Region-specific Exercises vs General Exercises in the Management of Spinal and Peripheral Musculoskeletal Disorders: A Systematic Review With Meta-analyses of Randomized Controlled Trials.

OBJECTIVE: To compare the efficacy of region-specific exercises to general exercises approaches for adults with spinal or peripheral musculoskeletal disorders (MSKDs). DATA SOURCES: Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health. STUDY SELECTION: Randomized control trials (RCTs) on the efficacy of region-specific exercises compared to general exercises approaches for adults with various MSKDs. DATA EXTRACTION: Mean differences and standardized mean differences were calculated using random-effects inverse variance modeling. Eighteen RCTs (n=1719) were included. Cohorts were composed of participants with chronic neck (n=313) or low back disorders (n=1096) and knee osteoarthritis (OA) (n=310). DATA SYNTHESIS: Based on low-quality evidence in the short-term and very low-quality in the mid- and long-term, there were no statistically significant differences between region-specific and general exercises in terms of pain and disability reductions for adults with spinal disorders or knee OA. Secondary analyses for pain reduction in the short-term for neck or low back disorders did not report any statistically significant differences according to very low- to low-quality of evidence. CONCLUSIONS: The difference in treatment effect remains uncertain between region-specific and general exercises approaches. Based on very low- to low-quality evidence, there appear to have no differences between both types of exercise approaches for pain reduction or disability for adults with spinal disorders. Future trials may change the current conclusions. More evidence is needed for region-specific exercises compared to general exercises for other peripheral MSKDs including knee OA.

Four-film X-ray series is more sensitive than 2-film for diagnosis of skull fractures in children.

OBJECTIVE: The objective of this study was to compare the sensitivity and specificity of 2- and 4-film x-ray series when interpreted by pediatric emergency medicine physicians in the diagnosis of skull fracture in children. METHODS: A noninferiority crossover study was performed. The skull radiographs of the 50 most recent cases of skull fracture for which a 4-film radiography series was available and 50 controls matched for age were reviewed. Two modules, containing a random sequence of 2- and 4-film series of each child, were constructed to have all children evaluated twice (once with 2 films and once with 4 films). Pediatric emergency physicians evaluated both modules 2 to 4 weeks apart. The interpretation of the 4-film series by a pediatric radiologist served as the criterion standard. The sensitivity and specificity of the 2-film versus the 4-film skull x-ray series, in the identification of fracture, were compared. RESULTS: Thirteen pediatric emergency physicians participated in the study. For sensitivity, the mean difference between the 2- and 4-view series was higher than the noninferiority margin of 0.055 with an absolute mean difference of 0.060 (4-view minus 2-view series) and a 1-sided 95% higher confidence limit of 0.099. However for specificity, the mean difference was within the margin with an absolute mean difference of 0.011 and a 1-sided 95% higher confidence limit of 0.033. CONCLUSIONS: For children sustaining a head trauma, the 2-film skull radiography series is not as sensitive as the 4-film series in the detection of fracture, when interpreted by pediatric emergency physicians.

Motor Control Exercises Compared to Strengthening Exercises for Upper- and Lower-Extremity Musculoskeletal Disorders: A Systematic Review With Meta-Analyses of Randomized Controlled Trials.

OBJECTIVE: The purpose of this review was to compare the efficacy of motor control exercises (MCEs) to strengthening exercises for adults with upper- or lower-extremity musculoskeletal disorders (MSKDs). METHODS: Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane CENTRAL, and CINAHL. Randomized controlled trials were identified on the efficacy of MCEs compared to strengthening exercises for adults with upper- or lower-extremity MSKDs. Data were extracted with a standardized form that documented the study characteristics and results. For pain and disability outcomes, pooled mean differences (MDs) and standardized mean differences (SMDs) were calculated using random-effects inverse variance models. RESULTS: Twenty-one randomized controlled trials (n = 1244 participants) were included. Based on moderate-quality evidence, MCEs lead to greater pain (MD = -0.41 out of 10 points; 95% CI = -0.72 to -0.10; n = 626) and disability reductions (SMD = -0.28; 95% CI = -0.43 to -0.13; n = 713) when compared to strengthening exercises in the short term; these differences are not clinically important. When excluding trials on osteoarthritis (OA) participants and evaluating only the trials involving participants with rotator cuff-related shoulder pain, shoulder instability, hip-related groin pain, or patellofemoral pain syndrome, there is moderate quality evidence that MCEs lead to greater pain (MD = -0.74 out of 10 points; 95% CI = -1.22 to -0.26; n = 293) and disability reductions (SMD = -0.40; 95% CI = -0.61 to -0.19; n = 354) than strengthening exercises in the short term; these differences might be clinically important. CONCLUSIONS: MCEs lead to statistically greater pain and disability reductions when compared to strengthening exercises among adults with MSKDs in the short term, but these effects might be clinically important only in conditions that do not involve OA. Inclusion of new trials might modify these conclusions. IMPACT: These results suggest that MCEs could be prioritized over strengthening exercises for adults with the included non-OA MSKDs; however, results are unclear for OA disorders.

Determinants of pain, disability, health-related quality of life and physical performance in patients with knee osteoarthritis awaiting total joint arthroplasty.

PURPOSE: In patients suffering from knee osteoarthritis awaiting knee arthroplasty, to measure associations between several selected determinants and pain, disability, health-related quality of life and physical performance. MATERIAL AND METHODS: Validated self-reported measures were collected: (1) Western Ontario and McMaster Universities Osteoarthritis Index, (2) Lower Extremity Functional Scale (LEFS) and (3) Short-Form 36 (SF-36). Physical performance was also assessed with four validated performance tests. Demographic, socioeconomic, psychosocial and clinical characteristics of the participants were also measured. Multivariate regression analyses were used to evaluate potential associations. RESULTS: Higher fear-avoidance beliefs, greater comorbidities, psychological distress and use of a walking aid were significantly associated with worse pain, function or HRQOL (p < 0.05) and explained 12%-35% of the variances of the self-reported measure scores. Pretest pain and change in pain during posttest, greater comorbidities, psychological distress and use of a walking aid were significantly associated with worse performance on the physical tests (p < 0.05) and explained 41%-59% of the variances of the different physical tests results. CONCLUSIONS: Several determinants were significantly associated with worse pain, disability, health-related quality of life or physical performance. Several of these associations may be considered clinically important, including psychosocial determinants in relation to self-reported measures, but to physical performance as well. Implications for rehabilitation Knee osteoarthritis is a highly prevalent and disabling condition incurring important socioeconomic costs. Several modifiable determinants have been shown to contribute to pain and disability in individuals suffering from knee OA awaiting TKA. Recent studies demonstrated the efficacy of education and rehabilitation (prehabilitation) in individuals awaiting TKA.

Diagnostic validity of physical examination tests for common knee disorders: An overview of systematic reviews and meta-analysis.

INTRODUCTION: More evidence on diagnostic validity of physical examination tests for knee disorders is needed to lower frequently used and costly imaging tests. OBJECTIVE: To conduct a systematic review of systematic reviews (SR) and meta-analyses (MA) evaluating the diagnostic validity of physical examination tests for knee disorders. METHODS: A structured literature search was conducted in five databases until January 2016. Methodological quality was assessed using the AMSTAR. RESULTS: Seventeen reviews were included with mean AMSTAR score of 5.5 ± 2.3. Based on six SR, only the Lachman test for ACL injuries is diagnostically valid when individually performed (Likelihood ratio (LR+):10.2, LR-:0.2). Based on two SR, the Ottawa Knee Rule is a valid screening tool for knee fractures (LR-:0.05). Based on one SR, the EULAR criteria had a post-test probability of 99% for the diagnosis of knee osteoarthritis. Based on two SR, a complete physical examination performed by a trained health provider was found to be diagnostically valid for ACL, PCL and meniscal injuries as well as for cartilage lesions. CONCLUSION: When individually performed, common physical tests are rarely able to rule in or rule out a specific knee disorder, except the Lachman for ACL injuries. There is low-quality evidence concerning the validity of combining history elements and physical tests.

Reliability of physical examination tests for the diagnosis of knee disorders: Evidence from a systematic review.

Clinicians often rely on physical examination tests to guide them in the diagnostic process of knee disorders. However, reliability of these tests is often overlooked and may influence the consistency of results and overall diagnostic validity. Therefore, the objective of this study was to systematically review evidence on the reliability of physical examination tests for the diagnosis of knee disorders. A structured literature search was conducted in databases up to January 2016. Included studies needed to report reliability measures of at least one physical test for any knee disorder. Methodological quality was evaluated using the QAREL checklist. A qualitative synthesis of the evidence was performed. Thirty-three studies were included with a mean QAREL score of 5.5 ± 0.5. Based on low to moderate quality evidence, the Thessaly test for meniscal injuries reached moderate inter-rater reliability (k = 0.54). Based on moderate to excellent quality evidence, the Lachman for anterior cruciate ligament injuries reached moderate to excellent inter-rater reliability (k = 0.42 to 0.81). Based on low to moderate quality evidence, the Tibiofemoral Crepitus, Joint Line and Patellofemoral Pain/Tenderness, Bony Enlargement and Joint Pain on Movement tests for knee osteoarthritis reached fair to excellent inter-rater reliability (k = 0.29 to 0.93). Based on low to moderate quality evidence, the Lateral Glide, Lateral Tilt, Lateral Pull and Quality of Movement tests for patellofemoral pain reached moderate to good inter-rater reliability (k = 0.49 to 0.73). Many physical tests appear to reach good inter-rater reliability, but this is based on low-quality and conflicting evidence. High-quality research is required to evaluate the reliability of knee physical examination tests.