Reliability of assessment methods for scapular dyskinesis in asymptomatic subjects: A systematic review.

OBJECTIVE: The aim of this systematic review was to evaluate the available published evidence on the intra- and inter-rater reliabilities of assessment methods used for identifying and measuring scapular dyskinesis (SD) in asymptomatic subjects. METHODS: A systematic electronic literature search was performed in PubMed, Physiotherapy Evidence Database, Scopus, and the Cochrane Library, and studies on the intra- and inter-rater reliabilities of physical examination tests used for identifying SD in asymptomatic people were identified. Methodological quality of the studies meeting the inclusion criteria was assessed using the Quality Appraisal of Reliability Studies (QAREL) checklist by two reviewers. The overall level of evidence of this systematic review was determined by the Modified Cochrane Back Pain Criteria based on previous research which was modified for reliability studies of the shoulder complex. RESULTS: The literature search generated 388 results, and only 14 articles met the inclusion criteria. In these studies, reliabilities of two qualitative and five quantitative methods for the assessment of SD were analyzed. The QAREL checklist revealed that 12 studies had moderate risk of bias and 2 had high risk of bias. Additionally, none of the studies were of high quality. On the basis of the Modified Cochrane Back Pain Criteria, the overall level of evidence was moderate. Most of the studies including quantitative measurement methods found good to excellent inter- and intra-rater reliability values. Most of the studies including qualitative methods found low-to-moderate intra- and inter-rater reliability values. CONCLUSION: Considering the available published evidence, there is lack of high-quality studies evaluating the inter- and intra-rater reliabilities of qualitative or quantitative methods used for the assessment of SD. There are no qualitative methods with high reliability that are fit for clinical applications. Some quantitative methods with higher reliability are present, but clinicians should be aware of the methodological flaws that studies evaluating these methods suffer from. LEVEL OF EVIDENCE: Level II, Diagnostic study.

What Is the Cost of a "Cast Holiday" in Treating Children With Early Onset Scoliosis (EOS) With Elongation Derotation Flexion (EDF, "Mehta") Casting?

INTRODUCTION: Serial casting of children with early onset scoliosis (EOS) is an established treatment option. A break from cast treatment often called a "cast holiday," (CH) is often allowed by some centers, particularly over the summer months. The impact of CHs on treatment duration or outcome has not been examined. METHODS: Institution review board approved retrospective review of children treated for EOS with elongation derotation flexion ("Mehta") casting at a children's hospital between 2001 and 2016 with a minimum of 2 years' follow-up. A CH was defined as a minimum of 4 weeks out of the cast, braced, or unbraced.The analysis was performed to determine the impact of a CH within the first 18 months of treatment. Separate analyses were performed for the entire cohort of children castedduring the study period, and then separately looking at idiopathic EOS in isolation. The impact of a CH was assessed in terms of the likelihood of achieving scoliosis <15 degrees at the final follow-up ("success"). Odds ratios were used to assess group differences between "success" ratios, and Student t tests assessed group differences for parametric data. RESULTS: Ninety children met inclusion and exclusion criteria, 31 of whom took a CH during the first 18 months of treatment (34%). This included 59 patients with idiopathic EOS (66%), 18 with syndromic EOS, 5 congenital, and 1 neuromuscular. There were no statistically significant differences between CH and no CH groups.Forty-four percent of the no CH group achieved scoliosis <15 degrees at final follow-up, as opposed to 13% of the CH group, an odds ratio of 5.3 for success without a CH. When limited to children with idiopathic EOS, 56% achieved success in the no CH, versus only 22% in the group that took a CH, an odds ratio of 4.4 for success with no CH. CONCLUSION: This study demonstrates that children treated for EOS with serial casting who take a CH within the first 18 months of treatment are less likely to achieve scoliosis <15 degrees than those who persist with treatment. LEVEL OF EVIDENCE: Level III.

Quantitative Assessment of Muscle Strength Following "Slow" Surgical Lengthening of the Medial Hamstring Muscles in Children With Cerebral Palsy.

BACKGROUND: Classic teaching for surgical lengthening of muscle contractures in children with cerebral palsy (CP) has emphasized complete correction of the deformity acutely, with immobilization of the targeted muscles in the fully corrected position. Clinical experience has led to the impression that the muscles are invariably weakened by this approach. We have developed an alternative technique for correction of contractures called slow surgical lengthening (SSL). The goal of the study was to determine the physical examination, kinematic, and muscle strength outcomes following SSL of the medial hamstring muscles in children with CP. METHODS: The study group included 41 children with CP who underwent SSL of the medial hamstring muscles as part of a comprehensive single-event multilevel surgery, who had preoperative and 1-year postoperative evaluations in our Motion Analysis Center, which included quantitative assessment of isometric and isokinetic muscle strength. RESULTS: All subjects were Gross Motor Function Classification System I and II. Mean age at the time of surgery was 10.8 years. The mean popliteal angle improved by 16.2 degrees (P<0.001) following SSL of the medial hamstrings. Sagittal plane kinematics following SSL of the medial hamstrings showed improvement of knee extension at initial contact of 10.2 degrees (P<0.001), decrease of peak knee flexion in mid-swing of 3.6 degrees (P=0.014), improved minimum knee flexion in stance of 4.9 degrees (P=0.002), and no significant change in mean anterior pelvic tilt (P=0.123). Mean peak isometric knee flexion torque remained unchanged from preoperative to postoperative studies (P=0.154), whereas mean peak isokinetic knee flexion torque significantly increased by 0.076 Nm/kg (P=0.014) following medial hamstring SSL. DISCUSSION: SSL was developed based upon clinical experience and improved understanding of the pathophysiology of skeletal muscle in children with CP. The SSL technique allows the tendinous tissue to separate spontaneously at the time of recession, but does not force further acute lengthening by intraoperative manipulation, thereby minimizing the damage to the underlying muscle. It is broadly believed that muscle weakness is inevitable following surgical lengthening. The current study shows that the SSL technique does not cause weakness. LEVEL OF EVIDENCE: Level IV-therapeutic.

Is softcast (3M) strong enough for potentially unstable paediatric forearm fractures?

INTRODUCTION: The majority of paediatric forearm fractures are treated using a circumferential splint, with prior manipulation as necessary. Plaster of Paris is often chosen for its ease of application, cost and proven reliability. Softcast is an alternative, providing a comfortable and water-resistant splint that can be removed without a plaster saw, and is in widespread use for immobilising buckle fractures. Softcast has not been recommended for acute unstable fractures. We established whether a Softcast splint could provide sufficient mechanical stability to control an unstable paediatric forearm fracture. METHODS: A laboratory study was undertaken to compare the 3 point (kinking) and 4 point bending, and torsion loads to defined clinical failure points withstood by standardised 4-wrap POP compared to Softcast splints with 6-wrap, 4 wrap and reinforced 4-wrap configurations. RESULTS: The load at clinically relevant failure of a 6-wrap Softcast forearm splint was 504N in 4 point bending, 202N in 3 point bending (kinking), and 11Nm in torsion (equalling 30.4%, 26% and 42.2% of the equivalent values for a circumferential 4-wrap POP). The 6-wrap Softcast was however stronger in all modes than a fibreglass-reinforced Softcast splint (previously recommended for acute fractures). Furthermore, the load to failure in all modes exceeds that which can be exerted by body weight in many paediatric patients. Softcast demonstrated complete recovery of its original shape on unloading, whereas POP was permanently deformed. 6-wrap Softcast splints were 4% lighter than POP. CONCLUSION: A 6-wrap Softcast splint provides adequate mechanical stability and protection for paediatric patients up to approximately 20kg, avoiding high-risk activities. The primary risk is not of fracture angulation and loss of position, but temporary indentation of the splint, causing discomfort or pain. Considering its ease of removal, Softcast may be preferable for younger paediatric patients. Its cost may be offset by reducing the number and duration of hospital visits.

Validity of a new assessment rubric for a short-answer test of clinical reasoning.

BACKGROUND: The validity of high-stakes decisions derived from assessment results is of primary concern to candidates and certifying institutions in the health professions. In the field of orthopaedic manual physical therapy (OMPT), there is a dearth of documented validity evidence to support the certification process particularly for short-answer tests. To address this need, we examined the internal structure of the Case History Assessment Tool (CHAT); this is a new assessment rubric developed to appraise written responses to a short-answer test of clinical reasoning in post-graduate OMPT certification in Canada. METHODS: Fourteen physical therapy students (novices) and 16 physical therapists (PT) with minimal and substantial OMPT training respectively completed a mock examination. Four pairs of examiners (n = 8) participated in appraising written responses using the CHAT. We conducted separate generalizability studies (G studies) for all participants and also by level of OMPT training. Internal consistency was calculated for test questions with more than 2 assessment items. Decision studies were also conducted to determine optimal application of the CHAT for OMPT certification. RESULTS: The overall reliability of CHAT scores was found to be moderate; however, reliability estimates for the novice group suggest that the scale was incapable of accommodating for scores of novices. Internal consistency estimates indicate item redundancies for several test questions which will require further investigation. CONCLUSION: Future validity studies should consider discriminating the clinical reasoning competence of OMPT trainees strictly at the post-graduate level. Although rater variance was low, the large variance attributed to error sources not incorporated in our G studies warrant further investigations into other threats to validity. Future examination of examiner stringency is also warranted.

Rereduction for Redisplacement of Both-Bone Forearm Shaft Fractures in Children.

BACKGROUND: There is a high rate of redisplacement after closed reduction and cast treatment of displaced both-bone forearm shaft fractures in children. Little evidence is available on the efficacy of rereduction of these redisplaced fractures. This study evaluates the impact of rereduction on radiographic outcomes and compares the cost to surgical stabilization. METHODS: This retrospective study included 31 children (mean age, 6.3 y; 18 boys) treated with rereduction for redisplacement of a displaced both-bone forearm shaft fracture between 2008 and 2013. Angulation was measured on anteroposterior and lateral radiographs of the radius and ulna at injury, after reduction, at redisplacement, after rereduction, and at fracture union. Average procedure costs for rereduction and surgical stabilization were calculated. RESULTS: Initial reduction decreased apex volar angulation (initially >20 degrees) of both bones to a median of ≤2 degrees. After an average of 15 days (range, 4 to 35 d), apex volar angulation of the radius worsened to 9 degrees, and apex ulnar angulation worsened to >10 degrees for both bones. For every 5 days after initial reduction, apex ulnar angulation of the radius worsened by 4 degrees. Rereduction reduced apex ulnar and volar angulation of both bones to <5 degrees, which was maintained after cast removal. There were no complications. The average procedure cost for rereduction was $2056 compared with $4589 for surgical stabilization with or without implant removal. CONCLUSION: Rereduction of both-bone forearm shaft fractures after redisplacement following initial closed reduction had satisfactory radiographic outcomes and is a safe, effective, and less expensive option than surgical stabilization. LEVEL OF EVIDENCE: Level IV-therapeutic.

Assessment of functional treatment versus plaster of Paris in the treatment of grade 1 and 2 lateral ankle sprains.

BACKGROUND: Despite the common occurrence of ankle sprains, no treatment is considered to be the gold standard for the management of such sprains. We assessed functional treatment versus plaster of Paris (POP) for the treatment of lateral ankle sprains, with pain and function employed as the outcome measures. MATERIALS AND METHODS: 126 Patients were eligible for inclusion. They were assigned to either the functional treatment Tubigrip (TG) group or the POP group after applying block randomization. Characteristics such as age, dominant ankle, and gender were assessed at baseline. Pain and functional assessments were done using the visual analog scale (VAS) and the Karlsson score (KS) at baseline (at the start of the study) and during the 2nd and 6th weeks, respectively. Data on other subjective parameters, such as the number of painkillers used, the number of days taken off work, and the number of sleepless nights, were requested from the patients at the end of the study. SPSS version 16 was used for analysis, and p < 0.05 was taken to indicate significance. RESULTS: 60 Patients completed the trial in each group. The mean ages were 28.77 ± 6.72 in the TG group and 29.83 ± 6.30 in the POP group (p = 0.034). There was a slight female predominance. Right and left ankles were equally involved in the TG group, while left ankles were mainly involved in the POP group. Mean differences in VAS and KS between the two groups were statistically significant at the end of the study. The mean number of painkillers used by the patients in the TG group was higher than the number used in the POP group (p < 0.001). The mean number of days taken off work was 4.18 ± 1.73 days in the TG group, and 6.25 ± 2.73 days in the POP group (p < 0.001). The mean number of sleepless nights was higher in the POP group. CONCLUSION: The results of our study indicate that functional treatment provides better functional support and pain reduction than a below-knee POP cast. LEVEL OF EVIDENCE: Level I.

Cost-effectiveness of the Ponseti method for treatment of clubfoot in Pakistan.

BACKGROUND: Clubfoot is disabling, with an incidence of 0.9/1,000 live births to 7/1,000 live births. It affects mobility, productivity, and quality of life. Patients are treated surgically or non-surgically using the Ponseti method. We estimated the cost per patient treated with both methods and the cost-effectiveness of these methods in Pakistan. METHODS: Parents of patients treated, either surgically or with the Ponseti method, at the Indus Hospital's free program for clubfoot were interviewed between February and May 2012. We measured the direct and indirect household expenditures for pre-diagnosis, incomplete treatment, and current treatment until the first brace for Ponseti method and the first corrective surgery for surgically treated patients. Hospital expenditure was measured by existing accounts. RESULTS: Average per-patient cost was $349 for the Ponseti method and $810 for patients treated surgically. Of these, the Indus hospital costs were $170 the for Ponseti method and $452 for surgically treated patients. The direct household expenditure was $154 and $314 for the Ponseti and surgical methods, respectively. The majority of the costs were incurred pre-diagnosis and after inadequate treatment, with the largest proportion spent on transportation, material, and fee for service. The Ponseti method is shown to be the dominant method of treatment, with an incremental cost-effectiveness ratio of $1,225. CONCLUSIONS: The Ponseti method is clearly the treatment of choice in resource-constrained settings like Pakistan. Household costs for clubfoot treatment are substantial, even in programs offering free diagnostics and treatments and may be a barrier to service utilization for the poorest patients.

Barriers to the Ponseti method in Peru: a two-year follow-up.

Idiopathic clubfoot affects approximately 100,000 children each year and is one of the leading causes of disability worldwide. The Ponseti method is an inexpensive, non-surgical treatment that, when executed correctly, is more than 95% effective; however, in Peru, a developing country where a low-cost alternative is greatly needed, physicians report up to 30% of patients do not complete treatment. This study involved semi-structured interviews with 25 physicians who practice the Ponseti Method in Peru to discuss obstacles for the method in their country. The most frequent obstacles to the Ponseti method in Peru reported by physicians included lack of physicians trained in the Ponseti method in the country, patient transportation and distance to treatment centers, and lack of parental knowledge of the Ponseti method. These data suggest the need to train more physicians in Peru, particularly in the provinces. Increasing access to trained physicians in provincial areas may reduce the financial and travel burden of parents to help increase compliance with treatment.

Ultrasound assessment of early clubfoot treatment: a comparison of the Ponseti method and a modified Copenhagen method.

The purpose of this study was to sonographically compare the early anatomical outcome of a group of clubfeet treated with the Ponseti method (group A, nine clubfeet) with a group treated with an adjustable plexidur splint, the Copenhagen method (group B, 19 feet). The clinical severity was assessed using the Diméglio-Bensahel classification. The need for complementary surgery was clinically assessed at the age of about 2 months. Ultrasound investigation was made in the neonatal period, after 2-3 months of non-surgical treatment and 1-2 months post-surgically. After 2 months of non-surgical treatment the correction obtained at the talo-navicular joint, expressed as the distance between the medial malleolus and the navicular (MM-N distance), was significantly greater in group A. After surgery, tenotomy of the Achilles tendon for all group A feet, and posterior or posteriomedial release for 13 feet in group B, the correction at the talo-navicular and calcaneo-cuboid joints was similar for the two groups. Anatomical correction of the displacement in these joints can be achieved without extensive interventional procedures. Ultrasound may be a valuable tool to assess the effects of different treatment protocols quantitatively.

Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment.

OBJECTIVE: To provide a qualitative systematic review of the risk of spinal manipulation in the treatment of lumbar disk herniations (LDH) and to estimate the risk of spinal manipulation causing a severe adverse reaction in a patient presenting with LDH. DATA SOURCES: Relevant case reports, review articles, surveys, and investigations regarding treatment of lumbar disk herniations with spinal manipulation and adverse effects and associated risks were found with a search of the literature. DATA SYNTHESIS: Prospective/retrospective studies and review papers were graded according to quality, and results and conclusions were tabulated. From the data published, an estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or cauda equina syndrome (CES) in patients presenting with LDH was calculated. This was compared with estimates of the safety of nonsteroidal anti-inflammatory drugs (NSAIDs) and surgery in the treatment of LDH. RESULTS: An estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million. CONCLUSION: The apparent safety of spinal manipulation, especially when compared with other "medically accepted" treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.

A proposed new classification system for whiplash associated disorders--implications for assessment and management.

The development of chronic symptoms following whiplash injury is common and contributes substantially to costs associated with this condition. The currently used Quebec Task Force classification system of whiplash associated disorders is primarily based on the severity of signs and symptoms following injury and its usefulness has been questioned. Recent evidence is emerging that demonstrates differences in physical and psychological impairments between individuals who recover from the injury and those who develop persistent pain and disability. Motor dysfunction, local cervical mechanical hyperalgesia and psychological distress are present soon after injury in all whiplash injured persons irrespective of recovery. In contrast those individuals who develop persistent moderate/severe pain and disability show a more complex picture, characterized by additional impairments of widespread sensory hypersensitivity indicative of underlying disturbances in central pain processing as well as acute posttraumatic stress reaction, with these changes present from soon after injury. Based on this heterogeneity a new classification system is proposed that takes into account measurable disturbances in motor, sensory and psychological dysfunction. The implications for the management of this condition are discussed.

Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis.

The inherent ability of pediatric metaphyseal radius fractures to heal and remodel made us question the need for immediate anatomic reduction under conscious sedation. We believe that isolated closed distal radius fractures with 15 degrees of angulation and 1 cm of shortening will heal well and remodel completely without clinical or functional sequelae. Time and expense can be decreased by splinting and follow-up without the need for immediate anatomic reduction in the emergency room. In order to answer this question, we retrospectively evaluated 34 pediatric metaphyseal wrist fractures that lost position after attempted reduction and healed in their angulated or shortened position. We looked at the time to healing, time to remodeling and any residual clinical or functional deficits. We then did a comparison cost analysis with time matched patients who had complete but minimally displaced fractures of the distal radius that were treated by immediate splinting with orthopaedic follow-up. Our results showed that skeletally immature patients with open physes, isolated injuries, dorsovolar and radioulnar angulations less than 15 degrees and less than 1 cm of shortening will heal and be out of cast within an average of 6 weeks and completely remodel within an average of 7.5 months. The average time in the emergency room was 2 h less with no reduction. The cost of the emergency room visit with attempted reduction was 50% more than splinting with early referral (US dollars 536 versus US dollars 270). None of our patients had significant clinical deformities or residual functional deficits.

Dynamic magnetic resonance guided treatment of developmental dysplasia of the hip.

This study demonstrates the feasibility and advantages of near real-time, multiplanar, dynamic magnetic resonance image-assisted treatment of patients with developmental dysplasia of the hip. Pathoanatomy and dynamic blocks to reduction are visualized with anatomic clarity not otherwise possible. Continuous imaging allows accurate assessment and maintenance of optimum positioning throughout the casting procedure. Patient charges for this new technique are less than standard methods of treatment, and the child receives no ionizing radiation.

Recurrent nursemaid's elbow (annular ligament displacement) treatment via telephone.

Annular ligament displacement (ALD)--also termed radial head subluxation, nursemaid's elbow, or pulled elbow--can be successfully diagnosed and treated over the telephone by properly trained medical professionals instructing nonmedical caretakers. Two case reports of successful ALD reduction via telephone are described. The pathology of ALD and techniques for its treatment are reviewed, and guidelines are given. The rationale for the introduction of the new term annular ligament displacement as well as areas for additional investigation are discussed. To our knowledge, this is the first published account of ALD reduction via telephone.

Comparison between closed reduction with percutaneous pinning and open reduction with pinning in children with closed totally displaced supracondylar humeral fractures: a randomized controlled trial.

This was a randomized controlled trial of 28 children 1 year to 12 years of age with closed totally displaced supracondylar humeral fracture. The purpose of the study was to compare closed reduction and pinning (group A) and open reduction and pinning (group B). Each group consisted of 14 children. The general characteristics of both groups (age, sex side, displacement, nerve injury preoperatively) were statistically the same (P > 0.05). All cases healed with good alignment without cubitus varus, without infection and with a good range of motion except for one. The mean +/- standard deviation of the Baumann's angle difference between the injured and uninjured side were 2.32 +/- 1.6 degrees in group A (range, 0-6.5 degrees) and 2.45 +/- 1.8 degrees in group B (range, 0-6.5 degrees). This difference was statistically not significant (P = 0.8). By Flynn criteria, group A had good to excellent results in 100%, and group B had good to excellent results in 93% and fair in 7%. This difference was not statistically significant (P = 1). The satisfaction score (0-10) was significantly higher in group A for both parents' and evaluator's (blinded to treatment) perspective (P = 0.017 and 0.019, respectively). The author concludes that both treatments gave good results. Closed reduction should be performed first and, if it fails, then open reduction can be performed. This will produce good results in the hands of an experienced surgeon.

Use of the dual force system to correct chronic knee deformities due to severe haemophilia.

In this study, the use of the dual force system to correct recent or relatively longstanding knee deformities in ten patients is described. (Nine of the patients had severe haemophilia and one had severe von Willebrand's disease.) The mean duration of deformity in these patients was 10 months. The mean range of movement at the affected knee joints increased from 50 degrees at pre-intervention to 110 degrees following 6 weeks of application of the dual force system. In nine of ten patients (90%) the residual flexion deformity ranged from 0 degrees to 10 degrees. The dual force system offers an easily affordable and effective means of correcting a flexion deformity of the knee joint in severely affected haemophilia and allied disorders. More extensive use of this technique in different centres is required to determine its place in the day-to-day management of such patients.