Transcript Physical Therapy Intervention for the Musculosketal System

Physical Therapy Intervention for
the Musculoskeletal System
JEFF ROBINSON, PT, FAAOMPT
FOCUSED PRESENTATION
Introduction
 Intervention defined in a general way is “any measure
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whose purpose is to improve health or alter the course of
disease.”1
Intervention is at the core of what a physical therapist
does.
One could argue the most important part of patient
interaction is intervention.
Ultimately, patients seek out physical therapists for a
solution to a problem.
The way in which physical therapists ultimately solve a
patient problem is through intervention.
Primary goals of presentation
 1) to define intervention as it relates to the practice
of physical therapy for the musculoskeletal system
 2) to provide a brief history of intervention in
physical therapy as it relates to the musculoskeletal
system
 3) to provide a general overview of the evidence of
procedural interventions in physical therapy related
to the musculoskeletal system
Secondary Goals of presentation
 1) to educate the reader about how to practice using
evidence to answer clinical questions
 2) to summarize evidence based principles and
concepts
 To accomplish the secondary goals, the author
defines evidence based principles and concepts and
shares with the reader the clinical questions asked in
gathering the evidence for this work.
Intervention
 According to The Guide to Physical Therapist
Practice, “intervention is the purposeful interaction
of the physical therapist with the patient/client and,
when appropriate, with other individuals involved in
patient/client care, using various physical therapy
procedures and techniques to produce changes in the
condition that are consistent with the diagnosis and
prognosis.” 2
History of Intervention in Physical Therapy
 Modern day musculoskeletal interventions in physical therapy
were born out of the need to treat victims of the poliomyelitis
epidemic of the late 1800s and the early 1900s for the
impairments of muscle weakness and decreased range of
motion. 3
 The various wars throughout history also resulted in many
musculoskeletal injuries which further drove the need for
intervention. 3
 Moffett describes interventions such as exercise programs,
hydrotherapy, massage, and other modalities used for
veterans of World War I. 3
 The first textbook written by a physical therapist was actually
named after musculoskeletal interventions. The book was
published in 1921 by Mary McMillan and titled, Massage and
Therapeutic Exercise. 3
Intervention
The Guide 2 divides interventions into 3 categories: 1)
coordination, communication, and documentation
2)Patient/Client-Related Instruction and 3) procedural
interventions.
The procedural intervention
category is further divided up into
9 general sub-headings:
 Therapeutic exercise.
 Functional Training in Self Care
and Home Management
 Functional Training in Work
 Manual Therapy Techniques
 Prescription, Application and as
Appropriate, Fabrication of
Devices and Equipment
 Airway Clearance Techniques
 Integumentary Repair and
Protection Techniques
 Electrotherapeutic modalities
 Physical Agents and Mechanical
Modalities
For the most part all of these, all
except for subheadings for airwar
clearance and integumentary
repair are applicable to
musculoskeletal intervention.
Intervention
 The first 2 headings (1) coordination,
communication, and documentation and
(2)Patient/Client-Related Instruction will not be
covered in this presentation
 This presentation will focus on the procedural
interventions for musculoskeletal conditions
Intervention
 The highest level of evidence for intervention studies
are systematic reviews of RCTs (Randomized
controlled trials) Level 1a. 4
 The next highest level of evidence is an individual
RCT (with narrow confidence interval).
 Once studies are located, they need to be critically
appraised to ensure validity. 4
Hierarchy of Evidence
Critically Appraising the Evidence - RCT
 “Is the evidence about therapy valid?”
 1. “Was the assignment of patients to treatment randomized?”
 2. “Was the randomization concealed?”
 3. “Were the groups similar at the start of the trial?”
 4. “Was the follow-up of patients sufficiently long and
complete?”
 5. “Were all patients analyzed in the groups to which they
were randomized?”
 6. “Were patients, clinicians and study personnel kept blind to
the treatment?”
 7. “ Were groups treated equally, apart from the experimental
therapy?”
Critically Appraising the Evidence
 “Is the valid evidence about therapy important?”
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1. “What is the magnitude of the treatment effect?”
2. “How precise is the estimate of the treatment effect?”
 “Can we apply this valid, important evidence about
therapy in caring for our patient?”
1. “Is our patient so different from those in the study that its results
cannot apply?”
2. “Is the treatment feasible in our setting?”
3. “What are our patient’s potential benefits and harms from the
therapy?”
4. “What are our patient’s values and expectations for both the
outcome we are trying to prevent and the treatment we are offering?
Foreground Question
 Foreground questions were generated throughout
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the presentation using the PICO method.
P – Patient
I – Intervention
C – Comparison
O - Outcome
Procedural Interventions
Therapeutic Exercise
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Smidt et al. 7 concluded that exercise is effective for several
musculoskeletal conditions including: knee osteoarthritis,
ankylosing spondylitis, hip osteoarthiritis. They concluded
that there was not enough evidence to support or not the
support the effectiveness for neck pain, shoulder pain, and
repetitive strain injury.
The authors concluded that exercise is not effective for acute
low back pain.
The general conclusion by the authors was, that “exercise
therapy is effective for a wide range of chronic disorders.”
Procedural Interventions
Therapeutic Exercise
 Taylor et al. 8 found evidence for effectiveness of
therapeutic exercise for arthritis, low back and neck
pain, fractures, and lower and upper limb disorders.
 Overall conclusions on therapeutic exercise: There is
robust evidence supporting the effectiveness of
therapeutic exercise for musculoskeletal conditions.
Procedural Interventions
Functional Training in Self – Care and Home Management
 Observations
 Dearth of evidence evaluating the use of functional training
in self care and home management for patients with
musculoskeletal dysfunction
 Most of research on functional training in physical therapy is
in the realm of back schools, but the evidence is lacking for
the effectiveness of back schools in the non-occupational
setting
 Much of research on back schools is on multidisciplinary
treatment not specific physical therapy functional training
interventions
Procedural Interventions
Functional Training in Self – Care and Home Management
 Best available evidence for this broad intervention
category was this RCT on functional vs. strength
training 9
 Functional training included sit to stand, forward
reaching to opposite foot, forward and side-step
walking, etc.
 Study concluded subjects with functional training
achieved equal strength gains compared to subjects
who underwent a strength program
 Functional training group had greater improvements in
balance and coordination in ADLs
Procedural Interventions
Functional Training in Self – Care and Home Management
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Best available evidence for specific type of functional training
(Back School).
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Recent (2010) RCT found “functional
multidisciplinary rehabilitation” (which
included back school) to be better than
outpatient PT in increasing function 10
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Systematic review found moderate evidence for
effectiveness of back school in decreasing pain
and increasing functional status (2005) 11
Procedural Interventions
Functional Training in Self – Care and Home Management
 Observations/Conclusions
 Evidence may be lacking because in musculoskeletal
patients often times we are treating at the level of
impairment (through therapeutic exercises, manual therapy,
etc.) which automatically results in increased function
 Perhaps more of the functional training literature in physical
therapy is done on neurological patients
 More research is needed to evaluate the effectiveness of
functional training in patients with musculoskeletal
dysfunction
Procedural Interventions
Functional Training in Work (job, school, play)
 2010 Cochrane review was able to efficiently
answer my clinical question:
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91 page study found that there “might” be a positive effect of
work hardening type program for sub-acute and chronic
back pain 12
Some of the studies reviewed did include exercise and
“physical conditioning”
Even in the well done studies there were conflicting results
Procedural Interventions
Functional Training in Work (job, school, play)
 2010 systematic review looked at what they called
“neuromuscular training” which in reading the
article included sport specific training or functional
training for play 13
 Results concluded there is evidence that this type
of training reduces the incidence of injury
Procedural Interventions
Functional Training in Work (job, school, play)
 Observations/Conclusions/Recommendations
 There is a lack of consensus on the effectiveness of functional
training in work as it relates to low back pain
 There is evidence to support functional training in sports for
injury prevention
 Functional training done in the clinic is most likely never done
solely, but rather as part of a comprehensive treatment plan
that includes other interventions.
 Future studies may need to compare functional training vs.
individualized physical therapy intervention plus functional
training.
Procedural Interventions
Manual Therapy Techniques
 Bronfort et al 14 included 322 references in a 33 page
report in the most comprehensive, thorough review
on manual therapy found
 In patients with low back pain, headache,
cervicogenic dizziness, spinal
mobilization/manipulation is effective
Procedural Interventions
Manual Therapy Techniques
 In patients with neck pain, thoracic manipulation is
effective.
 For neck pain alone, evidence is inconclusive
 Also inconclusive evidence for mid back pain,
sciatica, coccydinia, TMJ disorders, sciatica, tension
type headache, knee OA, fibromyalgia, migraines
 For low back pain, massage is effective
Procedural Interventions
Manual Therapy Techniques
 Observations/Conclusions/Recommendations:
 Manual therapy is effective for certain musculoskeletal
dysfunctions
 Studies that focus on manual therapy have increased
dramatically in recent years
 The profession should continue to study the various manual
therapy techniques used in physical therapy practice for
conditions where there is currently inconclusive evidence
Procedural Interventions
Prescription, Application of Equipment
 Spinal orthoses in the workplace
 A relatively recent systematic review 15(which included RCTs
and lower quality of studies due to lack of RCTs) concluded:
No
evidence to support the use of back belts in
the work environment in preventing injury or
decreasing lost time from work
Future research should focus on well designed
RCTs
Procedural Interventions
Prescription, Application of Equipment
 Custom semi-rigid FOs are effective in treating and
preventing plantar fasciitis and posterior tibial stress
fractures 16
 Custom semi rigid FOs show small to moderate
effects for patellofemoral pain syndrome 16
 Further research with high quality studies was
recommended
Procedural Interventions
Electrotherapeutic Modalities
 TENS
 Results of 3 systematic reviews done by the Cochrane
Collaboration provided mixed results
 One of the three studies did include musculoskeletal
and non-musculoskeletal conditions and could not
make any definitive conclusions 17
 One study could not support its use in chronic low
back pain 18
 One study could not make any definitive statements
for TENS use for neck pain 19
Physical Agents and Mechanical Modalities
 2 papers were located that offered broad summaries of
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the effectiveness of various physical agents
Unfortunately the reviews were not systematic in nature
One described a less than adequate grading system for
studies included and had no regard for randomization or
blindness 20
Another did not provide any information on how studies
were chosen for the review and included no information
on the rating system used 21
I chose the physical agent, ultrasound to search in depth
Ultrasound
 A recent Cochrane Review addressed therapeutic
ultrasound for OA of the knee and found no evidence
to support effectiveness22
 Robertson et al agreed in their review, concluding
there is little evidence that active therapeutic
ultrasound is more effective than placebo in their
study which looked at therapeutic ultrasound for
various afflictions23
Procedural Interventions - Summary
 There is robust evidence for effectiveness of
therapeutic exercise for musculoskeletal problems
 There is good evidence to support manual therapy
for musculoskeletal problems
 Ultrasound is not effective for musculoskeletal
problems
 More studies are needed to determine the
effectiveness of functional training for self care and
work, and TENS
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
The free dictionary by Farlex. Retrieved March 20, 2011, from http://medical dictionary
.thefreedictionary.com/intervention.
American Physical Therapy Association. Guide to Physical Therapist Practice. Second
Edition. Phys Ther. 2001;81:9-746.
Moffat M. History of physical therapy practice in the united states. J Phys Ther Ed.
2004;17:(3):15-25.
Portney LG, Watkins MP. Foundations of Clinical Research, 3rd edition. Upper Saddle
River: Pearson Prentice Hall, 2009.
Straus SE. Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine How to
Practice and Teach EBM, 3rd edition. Philadelphia: Elsevier Churchill Livingstone, 2005.
Evidence Based Medicine/Practice Pyramid & USD Databases. In The University of South
Dakota. Retrieved March 20, 2011, from http://libguides.usd.edu/EBM.
Smidt N, deVet CW, Bouter LM, Dekker J. Effectiveness of exercise therapy: A bestevidence summary of systematic reviews. Australian Journal of Physiotherapy. 2005;51:7185.
Taylor NF, Dodd KJ, Shields N, Bruder A. Therapeutic exercise in physiotherapy practice is
beneficial: a summary of systematic reviews 2002-2005. Australian Journal of
Physiotherapy. 2007;(53):7-16.
Krebs DE, Scarborough DM, McGibbon CA. Functional vs. strength training in disabled
elderly outpatients. Am J Phys Med Rehabil. 2007;86(2):93-103.
References
10.
11.
12.
13.
14.
15.
16.
17.
Henchoz Y, deGoumoens P, So AK Paillex R. Functional multidisciplinary rehabilitation
versus outpatient physiotherapy for non specific low back pain:randomized controlled trial.
Swiss Medical Weekly. 2010;(140):w13133.
Heymans MW, vanTulder MW, Esmail R, Bombardier C, Koes BW. Back schools for
nonspecific low back pain. Spine. 2005;30(19):2153-2163.
Schaafsma F, Schonstein E, Whelan KM, Ulvestad E, Kenny DT, Verbeek JH. Physical
conditioning programs for improving work outcomes in workers with back pain. Cochrane
Database Syst Rev. (1):CD001822,2010.
Hubscher M, Zech A, Pfeifer K, Hansel F, Vogt L, Banzer W. Neuromuscular training for
sports injury prevention: a systematic review. Med Sci Sports Exerc. 2010 Mar;42(3):41321.
Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the
UK evidence report. Chiropractic & Osteopathy. 2010;18(3).
Ammendolia C, Kerr MS, Bombardier C. Back belt use for prevention of occupational low
back pain: a systematic review. J of Manip and Phsiolog Therap. February 2005:128-134.
Hume P, Hopkins W, Rome K, Maulder P, Coyle G, Nigg B. Effectiveness of foot orthoses
for treatment and prevention of lower limb injuries: a review. Sports Medicine. 2008;
38(9):759-777.
Kroeling P, Gross A, Goldsmith CH, Burnie SJ, Haines T, Graham N, Brant A.
Electrotherapy for neck pain. Cochrane Database Sys Rev. 2009;(4):CD004251.
References
18. Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous
19.
20.
21.
22.
23.
electrical nerve stimulation (TENS) versus placebo for chronic low
back pain. Cochrane Database Sys Rev. 2008;(4):CD003008.
Walsh DM, Howe TE, Johnson MI, Sluka KA. Transcutaneous
electrical nerve stimulation for acute pain. Cochrane Database
Sys Rev. 2009;(2):CD006142.
Allen R. Physical agents in the management of chronic pain by
physical therapists. Phys Med Rehab Clinic of NA. 2006;17(2).
Rakel B, Barr JO. Physical modalities in chronic pain
management. Nursing Clin of NA. 2003;38(3).
Welch V, Brosseau L, Peterson J, Shea B, Tugwell P, Wells G.
Therapeutic ultrasound for osteoarthritis of the knee.
2010;Cochrane Database of Syst Rev. (3)CD0003132.
Robertson VJ, Baker KG. A review of therapeutic ultrasound:
effectiveness studies. Phys Ther. 2001;81(7):1339-1350.
References
26.
27.
28.
29.
30.
31.
Herno A, Airaksinen O, Saari T, Luukkonen M. Lumbar spinal stenosis: a
matched-pair study of operated and non-operated patients. Br J Neurosurg. Oct
1996;10(5):461-465.
Hurri H, Slatis P, Soini J, et al. Lumbar spinal stenosis: assessment of long-term
outcome 12 years after operative and conservative treatment. J Spinal Disord.
1998;11(2):110-115.
Johnsson KE, Uden A, Rosen I. The effect of decompression on the natural course
of spinal stenosis. A comparison of surgically treated and untreated patients.
Spine. 1991;16(6):615-619.
Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Blood EA,
Birkmeyer NJ, Hilibrand AS, Herkowitz H, Cammisa, FP, Albert TJ, Emery SE,
Lenke LG, Abdu WA, Longley M, Errico TJ, Hu SS. Surgical versus nonsurgical
treatment for lumbar degenerative spondylolisthesis. N Engl J Med.
2007;356(22):2257-70.
Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Blood EA,
Birkmeyer NJ, Hilibrand AS, Herkowitz H, Cammisa, FP, Albert TJ, Emery SE,
Lenke LG, Abdu WA, Longley M, Errico TJ, Hu SS. Surgical versus nonsurgical
treatment for lumbar spinal stenosis. N Engl J Med. 2008;358:794-810.
Iversen MD, Choudhary VR, Patel SC. Therapeutic exercise and manual therapy
for persons with lumbar spinal stenosis. Int J Rheumatol. 2010; 5(4):425-437.