Referral patterns for surgical consult in the management of patients with foot drop due to acute lumbar disc herniation: a survey study of physical therapists in the United States

BACKGROUND

There is a lack of consensus for optimal management of patients with foot drop due to acute lumbar disc herniation (LDH) with lumbar radiculopathy (LR), which is a clinical scenario that may be encountered by physical therapists. Consequently, it is important to explore physical therapists' referral practice patterns for surgical consult. Currently, physical therapist referral patterns for surgical consult in this patient population are unknown.

OBJECTIVES

To describe physical therapist referral patterns for immediate neurosurgical consult in patients with foot drop due to suspected acute LDH with LR.

DESIGN

Cross-sectional descriptive research design using an electronic, internet-based survey that utilized two clinical vignettes.

METHOD

An electronic survey was developed by an expert peer review panel. Survey participants were licensed physical therapists in the United States and members of the Orthopedic Section of the American Physical Therapy Association.

RESULTS

Of the individuals receiving the survey invitation, 2172 completed the survey. Depending on the severity of foot drop, 34-61% were likely to refer for immediate neurosurgical consult. Presence of imaging to confirm suspected clinical diagnosis slightly affected the likelihood of referral (4-12% increase) for immediate neurosurgical consult.

CONCLUSION

In patients with foot drop due to suspected acute LDH with LR, this study found that physical therapist referral patterns for immediate neurosurgical consult varied and are likely influenced by the severity of weakness and availability of MRI findings. Further research regarding the optimal management of this patient population and potential reasons for variation in practice is warranted.

PAIN, FUNCTION, AND STRENGTH OUTCOMES FOR MALES AND FEMALES WITH PATELLOFEMORAL PAIN WHO PARTICIPATE IN EITHER A HIP/CORE- OR KNEE-BASED REHABILITATION PROGRAM

BACKGROUND

Hip exercise has been recommended for females with patellofemoral pain (PFP). It is unknown if males with PFP will benefit from a similar treatment strategy.

HYPOTHESES/PURPOSE

The purpose of this study was to compare improvements in pain, function, and strength between males and females with PFP who participated in either a hip/core or knee rehabilitation program. The directional hypothesis was that females would respond more favorably to the hip/core rehabilitation program and males to the knee program.

STUDY DESIGN

Randomized-controlled clinical trial.

METHODS

Patients were randomly assigned to a six-week hip/core or knee rehabilitation program. Visual analog scale (VAS), Anterior Knee Pain Scale (AKPS), and hip and knee isometric strength were collected before and after subjects completed the rehabilitation program. Data were analyzed using an intention-to-treat basis. Separate mixed-model analyses of variance (ANOVA) with repeated measures were used to determine changes in VAS and AKPS and strength changes for subjects classified as treatment responders (successful outcome) and non-responders (unsuccessful outcome).

RESULTS

Regardless of sex or rehabilitation group, VAS (F_1,181=206.5; p<.0001) and AKPS (F_1,181 = 160.4; p < 0.0001) scores improved. All treatment responders demonstrated improved hip abductor (F_1,122 = 6.6; p = 0.007), hip extensor (F_1,122 = 19.3; p < 0.0001), and knee extensor (F_1,122 = 16.0; p < 0.0001) strength. A trend (F_1,122 = 3.6; p = 0.06) existed for an effect of sex on hip external rotator strength change. Males demonstrated a 15.4% increase compared to a 5.0% increase for females. All treatment non-responders had minimal and non-significant (p > 0.05) strength changes.

CONCLUSION

On average, males and females with PFP benefitted from either a hip/core or knee rehabilitation program. Subjects with successful outcomes likely had hip and knee weakness that responded well to the intervention. These males and females had similar and meaningful improvements in hip extensor and knee extensor strength. Only males had relevant changes in hip external rotator strength. Clinicians should consider a subgroup of males who may benefit from hip extensor and external rotator exercise and females who may benefit from hip extensor exercise.

LEVEL OF EVIDENCE

2b.

Comparison of hip and knee strength in males with and without patellofemoral pain

OBJECTIVES

The primary purpose of this study was to compare hip strength in males with and without patellofemoral pain (PFP). The secondary purpose was to compare knee strength in males with and without PFP.

DESIGN

Secondary analysis of cross-sectional data for males with and without PFP from a larger randomized controlled trial examining hip and core versus knee-muscle strengthening for the treatment of PFP.

SETTING

Laboratory setting.

PARTICIPANTS

Sixty-six males with PFP and 36 controls.

MAIN OUTCOME MEASURES

Peak isometric force for the hip abductors, external rotators, internal rotators, extensors, and knee extensors expressed as a percentage of body mass (%BM).

RESULTS

No differences existed with respect to any of the hip strength measures (P > .05). Males with PFP demonstrated almost 17% less knee extensor strength than controls (mean difference = 7.3 %BM; 95% confidence interval, 1.3-13.4 %BM; t = 2.41; P = .02).

CONCLUSIONS

Unlike females, males with PFP did not demonstrate hip muscle weakness. However, differences did exist with knee extensor strength. These data provide preliminary evidence for the potential need for sex-specific interventions for individuals with PFP.

Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: a multicenter randomized controlled trial

CONTEXT

Patellofemoral pain (PFP) is the most common injury in running and jumping athletes. Randomized controlled trials suggest that incorporating hip and core strengthening (HIP) with knee-focused rehabilitation (KNEE) improves PFP outcomes. However, no randomized controlled trials have, to our knowledge, directly compared HIP and KNEE programs.

OBJECTIVE

To compare PFP pain, function, hip- and knee-muscle strength, and core endurance between KNEE and HIP protocols after 6 weeks of rehabilitation. We hypothesized greater improvements in (1) pain and function, (2) hip strength and core endurance for patients with PFP involved in the HIP protocol, and (3) knee strength for patients involved in the KNEE protocol.

DESIGN

Randomized controlled clinical trial.

SETTING

Four clinical research laboratories in Calgary, Alberta; Chicago, Illinois; Milwaukee, Wisconsin; and Augusta, Georgia.

PATIENTS OR OTHER PARTICIPANTS

Of 721 patients with PFP screened, 199 (27.6%) met the inclusion criteria (66 men [31.2%], 133 women [66.8%], age = 29.0 ± 7.1 years, height = 170.4 ± 9.4 cm, weight = 67.6 ± 13.5 kg).

INTERVENTION(S)

Patients with PFP were randomly assigned to a 6-week KNEE or HIP protocol.

MAIN OUTCOME MEASURE(S)

Primary variables were self-reported visual analog scale and Anterior Knee Pain Scale measures, which were conducted weekly. Secondary variables were muscle strength and core endurance measured at baseline and at 6 weeks.

RESULTS

Compared with baseline, both the visual analog scale and the Anterior Knee Pain Scale improved for patients with PFP in both the HIP and KNEE protocols (P < .001), but the visual analog scale scores for those in the HIP protocol were reduced 1 week earlier than in the KNEE group. Both groups increased in strength (P < .001), but those in the HIP protocol gained more in hip-abductor (P = .01) and -extensor (P = .01) strength and posterior core endurance (P = .05) compared with the KNEE group.

CONCLUSIONS

Both the HIP and KNEE rehabilitation protocols produced improvements in PFP, function, and strength over 6 weeks. Although outcomes were similar, the HIP protocol resulted in earlier resolution of pain and greater overall gains in strength compared with the KNEE protocol.

Trunk kinematics and fall risk of older adults: translating biomechanical results to the clinic

This paper reviews some of our experiences over nearly 15 years of trying to determine modifiable factors that contribute to the high incidence of fall by older adults. As part of our approach, we have subjected healthy young and older adults to very large postural disturbances during locomotion, in the form of trips and slips, to which rapid compensatory responses have been necessary to avoid falling. For both trips and slips, the ability to limit trunk motion has consistently discriminated older adults who fall from both younger adults and older adults who have been able to avoid falling. We have shown that the ability to limit trunk motion can be rapidly acquired, or learned, by older adults as a result of task-specific training. The learned motor skill has demonstrated short-term retention and has been shown to effectively decrease fall-risk due to trips. Collectively, we believe the works strongly suggests that the traditional exercise-based fall-prevention and whole-body, task-specific training can synergize to reduce falls and fall-related injury in older adults.