Guidelines versus evidence: what we can learn from the Australian guideline for low-level laser therapy in knee osteoarthritis? A narrative review.

This narrative review analyses the Australian Guideline (2018) for the treatment of knee osteoarthritis (KOA) developed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The Guideline recommended against the use low-level laser therapy (LLLT). Why this conclusion was reached is discussed in this review in the context of evidence provided in other systematic reviews, the latest of which was published in 2019 and which provided strong support for LLLT for knee OA. We evaluated the reference list cited for the recommendation "against" LLLT and compared this with reference lists of systematic reviews and studies published before and after the publication date of the Guideline. Eight randomised controlled trials (RCTs) of LLLT were cited in the Guideline the latest of which was published in 2012. There were seventeen additional RCTs, five of which together with one systematic review were located in the year of publication, 2018. The most recent systematic review in 2019 included 22 RCTs in its analysis. Discordance with the levels of evidence and recommendations was identified. Although GRADE methodology is said to be robust for systematically evaluating evidence and developing recommendations, many studies were not identified in the Guideline. In contrast, the latest systematic review and meta-analysis provides robust evidence for supporting the use of LLLT in knee OA. The conflict between guidelines based on opinion and evidence based on meta-analysis is highlighted. Given the totality of the evidence, we recommend that the Australian Guideline should be updated immediately to reflect a "for" recommendation.

Acoustic Radiation Force Impulse Elastography Assessment of Lymphoedema Tissue: An Insight into Tissue Stiffness.

Palpation remains essential for evaluating lymphoedema to detect subtle changes that may indicate progression. As palpation sense is not quantifiable, this study investigates the utility of ultrasound elastography to quantify stiffness of lymphoedema tissue and explore the influence of the pitting test on tissue stiffness. Fifteen women with unilateral arm lymphoedema were scanned using a Siemens S3000 Acuson ultrasound (Siemens, Germany) with 18 MHz and 9 MHz linear transducers to assess tissue structure and tissue stiffness with Acoustic Radiation Force Impulse elastography. Ninety sites were assessed, three on each of the lymphoedema-affected and contralateral unaffected arms. A subgroup of seven lymphoedema-affected sites included additional elastography imaging after a 60-s pitting test. Dermal tissue stiffness was greater than subcutaneous tissue stiffness regardless of the presence of pathology (p < 0.001). Lymphoedematous tissue exhibited a higher dermal to subcutaneous tissue stiffness ratio than contralateral sites (p = 0.005). Subgroup analysis indicated that the pitting test reduces dermal tissue stiffness (p = 0.018) and may alter the stiffness of the subcutaneous tissue layer. Elastography demonstrates potential as a complement to lymphoedema palpation assessment. The novel pre-test and post-pitting elastography imaging protocol yielded information representative of lymphoedema tissue characteristics that could not be ascertained from pre-test elastography images alone.

A meta-analytic review of prospection deficits in Parkinson's disease.

Parkinson's disease (PD) is one of the most common neurodegenerative disorders, and is associated with prominent motor deficits. However, neurocognitive impairment is also a common clinical feature that can contribute greatly to the overall disease burden. In the current study, a meta-analysis was conducted to gain a clearer understanding of how PD affects one of the most functionally important domains of cognition: prospection. The results indicate that, relative to controls, PD is associated with a large deficit in the capacity to engage in planning (g = -0.81, K = 25) and a moderate-sized deficit in prospective memory (g = -0.57, K = 16). Sub-analyses indicated that these deficits are evident for both time and event-based prospective memory, as well as for prospective memory tasks that have relatively limited ecological validity. Significant impairment was also evident for both medicated and non-medicated PD sub-groups, but for planning, these deficits were substantially greater in the unmedicated sub-group. The theoretical and practical implications of these findings are discussed.

Effect of 830 nm laser phototherapy on osteoblasts grown in vitro on Biosilicate scaffolds.

OBJECTIVE: The purpose of this study was (i) to develop a method for successfully seeding osteoblasts onto a glass-ceramic scaffold designed for use in clinical settings, and (ii) to determine whether the application of laser phototherapy at 830 nm would result in osteoblast proliferation on the glass-ceramic scaffold. BACKGROUND: The use of bioscaffolds is considered a promising strategy for a number of clinical applications where tissue healing is sub-optimal. As in vitro osteoblast growth is a slow process, laser phototherapy could be used to stimulate osteoblast proliferation on bioscaffolds. METHODS: A methodology was developed to seed an osteoblastic (MC3T3) cell line onto a novel glass-ceramic scaffold. Seeded scaffolds were irradiated with a single exposure of 830 nm laser at 10 J/cm(2) (at diode). Non-irradiated seeded scaffolds acted as negative controls. Cell proliferation was assessed seven days after irradiation. RESULTS: Osteoblastic MC3T3 cells were successfully grown on discs composed of a glass-ceramic composite. Laser irradiation produced a 13% decrease in MC3T3 cell proliferation on glass-ceramic discs (mean +/- SD = 0.192 +/- 0.002) compared with control (non-irradiated) discs (mean +/-SD = 0.22 +/- 0.002). CONCLUSIONS: Despite successful seeding of bioscaffolds with osteoblasts, laser phototherapy resulted in a reduction in cell growth compared to non-irradiated controls. Future research combining laser phototherapy and glass-ceramic scaffolds should take into account possible interactions of the laser with matrix compounds.

Posteroanterior movements in tender and less tender locations of the cervical spine.

In order to determine how posteroanterior movements (PAs) are related to tenderness and thus possibly symptom production, we measured PA movements to a force of 25N on each side of the cervical spines of asymptomatic subjects. From 10 subjects (six females and four males; mean age 37.2, range 21-50), 10 locations with a difference in tenderness to pressure between sides were used for analysis. The force-displacement and stiffness-force curves for tender and control sides were compared in four ways: simultaneous confidence bands (SCBs) for each side; width of SCBs for each side; SCBs of the difference between pairs of the tender and control curves; and simultaneous prediction bands (SPBs) from the tender side were compared to individual curves of the controls. The tender side demonstrated greater variation of both displacement and stiffness. The tender sides demonstrated greater within-subject stiffness for all force levels above 12N. All individual stiffness-force curves of the tender sides were significantly different from the control side. Expected differences in single measures of either displacement or stiffness were not detected. The results suggest that the pattern of stiffness is a more effective method of characterizing PA mobility than single measures used in previous studies.

Postero-anterior movements of the cervical spine: repeatability of force displacement curves.

The repeatability of instrumented assessments of postero-anterior (PA) movements has been reported previously for lumbar and thoracic spines, but only in relation to limited parameters of the movement. This study describes a device for measuring PA movements of the cervical spine and reports on repeatability of the entire force/displacement (FD) curves. Repeatability was assessed using coefficients of multiple determination (CMDs) and adjusted CMDs (where the mean offset between the two curves are removed and the shape of the curve can be more directly assessed) for inter-rater intra-day (inter-rater), intra-rater inter-day (inter-day) and intra-rater intra-day (intra-rater) repeated measurements. The mean CMD and mean adjusted CMD for intra-rater measurements (0.90 and 0.99, respectively) were significantly higher than for the other measurement intervals. Inter-rater and inter-day mean CMDs were 0.76 and 0.73 and mean adjusted CMDs were 0.96 and 0.97. It is concluded that the maximum repeatability is achieved if the same operator reassesses the patient on the same day. It is hoped that the methodology described will form the basis for further research that will enable greater understanding of what characteristics of PA movements inform manual palpation and thereby enable improvement in both manual therapy treatment teaching efficiency of manual therapy skills.

Relation between changes in posteroanterior stiffness and active range of movement of the cervical spine following manual therapy treatment.

STUDY DESIGN: Repeated measures study of active and passive movements in patients with neck pain. OBJECTIVES: To determine if, following manual therapy: (1) changes occur in active range of movement (AROM) and stiffness of posteroanterior (PA) movements, (2) such changes are dependent on the location treated, and (3) there is a relation between changes in PA stiffness and AROM. SUMMARY OF BACKGROUND DATA: PA movements are frequently used to assess patients with neck pain but little is known about how these movements are related to patient symptoms. METHODS: One location deemed symptomatic and hypomobile and 1 asymptomatic location were selected in 20 patients with neck pain for more than 2 weeks. PA stiffness at each location and AROM were measured before and after each of 4 manual therapy interventions: PA movements to each location, a general treatment, and a control intervention. RESULTS: The general intervention had a greater increase in each axis of AROM than the other interventions (F = 2.814 to 7.929, DF = 3) but there were no differences in PA stiffness across interventions (F = 0.945, DF = 3). Differences in PA stiffness was divided into regions by applied force. After treatment to the symptomatic location, regions of stiffness at forces above 8 N demonstrated significant correlations with total AROM (R = -0.466 to -0.628). CONCLUSION: After manual therapy, increased AROM is related to decreased PA stiffness in patients with neck pain, but only for the treated location and only when that location had been identified previously as symptomatic and hypomobile.