Effectiveness of local exercise therapy versus spinal manual therapy in patients with patellofemoral pain syndrome: medium term follow-up results of a randomized controlled trial

Background

Increasing evidence has shown benefits of spinal manipulations in patients with patellofemoral pain syndrome (PFPS). There is scarcity regarding medium term effects of spinal manual therapy on outcome measures in PFPS patients. Therefore, the aim of the present study was to compare the effectiveness of local exercise therapy and spinal manual therapy for knee pain, function and maximum voluntary peak force (MVPF) velocity of the quadriceps in PFPS patients.

Methods

Forty-three patients with PFPS were randomly assigned to a local exercise or spinal manual therapy group. The local exercise group received six sessions (one session per week) of supervised training of the knee-and hip muscles with mobilization of the patellofemoral joint. The spinal manual therapy group received six interventions (one intervention per week) of high velocity low thrust manipulations at the thoracolumbar region, sacroiliac joint, and/or hip. All patients were also asked to do home exercises. Maximum, minimum and current pain were measured using the visual analogue scale. Function was assessed with the anterior knee pain scale (AKPS) and MPFV was recorded using a Biodex System 3 dynamometer. Patients were assessed before intervention, after 6 weeks of intervention and after 6 weeks of follow-up. Between-group differences at assessments were analysed by way of analysis of covariance with Bonferroni correction.

Results

Pain and functionality improved more following spinal manipulative therapy than local exercise therapy. After 6 weeks of intervention the between-group difference (local versus spinal) for maximal pain was 23.4 mm [95% CI: 9.3, 37.6; effect size (ES): 1.04] and − 12.4 [95% CI: − 20.2, − 4.7; ES: 1.00] for the AKPS. At 6 weeks of follow-up the between-group difference for maximal pain was 18.7 mm [95% CI: 1.4, 36.0; ES: 0.68] and − 11.5 [95% CI: − 19.9, − 3.3; ES: − 0.87] for the AKPS.

Conclusions

This study suggests that spinal manual therapy is more effective than local exercise therapy in improving pain and function in patients with PFPS in the medium term. We suggest for future research to investigate whether combining local exercise therapy and spinal manual therapy is more effective than either single intervention on its own.

This clinical trial study was approved by the Medical Ethics Committee METC Z under registration number NL57207.096. and registered retrospectively in ClinicalTrials.gov PRS with registration ID number NCT04748692 on the 10th of February 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04310-9.

Microcrack-associated bone remodeling is rarely observed in biopsies from athletes with medial tibial stress syndrome

The pathology of medial tibial stress syndrome (MTSS) is unknown. Studies suggest that MTSS is a bony overload injury, but histological evidence is sparse. The presence of microdamage, and its potential association with targeted remodeling, could provide evidence for the pathogenesis of MTSS. Understanding the pathology underlying MTSS could contribute to effective preventative and therapeutic interventions for MTSS. Our aim was to retrospectively evaluate biopsies, previously taken from the painful area in athletes with MTSS, for the presence of linear microcracks, diffuse microdamage and remodeling. Biopsies, previously taken from athletes with MTSS, were evaluated at the Department of Anatomy and Cell Biology at the Indiana University. After preparing the specimens by en bloc staining, one investigator evaluated the presence of linear microcracks, diffuse microdamage and remodeling in the specimens. A total of six biopsies were evaluated for the presence of microdamage and remodeling. Linear microcracks were found in 4 out of 6 biopsies. Cracking in one of these specimens was artefactual due to the biopsy procedure. No diffuse microdamage was seen in any of the specimens, and only one potential remodeling front in association with the microcracks. We found only linear microcracks in vivo in biopsies taken from the painful area in 50% of the athletes with MTSS, consistent with the relationship between linear cracks and fatigue-associated overloading of bone. The nearly universal absence of a repair reaction was notable. This suggests that unrepaired microdamage accumulation may underlie the pathophysiological basis for MTSS in athletes.

Factors associated with a more rapid recovery after anterior cruciate ligament reconstruction using multivariate analysis

BACKGROUND

In the past, several studies investigated factors that are prognostic or associated with outcome after anterior cruciate ligament (ACL) reconstruction. A recent review showed that only limited evidence is available for most studied factors, and that insufficient analysis methods were used commonly. Therefore, the aim of this study was to add more weight to the existing evidence, about factors that are associated with a more rapid outcome after ACL reconstruction. The second aim was to use multivariate analysis to study the possible factors independently.

METHODS

A cohort study was conducted with a follow-up of six months. Before surgery, patient variables were scored. Surgical variables were scored during arthroscopic ACL reconstructions with a single-bundle technique and hamstring autograft. The Lysholm score and subscales of the Knee Injury Osteoarthritis Outcome Score (KOOS) were assessed six months post surgery. A multiple analysis of variance (ANOVA) model was used to identify prognostic factors for outcome.

RESULTS

In total, 118 patients were included. Patients, aged ≤30years, with a subjective knee score ≥ six, with normal flexion range of motion (ROM) of the knee, with flexion and extension strength deficit of ≤20%, and those with no previous knee surgery in the same knee at baseline scored significantly higher on outcome after multivariate analysis. No significant effect of surgical factors could be found.

CONCLUSION

Younger age, higher subjective knee score, normal knee flexion, normal knee flexion and extension strength, and no previous knee surgery in the patients' history at baseline are associated with a more rapid recovery after ACL reconstruction.

LEVEL OF EVIDENCE

Level III, prognostic study.

Reliability, validity, and responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index for elderly patients with a femoral neck fracture

BACKGROUND

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture.

METHODS

Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older.

RESULTS

The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%).

CONCLUSIONS

The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations.

CLINICAL RELEVANCE

The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

Impact of Patient Sex on Clinical Outcomes: Data From an Anterior Cruciate Ligament Reconstruction Registry, 2008-2013

Background:

The Combined Quality Care Anterior Cruciate Ligament registry provides data for clinical research regarding primary anterior cruciate ligament (ACL) surgery.

Purpose:

To explore the data with regard to the clinical outcomes between sexes after ACL reconstruction in a Dutch population.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data involving patients diagnosed with an ACL tear and eligible for surgery were recorded. Isokinetic muscle strength, functional muscle performance, and anterior-posterior translation of the knee joint were documented preoperatively and at 3, 6, 9, and 12 months postoperatively. Patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and Tegner rating scales during each examination using a web-based questionnaire.

Results:

Approximately 90% of ACL injuries occurred during sport activities. The mean (SD) age at surgery was 28 (11) years for both men and women, and the majority of patients were treated with hamstring tendon autografts (94%). Four percent received bone–patellar tendon–bone autografts, and 2% of the patients received other grafts. Preoperatively, the KOOS, Lysholm, and Tegner scores were significantly higher in males. Twelve months postoperatively, both sexes showed comparable isokinetic strength (P = .336), knee laxity (P = .680), and hop test for distance (P = .122) when comparing the injured with the uninjured side. Self-reported knee function was comparable between sexes as assessed by the KOOS (P = .202), Lysholm (P = .872), and Tegner (P = .767) questionnaires during the 12-month follow-up.

Conclusion:

One year after ACL surgery, all patients had improved greatly, showing only minor differences between sexes. The male group showed slightly better results when evaluating self-reported knee questionnaires. Comparable outcomes and knee function between sexes can therefore be presumed with patients who are treated with hamstring tendon autografts in a Dutch population.

Clinical Relevance:

These results can be used during the clinical evaluation of patients who are eligible for ACL reconstruction.

Prevalence of unrecognized heart failure in older persons with shortness of breath on exertion

AIMS

The majority of patients with heart failure are diagnosed in primary care, but underdiagnosis is common. Shortness of breath is a prevalent complaint of older persons and one of the key symptoms of heart failure. We assessed the prevalence of unrecognized heart failure in elderly patients presenting to primary care with shortness of breath on exertion.

METHODS AND RESULTS

This was a cross-sectional selective screening study. Patients aged 65 years or over presenting to primary care with shortness of breath on exertion in the previous 12 months were eligible when not known to have an established, echocardiographic confirmed diagnosis of heart failure. All participants underwent history taking, physical examination, electrocardiography, and a blood test of N-terminal pro B-type natriuretic peptide (NTproBNP). Only those with an abnormal electrocardiogram or NTproBNP level exceeding the exclusionary cut-point for non-acute onset heart failure (>15 pmol/L (≈125 pg/mL) underwent open-access echocardiography. An expert panel established presence or absence of heart failure according to the criteria of the European Society of Cardiology heart failure guidelines. The mean age of the 585 participants was 74.1 (SD 6.3) years, and 54.5% were female. In total, 92 (15.7%, 95% CI 12.9-19.0) participants had heart failure: 17 (2.9%, 95% CI 1.8-4.7) had heart failure with a reduced ejection fraction (≤45%), 70 (12.0%, 95% CI 9.5-14.9) had heart failure with preserved ejection fraction, and five (0.9%, 95% CI 0.3-2.1) had isolated right-sided heart failure.

CONCLUSION

Elderly primary care patients with shortness of breath on exertion often have unrecognized heart failure, mainly with preserved ejection fraction.

Strategy to recognize and initiate treatment of chronic heart failure in primary care (STRETCH): a cluster randomized trial

BACKGROUND

Most patients with heart failure are diagnosed and managed in primary care, however, underdiagnosis and undertreatment are common. We assessed whether implementation of a diagnostic-therapeutic strategy improves functionality, health-related quality of life, and uptake of heart failure medication in primary care.

METHODS/DESIGN

A selective screening study followed by a single-blind cluster randomized trial in primary care. The study population consists of patients aged 65 years or over who presented themselves to the general practitioner in the previous 12 months with shortness of breath on exertion. Patients already known with established heart failure, confirmed by echocardiography, are excluded. Diagnostic investigations include history taking, physical examination, electrocardiography, and serum N-terminal pro B-type natriuretic peptide levels. Only participants with an abnormal electrocardiogram or an N-terminal pro B-type natriuretic peptide level exceeding the exclusionary cutpoint for non-acute onset heart failure (> 15 pmol/L (≈ 125 pg/ml)) will undergo open-access echocardiography. The diagnosis of heart failure (with reduced or preserved ejection fraction) is established by an expert panel consisting of two cardiologists and a general practitioner, according to the criteria of the European Society of Cardiology guidelines.Patients with newly established heart failure are allocated to either the 'care as usual' group or the 'intervention' group. Randomization is at the level of the general practitioner. In the intervention group general practitioners receive a single half-day training in heart failure management and the use of a structured up-titration scheme. All participants fill out quality of life questionnaires at baseline and after six months of follow-up. A six-minute walking test will be performed in patients with heart failure. Information on medication and hospitalization rates is extracted from the electronic medical files of the general practitioners.

DISCUSSION

This study will provide information on the prevalence of unrecognized heart failure in elderly with shortness of breath on exertion, and the randomized comparison will reveal whether management based on a half-day training of general practitioners in the practical application of an up-titration scheme results in improvements in functionality, health-related quality of life, and uptake of heart failure medication in heart failure patients compared to care as usual.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01202006.

Preoperative patient and injury factors of successful rehabilitation after anterior cruciate ligament reconstruction with single-bundle techniques

PURPOSE

The aim of this systematic review was to determine which patient determinants and injury factors, before anterior cruciate ligament reconstruction by arthroscopic single-bundle techniques, affect postoperative rehabilitation.

METHODS

A search of PubMed, Embase, and the Cochrane Database of Clinical Trials was performed up to February 2013. After application of our inclusion criteria, a final selection was made based on studies' methodologic score assessed with the Newcastle-Ottawa Scale. Meta-analysis was planned for each prognostic factor when data were considered clinically and statistically homogeneous.

RESULTS

Meta-analysis showed that male patients have better functional outcomes. Qualitative synthesis from 18 high-quality studies showed that patients operated on before 30 years of age reach higher activity levels. Patients with high baseline body mass index have lower activity levels after surgery. Smoking results in more symptoms and lower activity levels and subjective scores. Reconstruction before 3 months results in higher activity levels. Preoperatively, a less than 20% quadriceps strength difference, 50° of tibial external rotation or less, absence of flexion deficits, low knee influence on the patient's activity level, and less anterior knee pain result in higher functional scores. Preoperative anterior laxity difference does not predict functional scores. The prognostic value of preoperative activity and competition level for postoperative functional outcome is controversial. Patients with concomitant meniscal injuries have worse functional outcomes. The prognostic value of concomitant chondral pathology for postoperative functional outcome is controversial. Collateral ligament injury could predict functional scores or activity level.

CONCLUSIONS

Male gender, patient age younger than 30 years, reconstruction before 3 months, and high baseline activity level contribute to better functional outcomes. Smoking, high body mass index, quadriceps strength, and range-of-motion deficits affect rehabilitation negatively. Preoperative anterior laxity does not influence rehabilitation. The role of preoperative prognostic injury factors remains unclear because of limited evidence.

LEVEL OF EVIDENCE

Level III, systematic review of Level II and III studies.

Use of platelet rich plasma to treat plantar fasciitis: design of a multi centre randomized controlled trial

Background

If conservative treatment for chronic plantar fasciitis fails, often a corticosteroid injection is given. Corticosteroid injection gives temporarily pain reduction, but no healing. Blood platelets initiate the natural healing rate. GPS^® gives an eightfold concentrate platelets of patients own blood. Injection of these platelets in the attachment of the fascia to the os calcis might induce a healing rate.

Methods and design

A randomized controlled multi centre trial will be performed. The study population consists of 120 patients of 18 years and older. Patients with chronic plantar fasciitis will be allocated randomly to have a steroid injection or an autologous platelet concentrate injections. Data will be collected before the procedure, 4,8,12,26 weeks and 1 year after the procedure.

The main outcome measures of this study are pain and function measured with questionnaires.

Conclusion

Recent literature show positive effects for the treatment of tendinosis with autologous platelet injections. The forthcoming trial will compare treatment for chronic plantar fasciitis with a steroid injection versus an autologous platelet injection. Our results will be published as soon as they become available.

Trial Registration

Trial registration number: http://www.clinicaltrials.gov NCT00758641.

Posterolateral elbow impingement in professional boxers

BACKGROUND

Elbow injury is common in boxing, but it has not been reported in the literature. The onset is often a hyperextension trauma caused by a missed hit. Clinically the boxers complain of pain, stiffness, and an extension deficit.

PURPOSE

To evaluate the pathogenesis, diagnostic approach, and arthroscopic treatment of elbow injury in boxers, and to compare these with other sports-related elbow injuries.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2003 and 2005, a group of 5 professional boxers received a diagnosis of posterior elbow impingement. An arthroscopic debridement was performed. All patients were evaluated preoperatively and 1 year postoperatively with the Hospital for Special Surgery Elbow Assessment Scale.

RESULTS

An arthroscopic partial resection of the posterior olecranon tip was performed, and osteophytes and fibrous tissue were removed in this area. Loose bodies were removed from the elbow in 3 patients. They were present in the posterior compartment in 2 patients and the anterior compartment in 1. The Hospital for Special Surgery score showed satisfactory to good improvement after 1 year in all 5 cases. They all showed a normal function at follow-up and had a full return to their sports activities. In contrast with the valgus extension overload syndrome, our patients did not show any signs of concomitant ulnar collateral ligament injury.

CONCLUSION

Posterolateral elbow impingement in boxers is caused by hyperextension trauma. Concomitant medial elbow instability was not present. Standard arthroscopic debridement showed good results.