Efficacy and safety of hyaluronan treatment in combination therapy with home exercise for knee osteoarthritis pain.

OBJECTIVE: To assess the efficacy and safety of intra-articular injections of sodium hyaluronate combined with a home exercise program (HEP) in the management of pain associated with osteoarthritis (OA) of the knee. DESIGN: Single-blinded, parallel-design, 1-year clinical study with sequential enrollment. SETTING: University-based outpatient physiatric practice. PARTICIPANTS: Sixty patients (18 men, 42 women; age, > or =50 y) with moderate-to-severe pain associated with OA of the knee. INTERVENTIONS: (1) Five weekly intra-articular hyaluronate injections (5-HYL); (2) 3 weekly intra-articular hyaluronate injections (3-HYL); or (3) a combination of an HEP with 3 weekly intra-articular hyaluronate injections (3-HYL+HEP). MAIN OUTCOME MEASURES: The primary outcome measure was a 100-mm visual analog scale for pain after a 50-foot walk (15.24 m). Secondary measures included the Western Ontario and McMaster Universities Osteoarthritis Index subscales. RESULTS: The 3-HYL+HEP group had significantly faster onset of pain relief compared with the 3-HYL (P<.01) and 5-HYL groups (P=.01). All groups showed a mean symptomatic improvement from baseline (reduction in baseline pain at 3 mo was 59%, 49%, and 48% for the 3-HYL+HEP, 3-HYL, and 5-HYL groups, respectively) that was clinically and statistically significant. There were no between-group differences in the incidence or nature of adverse events. CONCLUSIONS: The combined use of hyaluronate injections with HEP should be considered for management of moderate-to-severe pain in patients with knee OA.

Occupational low back pain.

Low back injury is one of the most common conditions in the workplace. The causes are multifactorial and must be sought during the physician's examination. Failure to perform a comprehensive history and physical examination ultimately can lead to treatment failure and injury recurrence. A comprehensive history and physical may help clinicians to differentiate organic and nonorganic causes of low back pain. Different diagnoses need specific rather than generalized treatment programs. Teaching clinicians the nuances of the history and physical examination in a setting with an injured worker is the goal of this article.

Injections in patients with osteoarthritis and other musculoskeletal disorders: use of synthetic injection models for teaching physiatry residents.

This study examined whether resident injection skills could be enhanced using synthetic injection models. A total of 30 physiatry residents underwent written and injection-model pretesting and posttesting. After randomization into injection-model and control groups, the experimental group trained by watching an instructional videotape and by using models that gave visual feedback on injection accuracy, whereas the control group studied technical aspects of injections. Immediately after patient injections, a blinded attending graded residents on the required level of verbal or manual assistance. The experimental group performed significantly better during patient injections as per first injection data (i.e., the scores obtained from performing a procedure for the first time on each particular body region; P = 0.013), total injection data (i.e., the mean scores obtained from performing all procedures on each particular body region; P = 0.017), and postrotation practical testing (P < 0.007) but not for didactic knowledge (postrotation written testing; P < 0.039). Data analysis by body region showed significant benefit only for occasionally performed patient injection procedures. The benefit was most evident in less experienced residents. Injection-model accuracy testing correlated with actual patient injections, both for first injections into each major body region (r = 0.52, P = 0.005) and for all injections (r = 0.55, P = 0.003). Consideration should be given for incorporating injection-model training into residency education, especially for residents with less injection experience and for occasionally performed procedures. The overall correlation between model practical testing and subsequent patient injection performance suggests that models can measure injection competence.

Nonpharmacologic management of pain.

Pain is a complex phenomenon with various causes and issues associated with its occurrence. This complexity is especially true for those who have chronic pain. In light of the multifactorial nature of this problem, the treatment plan has to be individualized for each patient. The nonpharmacologic management of pain is the focus of this review article with an attempt to substantiate the individual components through the peer-reviewed medical literature. Strategies that have support in patients with chronic pain include the use of manipulation and mobilization, exercise, and psychological intervention; bed rest, bracing, and therapeutic modalities have not been validated in this patient population. The active use of heat modalities through a wearable wrap that allows patients to remain active during treatment has demonstrated efficacy in patients with acute pain and may be beneficial in patients with chronic pain, as well. The goal of treatment may not necessarily be to cure pain, but to manage it and restore functionality.

Positive straight-leg raising in lumbar radiculopathy: is documentation affected by insurance coverage?

OBJECTIVE: To evaluate whether differences exist in documentation of straight-leg raising (SLR), based on insurance coverage. DESIGN: Retrospective study. SETTING: Managed care organization (MCO). PARTICIPANTS: Two hundred people with a diagnosis of lumbar radiculopathy or herniated disk were referred to an MCO for authorization of further treatment. Half were self-directed under a personal injury program (PIP) after automobile collisions, and half were covered under a managed care workmen's compensation (WC) program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Documentation of an SLR test, strength, sensation, and/or reflexes were eligible for the study. The results of SLR were coded as 0, 1, or 2, for absent, positive unilateral, and positive bilateral, respectively. Additional information included subject age, sex, date of injury, provider type, and presence of attorney representation RESULTS: A positive (unilateral, bilateral) SLR in women was 7.4 times more likely if they were covered by PIP than by WC (95% confidence interval [CI], 1.4-38.7; P=.018). For men, a positive SLR was 23.5 times more likely if they were covered by a PIP (95% CI, 2.9-189.9; P=.003). The odds of bilateral SLR (radicular pain on both sides) were even more strongly associated with type of reimbursement. For women, bilateral SLR was 105.1 times more likely if they were covered by a PIP than by WC (95% CI, 11.1-992.6; P<.001). For men, bilateral SLR was 38.9 times more likely if covered by a PIP (95% CI, 11.3-133.6; P<.001). CONCLUSIONS: Reasons for reporting higher rates of positive SLR in the PIP group include an added incentive to treat, poor knowledge of proper interpretation of the SLR test, and/or an increased exaggeration of symptoms.

Sport-specific shoulder injuries.

This article reviews basic shoulder anatomy and biomechanics and discusses the impact these have on the etiology of shoulder injuries in sports. Four types of sport activities lead to shoulder injuries:muscle and tendon overuse, acute tears of the dynamic stabilizers,impingement and overuse injury. Most shoulder injuries initially are treated nonoperatively with rehabilitation. Rehabilitation protocols are successful in most patients. This article also discusses why postoperative rehabilitation is vital to the ultimate success of patients who require operative treatment.

The intra- and interrater reliability of hip muscle strength assessments using a handheld versus a portable dynamometer anchoring station.

OBJECTIVE: To compare the inter- and intrarater reliability of a portable dynamometer anchoring station (DAS) to a handheld dynamometer (HHD). DESIGN: Repeated-measures design. SETTING: Human performance and movement analysis laboratory. PARTICIPANTS: Fifteen healthy participants, ages 23 to 44 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Three consecutive measures of peak bilateral isometric strength were obtained for hip abduction, extension, and flexion by 2 investigators by using the DAS and the HHD after a 1-hour rest period. This testing scenario was repeated 1 week later. Intraclass correlation coefficients (ICCs) were used to determine reliability. RESULTS: Interrater ICCs of average peak strength ranged from.84 to.92 (hip flexors),.69 to.88 (hip abductors), and.56 to.80 (hip extensors). Intrarater ICCs ranged from.59 to.89 for tester A and from.72 to.89 for tester B using the DAS, and from.67 to.81 for the HHD across muscle groups. CONCLUSIONS: The DAS showed good intrarater reliability for hip flexion and abduction, whereas the HHD demonstrated higher reliability for hip extension. The results support the use of dynamometers that are quick and reliable and that reduce tester bias during hip strength assessment.

Sports and performing arts medicine. 1. General considerations for sports and performing arts medicine.

UNLABELLED: This self-directed learning module highlights general considerations in sports and performing arts medicine. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. OVERALL ARTICLE OBJECTIVE: To discuss similarities and differences of injuries sustained in sports and performing arts using case vignettes.

Sports and performing arts medicine. 2. Shoulder and elbow overuse injuries in sports.

UNLABELLED: This self-directed learning module discusses classic topics and highlights new advances in this area. This article discusses upper-limb sports injuries as part of a section of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article uses case vignettes as a vehicle to elaborate on shoulder and elbow pain in the athlete. OVERALL ARTICLE OBJECTIVE: To discuss shoulder and elbow overuse injuries in sports.

Sports and performing arts medicine. 3. Lower-limb injuries in endurance sports.

UNLABELLED: This self-directed learning module highlights new advances in this topic area. It is part of the study guide on sports medicine and performing arts in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article uses case vignettes as a vehicle to elaborate on (1) ankle pain in a runner, (2) heel pain in an adolescent, (3) anterior knee pain in a runner, (4) lateral knee pain in a cyclist, (5) shin splints in a runner, (6) buttock pain in a hiker, and (7) collapse of a marathoner from hyponatremia. OVERALL ARTICLE OBJECTIVE: To summarize lower-limb injuries commonly seen in endurance sports.

Sports and performing arts medicine. 4. Traumatic injuries in sports.

UNLABELLED: This self-directed learning module focuses on injuries often seen in contact sports. It includes information on trauma to the cervical spine, wrist, shoulder, knee, ankle, foot, and chest and also discusses concussion in sport. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the etiology, differential diagnoses, treatment, and return-to-play criteria for traumatic sports injuries. OVERALL ARTICLE OBJECTIVE: To summarize the approach to common traumatic sports injuries.

Sports and performing arts medicine. 6. Issues relating to dancers.

UNLABELLED: This self-directed study module highlights biomechanics unique to dance that predispose to common injuries of the lower extremity and discusses preventative strategies. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. OVERALL ARTICLE OBJECTIVE: To summarize lower-limb and back injuries commonly seen in dancers.

Sports and performing arts medicine. 5. Issues relating to musicians.

UNLABELLED: This self-directed learning module discusses classic topics and highlights new advances in this topic area. This article, which discusses upper-limb injuries in musicians, is a section of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article uses case vignettes to elaborate on issues relating to musicians. OVERALL ARTICLE OBJECTIVE: To summarize overuse injury, nerve entrapment, and focal dystonia in instrumental musicians.

Core strengthening.

UNLABELLED: Core strengthening has become a major trend in rehabilitation. The term has been used to connote lumbar stabilization, motor control training, and other regimens. Core strengthening is, in essence, a description of the muscular control required around the lumbar spine to maintain functional stability. Despite its widespread use, core strengthening has had meager research. Core strengthening has been promoted as a preventive regimen, as a form of rehabilitation, and as a performance-enhancing program for various lumbar spine and musculoskeletal injuries. The intent of this review is to describe the available literature on core strengthening using a theoretical framework. OVERALL ARTICLE OBJECTIVE: To understand the concept of core strengthening.

The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner.

Cryotherapy and thermotherapy are useful adjuncts for the treatment of musculoskeletal injuries. Clinicians treating these conditions should be aware of current research findings regarding these modalities, because their choice of modality may affect the ultimate outcome of the patient being treated. Through a better understanding of these modalities, clinicians can optimize their present treatment strategies. Although cold and hot treatment modalities both decrease pain and muscle spasm, they have opposite effects on tissue metabolism, blood flow, inflammation, edema, and connective tissue extensibility. Cryotherapy decreases these effects while thermotherapy increases them. Continuous low-level cryotherapy and thermotherapy are newer concepts in therapeutic modalities. Both modalities provide significant pain relief with a low side-effect profile. Contrast therapy, which alternates between hot and cold treatment modalities, provides no additional therapeutic benefits compared with cryotherapy or thermotherapy alone. Complications of cryotherapy include nerve damage, frostbite, Raynaud's phenomenon, cold-induced urticaria, and slowed wound healing. With thermotherapy, skin burns may occur, especially in patients with diabetes mellitus, multiple sclerosis, poor circulation, and spinal cord injuries. In individuals with rheumatoid arthritis, deep-heating modalities should be used with caution because increased inflammation may occur. Whirlpool and other types of hydrotherapy have caused infections of the skin, urogenital, and pulmonary systems. Additionally, ultrasound should not be used in patients with joint prostheses.

Complications from therapeutic modalities: results of a national survey of athletic trainers.

OBJECTIVE: To understand better the frequency and type of complications encountered by athletic trainers. DESIGN: A descriptive questionnaire. SETTING: Athletic training facilities at the high school, college, and professional levels, as well as physical therapy clinics. PARTICIPANTS: A total of 3012 certified athletic trainers employed in above-mentioned settings. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Frequency and types of complications encountered for different modalities were computed. Primary modality type used and frequency of complications in different settings were explored. RESULTS: Of the 3012 surveyed, 905 (30%) responded, 26% of whom reported a complication; 362 total complications were documented. Cryotherapy accounted for 42% of complications, with allergic reactions (n=86), burns (n=23), and intolerance/pain (n=16) most commonly listed. Electric stimulation accounted for 29% of complications, with skin irritation (n=41), burns (n=40), and intolerance/pain (n=18) most commonly listed. Therapeutic heat accounted for 22% of complications; therapeutic exercise accounted for 7% of complications. CONCLUSIONS: Compared with documented complications in the peer-reviewed literature, our survey results differed vastly with regard to the complications encountered. This may reflect a learning phenomenon, a shift in modality usage, or a general underreporting of complications.

Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests.

OBJECTIVES: To present the original descriptions of common orthopedic physical examination maneuvers of the knee and then to review the literature to support the scientific validity of these tests. DATA SOURCES: MEDLINE (1970-2000) searches were performed, as were reviews of various musculoskeletal examination textbooks that describe physical examination maneuvers of the knee. These references were then reviewed for additional references and crossed back to the original description (when possible) of these named tests. STUDY SELECTION: All articles that discussed the sensitivity and specificity of the physical examination maneuvers were extracted. This information was reviewed for accuracy and then summarized. DATA EXTRACTION: Multiple MEDLINE and text searches were performed by using the terms of the test maneuver, the joint tested, and the term physical examination. Any article with this information was reviewed until the article describing the original description was found. Articles dating from that original article to the present were reviewed for information on the sensitivity and specificity of the test. DATA SYNTHESIS: Literature reviewing the sensitivity and specificity of the tests reviewed is summarized in text and table form. The Lachman test seems to be very sensitive and specific for the detection of anterior cruciate ligament tears. For posterior cruciate ligament tears, the posterior drawer test is also very sensitive and specific and is enhanced with other tests, such as the posterior sag sign. For meniscal tears, the McMurray test is very specific but has a very low sensitivity, whereas joint line tenderness has fairly good sensitivity but lacks good specificity. Although collateral ligament testing seems to be sensitive and specific, there is a lack of well-designed studies that scientifically validate the sensitivity and specificity of these tests. Common tests for patellofemoral pain and patellar instability lack sensitivity when correlated with pathologic operative findings. CONCLUSIONS: Most physical examination tests could be referenced back to an original description, with variable information on the sensitivity and specificity along with other information about the validity of these tests in clinical practice. To standardize how physical examinations are performed and compared, they should follow the original description or agreed-on standards. In addition, the significance of a physical examination finding must be understood to ensure that patients with knee complaints are accurately diagnosed and properly treated.