine whether an optimum dose of eccentric exercises could be recommended. Three selected RCTs showed positive effects of very similar eccentric exercise protocols for chronic non‐insertional AT. Owing to insufficient reported compliance data, a conclusion on the relative effectiveness of various compliances was not feasible. According to our review, the relative effectiveness of various dosages of eccentric exercises for AT is still unclear. However, it appears that highly variable compliance rates result in similar positive outcomes; these findings, therefore, highlight the need for further investigations.

A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation

The aim of this systematic review of systematic reviews was to critically appraise systematic reviews on Anterior Cruciate Ligament (ACL) reconstruction rehabilitation to determine which interventions are supported by the highest quality evidence. Electronic searches were undertaken, of MEDLINE, AMED, EMBASE, EBM reviews, PEDro, Scopus, and Web of Science to identify systematic reviews of ACL rehabilitation. Two reviewers independently selected the studies, extracted data, and applied quality criteria. Study quality was assessed using PRISMA and a best evidence synthesis was performed. Five systematic reviews were included assessing eight rehabilitation components. There was strong evidence (consistent evidence from multiple high quality randomised controlled trials (RCTs)) of no added benefit of bracing (0-6 weeks post-surgery) compared to standard treatment in the short term. Moderate evidence (consistent evidence from multiple low quality RCTs and/or one high quality RCT) supported no added benefit of continuous passive motion to standard treatment for increasing range of motion. There was moderate evidence of equal effectiveness of closed versus open kinetic chain exercise and home versus clinic based rehabilitation, on a range of short term outcomes. There was inconsistent or limited evidence for some interventions. Recommendations for clinical practice are made at specific time points for specific outcomes.

The effects of spinal mobilizations on the sympathetic nervous system: A systematic review

The activity of the sympathetic nervous system is of importance to manual therapists, since the experience of pain is associated with sympathetic activity. There has been little exploration into the effects of mobilizing vertebral segments below the cervical spine. In addition to this, a synthesis of the evidence for changes in sympathetic outcome measures has not been completed. The primary aim of this review was to investigate the effects of spinal mobilizations compared to a control or placebo on sympathetic outcome measures. The secondary aim was to establish the level of change, either excitatory or inhibitory, in sympathetic outcome measures. Five electronic databases (Ovid Medline, Embase, AMED, PEDro, and the Cochrane library; from database inception to May 2012) were searched for randomized controlled trials. Two independent raters applied inclusion criteria and rated studies for methodological quality. Seven studies met the inclusion criteria. All studies demonstrated a consistent increase in sympathetic outcome measures, indicative of sympathetic excitation, irrespective of the segments mobilized. Synthesis of the results established strong evidence (multiple high-quality randomised controlled trials (RCTs) for a positive change in skin conductance, respiratory rate, blood pressure, and heart rate among the healthy population. As only one study investigated changes in a symptomatic population, there was limited evidence (one RCT) for an increase in skin conductance and decrease in skin temperature. Evidence from this systematic review supports a sympatho-excitatory response to spinal mobilizations irrespective of the segment mobilized.

Validity and reliability of palpation-digitization for non-invasive kinematic measurement – A systematic review

Joint kinematic assessment using an electromagnetic tracking device (EMTD) requires palpation-digitization (PD) of bony landmarks to define the anatomical axes. Errors in PD of bony landmarks can perturb the anatomical axes and affect the validity and reliability of kinematic measurements. The validity and reliability of PD for kinematic measurement needs to be explored before recommending its wider use. A systematic search of 15 electronic databases located studies assessing validity and/or reliability of PD for joint kinematic assessment. Two independent reviewers used the QUADAS and QAREL tools to assess quality of validity and reliability studies respectively. The results were synthesized qualitatively using a level of evidence approach. Eight studies satisfied the final eligibility criteria and were included in the review. The validity, intra-rater reliability and inter-rater reliability were assessed in three, seven and one study respectively. The overall level of evidence for validity of PD technique was strong with high correlation (≥0.80) reported by three high (≥60%) quality studies. The overall level of evidence for intra-rater reliability was also strong with very high ICC (≥0.90) and satisfactory SEM (SEM% ≤ 10%) reported by four high quality studies. However the level of evidence for inter-rater reliability was limited and needs to be addressed by future research.

Laser Acupuncture for Treating Musculoskeletal Pain: A Systematic Review with Meta-analysis

Laser acupuncture has been studied extensively over several decades to establish evidence-based clinical practice. This systematic review aims to evaluate the effects of laser acupuncture on pain and functional outcomes when it is used to treat musculoskeletal disorders and to update existing evidence with data from recent randomized controlled trials (RCTs). A computer-based literature search of the databases MEDLINE, AMED, EMBASE, CINAHL, SPORTSDiscus, Cochrane Library, PubMed, Current Contents Connect, Web of Science, and SCOPUS was used to identify RCTs comparing between laser acupuncture and control interventions. A meta-analysis was performed by calculating the standardized mean differences and 95% confidence intervals, to evaluate the effect of laser acupuncture on pain and functional outcomes. Included studies were assessed in terms of their methodological quality and appropriateness of laser parameters. Forty-nine RCTs met the inclusion criteria. Two-thirds (31/49) of these studies reported positive effects, were of high methodological quality, and reported the dosage adequately. Negative or inconclusive studies commonly failed to demonstrate these features. For all diagnostic subgroups, positive effects for both pain and functional outcomes were more consistently seen at long-term follow-up rather than immediately after treatment. Moderate-quality evidence supports the effectiveness of laser acupuncture in managing musculoskeletal pain when applied in an appropriate treatment dosage; however, the positive effects are seen only at long-term follow-up and not immediately after the cessation of treatment.

Physical activity and lower-back pain in persons with traumatic transfemoral amputation: A national cross-sectional survey

Lower-back pain (LBP) is a common secondary condition following lower-limb amputation. The purpose of this study was to investigate LBP prevalence and the relationship between LBP and physical activity (PA) levels in a national sample of persons with traumatic transfemoral amputation (TFA). Questionnaires were mailed to a random sample of people with traumatic TFA (n = 322) from the New Zealand Artificial Limb Board national database. Of the participants who completed the survey (55% response rate), 64.1% reported LBP and 39.1% reported restricted PA due to LBP. There was no relationship between the PA levels of persons with and without LBP (chi-square = 2.11, p > 0.05). There was an equal distribution of persons with LBP in low, medium, and high PA subgroups. However, persons who reported restricted PA due to LBP had lower PA scores than persons with LBP and no restricted PA (chi-square = 11.56, p < 0.05). Based on our results, LBP is prevalent in the traumatic TFA population. PA levels are not influenced by the presence or absence of LBP. However, future studies investigating LBP coping strategies and using objective PA outcome measures might further elucidate the relationship between PA and LBP in this population.

Achilles tendon rupture: rising incidence in New Zealand follows international trends

Abstract It is often reported in the literature that the incidence of Achilles tendon ruptures has increased over the last few decades. In New Zealand, for the period July 1998 to June 2003, the incidence of Achilles tendon ruptures rose from 4.7/100,000 in 1998 to 10.3/100,000 in 2003, an increase of 119%. Over the same period, the population rose from 3.8 million to 4 million, an increase of a little over 5%. From June 2002 to July 2003, the costs incurred for 412 Achilles tendon ruptures was NZ

The use of the Patient-Specific Functional Scale to measure rehabilitative progress in a physiotherapy setting

1.8 million. Rehabilitating these patients places an extra burden on the health system in this relatively small country. With this in mind, a literature search was undertaken in an attempt to answer the questions: has the incidence of Achilles tendon rupture changed, is this related to any life-style changes, and do New Zealand statistics follow international trends? Current evidence would indicate that this is a global trend, which is apparently linked, at least in part, to increased levels of participation in sports.

The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: A systematic review and meta-analysis

Abstract Objective: The Patient-Specific Functional Scale (PSFS) and the Numeric Pain Rating Scale (NPRS) are two measures which the Accident Compensation Corporation (ACC) of New Zealand have made compulsory for physiotherapists to record at a patients initial visit and discharge. Therefore, it is important to assess clinicians’ compliance to this reporting requirement, and whether research results regarding effectiveness of these measures are transferable to the clinic. Method: A retrospective observational study that assessed compliance in recording these measures, and analyzed the changes in scores seen across 11 physiotherapy practices in New Zealand over a 12-month period. Results: Overall compliance rates of 51·8% [95% confidence interval (CI): 50·7–52·9] for PSFS and 51·9% (95% CI: 50·7–53·0) for NPRS were reported. These figures increase to 85·3% (95% CI: 82·0–88·6) PSFS; and 85·1% (95% CI: 81·7–88·4) NPRS, when a full discharge for the patient was made. Mean change in PSFS scores were 5·1 (95% CI: 5·0–5·1) points representing an 85·2% (95% CI: 84·1–86·3) change in total score. Discussion: The study has shown that when patients complete a prescribed course of rehabilitation, clinicians show good compliance in recording PSFS and NPRS. Change in PSFS score is, on average, above the minimal clinically important difference shown in previous studies.