Efficacy of Conservative Interventions for Musculoskeletal Conditions on Pain and Disability in Active Serving Military Personnel-A Systematic Review.

INTRODUCTION: Musculoskeletal (MSK) injuries and associated pain disorders are one of the leading causes for soldiers not being medically fit for deployment, impacting force capability and readiness. Musculoskeletal pain continues to be a leading cause of disability within military services and is associated with a substantial financial burden. A better understanding of the effectiveness of MSK pain management strategies is required. This review was designed to determine the efficacy of nonsurgical interventions, such as physiotherapy, exercise, pharmacology, and multidisciplinary programs, to manage MSK conditions in active serving military populations. MATERIALS AND METHODS: MEDLINE, Embase, CINAHL, and SPORTDiscus were searched to identify relevant randomized clinical trials. Recommended methods were used for article identification, selection, and data extraction. The Cochrane Risk of Bias tool and the Grade of Recommendation, Assessment, Development, and Evaluation were used to appraise the studies. Where possible, meta-analyses were performed. The review was conducted according to the PRISMA guidelines. RESULTS: Nineteen articles (1,408 participants) met the eligibility criteria. Low back pain (LBP) was the most frequently investigated condition, followed by knee pain, neck pain, and shoulder pain. Early physiotherapy, exercise and adjunct chiropractic manipulation (for LBP), and multidisciplinary pain programs (physiotherapy, occupational therapy, and psychology) (for chronic MSK pain) improved pain (standardized mean difference ranged from -0.39 to -1.34; low strength of evidence). Participation in multidisciplinary pain programs, adjunct chiropractic manipulation, and early physiotherapy improved disability (for LBP) (standardized mean difference ranged from -0.45 to -0.86; low to very low strength of evidence). No studies evaluated pain medication. Dietary supplements (glucosamine, chondroitin sulfate, and manganese ascorbate), electrotherapy, isolated lumbar muscle exercises, home cervical traction, or training in virtual reality showed no benefit. The studies had a high risk of bias, were typically underpowered, and demonstrated high clinical heterogeneity. CONCLUSIONS: Currently available randomized clinical trials do not provide sufficient evidence to guide military organizations or health care professionals in making appropriate treatment decisions to manage MSK pain in active serving military personnel. Future research is essential to enable evidence-based recommendations for the effective management of MSK pain conditions in this unique population.

Patient experiences of referral practices and primary care physiotherapy for chronic nonspecific low back pain.

BACKGROUND: Low back pain (LBP) clinical practice guidelines recommend referral for patients with persistent LBP however discordance persists between recommended care and implementation in practice. Understanding patient experiences of referral practices and physiotherapy care could be important for optimizing LBP management in primary care settings. PURPOSE: This study explored referral experiences of people with nonspecific LBP in Australian primary care and their knowledge and experience of physiotherapy. METHODS: An interpretive descriptive qualitative framework was used with 17 participants interviewed from community-based physiotherapy practices. RESULTS: Four themes described the participants' experiences of referrals in primary care settings: 1) Referral practices ranged from formal to informal to non-existent; 2) Fragmented inter-and intra-professional LBP care management; 3) Patient perceived differences in the roles of physiotherapists and specialist physiotherapists; and 4) Patient nominated barriers and facilitators to optimal referral practices. CONCLUSION: Physiotherapists support people with LBP to improve strength and function, whereas the specialist physiotherapist's role was seen as more holistic. Referral pathways that align to clinical guideline recommendations for non-surgical management and treatment remain underdeveloped. Improved referral pathways to clinicians such as physiotherapists with additional credentialed skills and competence in musculoskeletal care could improve people's experiences of care and health outcomes.

Patient perspectives of care pathways for people with low back pain: A qualitative study.

BACKGROUND: Low back pain (LBP) care pathways aim to enhance health outcomes through patient-clinician mutual decision-making and care coordination. However, challenges to successful translation into practice include patients' understanding, expectation, and acceptance of treatment and management strategies for LBP. This study explored patients' perspectives and/or experience of care pathways and their involvement in decision-making in primary care. METHODS: A qualitative descriptive design was adopted. Semi-structured interviews were conducted with 14 participants with LBP recruited from the community. Inductive thematic analysis of the qualitative data was conducted within the design framework to enable a systematic comparison of experiences across participants and within individual cases. RESULTS: Five themes described participant perspectives and understanding of care pathways: i) care pathways can guide decision-making; ii) familiarity with no and/or stepped care pathway, but preference for matched or blend of care pathways; iii) engaging in shared decision-making; iv) patient-related barriers to implementation; v) patient-related facilitators to implementation. CONCLUSIONS: Participants felt that existing care pathways did not meet their needs when pain persisted. Participants preferred matched or hybrid care pathways and suggested that implementation of such pathways should focus on addressing an individual's needs. Adopting a holistic approach, and clarity in shared decision-making, were deemed crucial for effective implementation of LBP pathways in practice. Consumer (patient) engagement in the design of LBP care pathways is recommended.

Investigating the effects of mobilization with movement and exercise on pain modulation processes in shoulder pain - a single cohort pilot study with short-term follow up.

OBJECTIVE: To explore the association between manual therapy and exercise and pain modulation and clinical characteristics in people with musculoskeletal shoulder pain. METHODS: This is a prospective, longitudinal, single cohort pilot study. People with shoulder pain for longer than 6 weeks underwent 4 weeks of glenohumeral mobilization with movement and shoulder exercises. Measures of pain modulation, shoulder pain, disability, range of motion and psychosocial factors were assessed at baseline and immediately after the 4-week period of treatment. Treatment effectiveness was assessed through parametric, non-parametric and multilevel modeling statistics. RESULTS: Twenty-three individuals participatedwith no loss to follow-up. Significant and meaningful improvements in shoulder pain (NRS mean change 1.6/10, 95% CI 0.4 to 2.7), disability (SPADI mean change 20.5/100, 95% CI 13.1 to 27.9) and range of motion (mean change 33°, 95% CI 23 to 43°) were observed following treatment. Statistical but non-clinically meaningful changes were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55). Significant reductions were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55), however these were not considered clinically important. No association was found between clinical characteristics and sensory measures. No association was found between clinical characteristics and sensory measures. CONCLUSION: Glenohumeral mobilization with movement and exercise did not improve pain modulation, despite improvements in pain, function and range of motion, in people with shoulder pain.

Localised manual therapy treatment has a preferential effect on the kinematics of the targeted motion segment.

AIM: An observational cohort study to determine whether localised manual therapy results in a preferential increase in mobility of the targeted motion segment. METHOD: Eighteen participants with mechanical neck pain had three MRIs of their cervical spine. The first two were taken prior to treatment in neutral and at the end of active rotation in their more limited rotation. Participants received localised manual therapy targeting a motion segment deemed to be relevant to their presentation until either their range increased by > 10° or 8 min, whichever came first. A third MRI was performed immediately after treatment with their head in the same rotated position as pre-treatment. In the images, each vertebra was segmented using a semi-automated process. Movement between neutral and rotated positions was calculated as Euler angles and distance of facet translations for each motion segment. RESULTS: Rotation and lateral flexion at the targeted location increased by 40% (mean 0.86° (CI: 0.24-1.48) and 15% (mean 0.52° (CI: 0.17-1.21) respectively with only the CIs for rotation not containing zero. The mean changes for the non-targeted locations were less than 0.1° for each axis and all CIs contained zero. Facet translations at the targeted location increased by 25% (0.419 mm) and decreased by >4% (>0.01 mm) at the untreated locations but the wide CIs both contained zero. CONCLUSION: Localised manual therapy seems to have a preferential effect on mobility of the targeted motion segment. The findings support considering segmental dysfunction in clinical reasoning and the use of specifically targeted manual therapy interventions.

The association of concussion history and symptom presentation in combat sport athletes.

OBJECTIVE: The purpose of this study was to describe the concussion-related symptoms reported among combat sport athletes with and without a history of concussion, and a history of neck injury. DESIGN: Cross-sectional survey. SETTING: Data were collected using an online survey instrument. PARTICIPANTS: Three hundred and nine adult combat sport athletes. MAIN OUTCOME MEASURES: Self-reported 12-month concussion history and neck injury history and a 22-item symptom checklist. RESULTS: A history of concussion was reported by 19.1% of athletes, a history of neck injury was reported by 23.0%, and 13.6% reported both injuries. Neck pain was the most frequently reported symptom. Athletes with a history of injury had significantly greater proportions of 'high' total symptoms and symptom severity scores compared with athletes with no history of injury. Athletes with a history of concussion had 2.35 times higher odds of reporting 'high' total symptoms and symptoms severity scores. CONCLUSION: Athletes with a history of concussion or neck injury have greater odds of presenting with higher symptom scores. The presence of high total symptom scores and high symptom severity scores may indicate a need for further investigation into domains commonly associated with concussion.

Reliability of 2 protocols for assessing pressure pain threshold in healthy young adults.

OBJECTIVE: The purposes of this study were to determine whether there were differences in mean values or reliability for 2 frequently used protocols for pressure pain threshold (PPT) and to calculate how large a difference in PPT is necessary to be 95% confident that a real change has occurred. METHODS: Thirteen participants (8 females) aged 22.3 (±2.3) years from a university community were included. Two testers evaluated participants using 2 protocols, in which PPT was measured 3 times at 8 different body locations. The "cluster protocol" consisted of 3 successive measurements at each location with a 30-second rest between each measurement. The "circuit protocol" consisted of 1 measurement taken at each anatomical location until "the circuit" was complete and then repeated a total of 3 times. RESULTS: A 2-way analysis of variance did not reveal significant differences between protocols at any body location (P = .46-.98). Intertester reliability was good to excellent for all locations (intraclass correlation coefficient, 0.84-0.96), and limits of agreement ranged from 108 to 223 kPa. CONCLUSIONS: Either the cluster or circuit protocol can be used to measure PPT in clinical or research setting. A difference of 160 kPa is considered sufficient to indicate a real difference between repeated measures of PPT regardless of protocol used for testing.

Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial.

OBJECTIVE: To compare the effectiveness and cost-effectiveness of eccentric loading exercises (ELE) with prolotherapy injections used singly and in combination for painful Achilles tendinosis. DESIGN: A single-blinded randomised clinical trial. The primary outcome measure was the VISA-A questionnaire with a minimum clinically important change (MCIC) of 20 points. SETTING: Five Australian primary care centres. PARTICIPANTS: 43 patients with painful mid-portion Achilles tendinosis commenced and 40 completed treatment protocols. INTERVENTIONS: Participants were randomised to a 12-week program of ELE (n=15), or prolotherapy injections of hypertonic glucose with lignocaine alongside the affected tendon (n=14) or combined treatment (n=14). MAIN OUTCOME MEASUREMENTS: VISA-A, pain, stiffness and limitation of activity scores; treatment costs. RESULTS: At 12 months, proportions achieving the MCIC for VISA-A were 73% for ELE, 79% for prolotherapy and 86% for combined treatment. Mean (95% CI) increases in VISA-A scores at 12 months were 23.7 (15.6 to 31.9) for ELE, 27.5 (12.8 to 42.2) for prolotherapy and 41.1 (29.3 to 52.9) for combined treatment. At 6 weeks and 12 months, these increases were significantly less for ELE than for combined treatment. Compared with ELE, reductions in stiffness and limitation of activity occurred earlier with prolotherapy and reductions in pain, stiffness and limitation of activity occurred earlier with combined treatment. Combined treatment had the lowest incremental cost per additional responder ($A1539) compared with ELE. CONCLUSIONS: For Achilles tendinosis, prolotherapy and particularly ELE combined with prolotherapy give more rapid improvements in symptoms than ELE alone but long-term VISA-A scores are similar. TRIAL REGISTRATION NUMBER: ACTRN: 12606000179538.