Effectiveness of splinting for pain and function in people with thumb carpometacarpal osteoarthritis: a systematic review with meta-analysis.

OBJECTIVE: To examine the effectiveness of splinting for reducing pain and improving function and health-related quality of life (HR-QoL) in people with thumb carpometacarpal osteoarthritis (CMC OA). DESIGN: The Cochrane Library, MEDLINE, Embase, CINAHL, ISI Web of Science, Scopus and Google Scholar, 3 trial registries and 4 conference proceedings were systematically searched for randomised and non-randomised controlled trials up to March 17th, 2018. Two reviewers independently applied the inclusion criteria to select potential studies and assess risk of methodologic bias using the Cochrane Collaboration's Risk of Bias Tool. Studies were pooled using the inverse variance method to calculate standardised mean difference (SMD). Sensitivity analyses were conducted and the quality of evidence for each outcome was judged following the Grades of Recommendation Assessment, Development and Evaluation (GRADE) approach. RESULTS: Twelve studies were retrieved (n = 1353), 4 comparing a splint to control and 8 to another splint. In the medium-term (3-12 months), low quality evidence showed that splints cause a moderate to large reduction in pain (SMD 0.7 [95% confidence interval (CI) 1.04, 0.35], P < 0.0001) and small to moderate improvement in function (SMD 0.42 [95% CI 0.77, 0.08], P = 0.02). No significant effect was found at short-term or for different types of splints. No studies reported HR-QoL. CONCLUSIONS: Splinting demonstrated a moderate to large effect for pain and small to moderate effect for function in the medium-term but not in the short term. Quality of the evidence is low. Major challenges are the lack of diagnostic criteria and of a gold-standard outcome measure for thumb CMC OA.

Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness.

OBJECTIVE: To evaluate the clinical effectiveness of manual physiotherapy and/or exercise physiotherapy in addition to usual care for patients with osteoarthritis (OA) of the hip or knee. DESIGN: In this 2 × 2 factorial randomized controlled trial, 206 adults (mean age 66 years) who met the American College of Rheumatology criteria for hip or knee OA were randomly allocated to receive manual physiotherapy (n = 54), multi-modal exercise physiotherapy (n = 51), combined exercise and manual physiotherapy (n = 50), or no trial physiotherapy (n = 51). The primary outcome was change in the Western Ontario and McMaster osteoarthritis index (WOMAC) after 1 year. Secondary outcomes included physical performance tests. Outcome assessors were blinded to group allocation. RESULTS: Of 206 participants recruited, 193 (93.2%) were retained at follow-up. Mean (SD) baseline WOMAC score was 100.8 (53.8) on a scale of 0-240. Intention to treat analysis showed adjusted reductions in WOMAC scores at 1 year compared with the usual care group of 28.5 (95% confidence interval (CI) 9.2-47.8) for usual care plus manual therapy, 16.4 (-3.2 to 35.9) for usual care plus exercise therapy, and 14.5 (-5.2 to 34.1) for usual care plus combined exercise therapy and manual therapy. There was an antagonistic interaction between exercise therapy and manual therapy (P = 0.027). Physical performance test outcomes favoured the exercise therapy group. CONCLUSIONS: Manual physiotherapy provided benefits over usual care, that were sustained to 1 year. Exercise physiotherapy also provided physical performance benefits over usual care. There was no added benefit from a combination of the two therapies. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry ACTRN12608000130369.

The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review.

BACKGROUND: It has been suggested that health care professional (HCP) attitudes and beliefs may negatively influence the beliefs of patients with low back pain (LBP), but this has not been systematically reviewed. This review aimed to investigate the association between HCP attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of this patient population. METHODS: Electronic databases were systematically searched for all types of studies. Studies were selected by predefined inclusion criteria. Methodological quality was appraised and strength of evidence was determined. RESULTS: Seventeen studies from eight countries which investigated the attitudes and beliefs of general practitioners, physiotherapists, chiropractors, rheumatologists, orthopaedic surgeons and other paramedical therapists were included. There is strong evidence that HCP beliefs about back pain are associated with the beliefs of their patients. There is moderate evidence that HCPs with a biomedical orientation or elevated fear avoidance beliefs are more likely to advise patients to limit work and physical activities, and are less likely to adhere to treatment guidelines. There is moderate evidence that HCP attitudes and beliefs are associated with patient education and bed rest recommendations. There is moderate evidence that HCP fear avoidance beliefs are associated with reported sick leave prescription and that a biomedical orientation is not associated with the number of sickness certificates issued for LBP. CONCLUSION: HCPs need to be aware of the association between their attitudes and beliefs and the attitudes and beliefs and clinical management of their patients with LBP.

Promoting physical activity for individuals with neurological disability: indications for practice.

PURPOSE: This study explored processes that influenced involvement in recreational exercise for individuals with neurological disability, to identify strategies to promote physical activity for health and well-being in this population. METHOD: Nineteen participants (11 males and eight females), aged 20-71 years, with a range of neurological conditions and functional limitations, were recruited in one large metropolitan area in New Zealand. Individual semi-structured interviews explored participants' views, perceptions, and experiences of undertaking recreational exercise. Data were analysed for themes. RESULTS: For some individuals, recreational exercise is undertaken for its physical, psychological, or social benefits, despite the physical activity itself feeling relatively unsatisfactory. In contrast, individuals who are able to undertake their preferred choice of recreational exercise experience intense satisfaction. This motivates self-maintenance of physical activity, even for those individuals who require carer support or assistance to do so. CONCLUSIONS: This study has identified that there can be two forms of involvement in recreational exercise that allows individuals with neurological disability to become more physically active. The information could be further developed and tested in intervention studies to provide strategies for health professionals to facilitate engagement in physical activity for people with neurological disability.

Complementary and alternative medicine: perception and use by physiotherapists in the management of low back pain.

BACKGROUND AND PURPOSE: The aim of this survey was to investigate complementary and alternative medicine (CAM) use by physiotherapists for the treatment of low back pain (LBP). METHODS: Questionnaires (n=1000) were distributed to physiotherapists randomly selected from the UK's Organisation of Chartered Physiotherapists in Private Practice (OCPPP). Results were analysed by SPSS. RESULTS: A response rate of 46% was obtained (n=459). 94.3% of respondents stated that they currently treated LBP; the most common CAMs used by physiotherapists were acupuncture (46.9%) and massage (2.1%). Physiotherapists perceived acupuncture, massage, osteopathy, chiropractic and yoga to be effective in the treatment of LBP, but were unsure about the effectiveness of other CAMs. DISCUSSION AND CONCLUSION: Physiotherapists in this sample often use acupuncture and massage to treat LBP, but appear to have little knowledge of other CAMs. Physiotherapists use mainstream methods such as mobilization and massage which could be perceived as CAM depending on the physiotherapists' perceptions and training, as these therapies have also been used and investigated by CAM practitioners. More research is required on the use of CAM as little is known regarding the effectiveness of these therapies on LBP.

Lower limb injuries in soldiers: feasibility of reduction through implementation of a novel orthotic screening protocol.

At any one time, 10% of personnel within the New Zealand Army are affected by injuries caused by inadequate footwear. The purpose of this study was to assess the feasibility of addressing this problem by orthotic issue on the basis of a novel screening protocol. A total of 909 military personnel were included in this study. Data were collected over 3 months, and injuries of interest included stress fractures of the lower limb, foot, or back; chronic pain or discomfort in the hip, knee, or lower back; overuse injury in the ankle, knee, or hip; and plantar fasciitis. A novel screening protocol was used to prescribe orthotics (n = 47/102) as a preventative measure in a cohort of recruits. All injuries were significantly reduced (p = 0.000) in the intervention group compared to control, with the exception of stress fracture of the femur and overuse lower limb injury (p = 0.106 and p = 0.108, respectively).

The relationship between physical activity and low back pain outcomes: a systematic review of observational studies.

Although clinical guidelines advocate exercise and activity in the management of non-specific low back pain (NSLBP), the link between levels of physical activity and outcomes is unclear. This systematic review investigated the relationships between free living activity levels after onset of low back pain (LBP) and measures of pain, and disability in patients with NSLBP. Cohort and cross-sectional studies were located using OVID, CINAHL, Medline, AMED, Embase, Biomed, PubMed-National Library of Medicine, Proquest and Cochrane Databases, and hand searches of reference lists. Studies were included if a statistical relationship was investigated between measures of free living physical activity (PA) in subjects with LBP and LBP outcome measures. Twelve studies (seven cohort and five cross-sectional) were included. One prospective study reported a statistically significant relationship between increased leisure time activity and improved LBP outcomes, and one cross-sectional study found that lower levels of sporting activity were associated with higher levels of pain and disability. All other studies (n = 10) found no relationship between measures of activity levels and either pain or disability. Heterogeneity of study designs, particularly in terms of activity measurement, made comparisons between studies difficult. These data suggest that the activity levels of patients with NSLBP are neither associated with, nor predictive of, disability or pain levels. Validated activity measurement in prospective research is required to better evaluate the relationships between PA and LBP.

The vastus lateralis muscle: an anatomical investigation.

Anterior knee pain or patellofemoral pain syndrome is commonly encountered by clinicians, but the pathogenesis of this condition is not well understood. While much research has centred around the relationship between vastus medialis and anterior knee pain, little is known about the most lateral of the quadriceps muscle group, vastus lateralis (VL). Knowledge of the anatomical organization of VL is not only necessary to understand its precise function, but to also assist in the development of clinical and biomechanical models of knee dysfunction. The purpose of this study was to investigate the detailed morphology of VL, specifically to provide data relating to architecture, attachment sites, innervation, and the presence of anatomical partitioning within the muscle. The VL muscle was examined in 10 cadaveric lower limbs using macrodissection techniques. On the basis of architecture and innervation, this muscle comprised four partitions with each receiving its own unique nerve branch. The mean fascicular length of VL was 7 cm and the mean fascicular and muscle physiological cross-sectional areas were 1.2 cm(2) and 21.6 cm(2), respectively. In addition to inserting proximally at the base of the greater trochanter and distally into the superolateral border and base of the patella, three additional attachment sites were identified: the lateral intermuscular septum, iliotibial band, and the rectus tendon. The results of this study suggest that the gross morphology of VL is more complex than previously described, and the information provided regarding architecture will contribute to knowledge regarding the function of VL as well as its role in knee joint dysfunction.

Eccentric exercise protocols for chronic non-insertional Achilles tendinopathy: how much is enough?

Eccentric exercises for the calf muscles have been shown to be effective for chronic non-insertional Achilles tendinopathy (AT). However, the relative effectiveness of various dosages is unknown. A systematic review of randomized-controlled trials (RCTs) was designed to determine whether an optimum dose of eccentric exercises could be recommended. Three selected RCTs showed positive effects of very similar eccentric exercise protocols for chronic non-insertional AT. Owing to insufficient reported compliance data, a conclusion on the relative effectiveness of various compliances was not feasible. According to our review, the relative effectiveness of various dosages of eccentric exercises for AT is still unclear. However, it appears that highly variable compliance rates result in similar positive outcomes; these findings, therefore, highlight the need for further investigations.

Acupuncture for acute non-specific low back pain: a pilot randomised non-penetrating sham controlled trial.

OBJECTIVE: A pilot study to assess the feasibility of a trial to investigate the efficacy of acupuncture compared to placebo needling for the treatment of acute low back pain (LBP). As part of this, the study was designed to establish the credibility of the placebo control, and to provide data to inform a power analysis to determine numbers for a future trial. STUDY DESIGN: A pilot patient and assessor blinded randomized controlled trial. SETTING: Primary care health centre facility, South and East Belfast Trust, Northern Ireland. PATIENTS: Patients from the physiotherapy waiting list (n=48) with LBP of less than 12 weeks duration. OUTCOME MEASURES: Roland and Morris Disability Questionnaire (RMDQ), Visual Analogue Scale (VAS), medication use and an exit questionnaire were completed at baseline, end of treatment, and at 3 months follow up. RESULTS: Ninety-four percent (45/48) of patients completed assigned treatment, 83% (40/48) completed 3 months follow-up. The sham needle used here proved to be credible: 91.7% in the placebo group believed they had received acupuncture, compared to 95.8% in the verum acupuncture group. Differences in baseline characteristics were accounted for using ANCOVA. There was no significant difference between groups on the RMDQ over time. For pain, the only statistically significant difference was at the 3 months follow up (worst VAS, point estimate, 18.7, 95% CI 1.5-36.0, p=0.034). The majority of patients were taking some form of analgesic medication for LBP at the start of treatment (n=44; 92%), and at the end of treatment the verum acupuncture group were taking significantly fewer tablets of pain control medication (mean (S.D.): 1.0+/-0.3) than the placebo group (mean (S.D.): 4.2+/-0.6, p<0.05). Based upon these data, power analysis (power=90%, alpha=0.05, minimal clinically important difference (MCID) for RMDQ=2.5 points) indicated that 120 participants (60 per group) would be needed to complete an adequately powered randomized controlled trial. CONCLUSIONS: This study has demonstrated the feasibility of a randomized controlled trial of penetrating needle acupuncture compared to a non-penetrating sham for the treatment of acute LBP in primary care; 120 participants would be required in a fully powered trial. The placebo needle used in this study proved to be a credible form of control.

Doctors' attitudes and beliefs regarding acute low back pain management: A systematic review.

The aim of this systematic review was to determine the attitudes and beliefs of doctors to acute low back pain, and the factors that influence these. The review comprised three phases: a methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified potential papers; these were screened for inclusion criteria by two independent reviewers, the extraction of data and the rating of internal validity and strength of the evidence, using valid and reliable scales from accepted papers. Themes were then identified from the accepted literature. The search generated a total of 15 papers of both qualitative (n=3) and quantitative (n=12) methodologies. Themes that emerged included doctors' attitudes and beliefs, and four factors that influenced attitudes and beliefs: doctors' specialty, demographic factors, personal beliefs and education. There was consistent evidence that doctors' specialty impacted their attitudes and beliefs: lack of consensus regarding the natural history of LBP, around treatment options, and issues regarding work. There was inconsistent evidence that demographic factors (age) and level of education impacted doctors' attitudes and beliefs. Strategies to address/ modify these attitudes and beliefs are required, as in some cases they are at odds with guideline recommendations. Long term, these changes in these areas have the potential to maximise patient-care, and reduce costs to health services.

Exercise and manual auricular acupuncture: a pilot assessor-blind randomised controlled trial. (The acupuncture and personalised exercise programme (APEP) trial).

BACKGROUND: Evidence supports the use of exercise for chronic low back pain (CLBP); however, adherence is often poor due to ongoing pain. Auricular acupuncture is a form of pain relief involving the stimulation of points on the outer ear corresponding with specific body parts. It may be a useful adjunct to exercise in managing CLBP; however, there is only limited evidence to support its use with this patient group. METHODS/DESIGN: This study was designed to test the feasibility of an assessor-blind randomised controlled trial which assess the effects on clinical outcomes and exercise adherence of adding manual auricular acupuncture to a personalised and supervised exercise programme (PEP) for CLBP. No sample size calculation has been carried out as this study aims to identify CLBP referral rates within the catchment area of the study site. The researchers aim to recruit four cohorts of n = 20 participants to facilitate a power analysis for a future randomised controlled trial. A computer generated random allocation sequence will be prepared centrally and used to allocate participants by cohort to one of the following interventions: 1) six weeks of PEP plus manual auricular acupuncture; 2) six weeks of PEP alone. Both groups will also complete a further six weeks of self-paced exercise with telephone follow-up support. In addition to a baseline and exit questionnaire at the beginning and end of the study, the following outcomes will be collected at baseline, and after 7, 13 and 25 weeks: pain frequency and bothersomeness, back-specific function, objective assessment and recall of physical activity, use of analgesia, perceived self-efficacy, fear avoidance beliefs, and beliefs about the consequences of back pain. Since this is a feasibility study, significance tests will not be presented, and treatment effects will be represented by point estimates and confidence intervals. For each outcome variable, analysis of covariance will be performed on the data, conditioning on the baseline value. DISCUSSION: The results of this study investigating the adjuvant effects of auricular acupuncture to exercise in managing CLBP will be used to inform the design of a future multi-centre randomised controlled trial. TRIAL REGISTRATION: Current Controlled Trials ISRCTN94142364.

Reflexology in the management of low back pain: a pilot randomised controlled trial.

OBJECTIVE: The current study was designed as a pilot study for a randomised controlled trial to investigate the effectiveness of reflexology in the management of low back pain (LBP). MATERIALS AND METHODS: Participants suffering non-specific LBP were recruited and randomised into either a reflexology or a sham group. Patients and outcome assessor were blinded to group allocation. Each patient received either a 40 min reflexology treatment or sham treatment (according to group allocation) once per week for six consecutive weeks. The primary outcome measure was pain (visual analogue scale), secondary outcome measures were the McGill pain questionnaire, Roland-Morris disability questionnaire, and SF-36 health survey. Outcome measures were performed at baseline, week 6, week 12 and week 18. RESULTS: VAS scores for pain reduced in the treatment group by a median value of 2.5 cm, with minimal change in the sham group (0.2 cm). Secondary outcome measures produced an improvement in both groups (McGill pain questionnaire: 18 points in the reflexology group and 11.5 points in the sham group). Results indicate that reflexology may have a positive effect on LBP. CONCLUSION: Reflexology appears to offer promise as a treatment in the management of LBP; however, an adequately powered trial is required before any more definitive pronouncements are possible.

Complementary therapies in the management of low back pain: a survey of reflexologists.

OBJECTIVE: To investigate current management of low back pain (LBP) by reflexologists. METHODS: A postal survey of reflexologists (n=500) sampled from the International Institute of Reflexology. The questionnaire used investigated a range of areas including: professional details, reflexology training and practice, views and experiences of reflexology, reflexology and LBP, and views on other complementary therapies. RESULTS: Response rate was 49.6% (n=248). The majority of respondents were female (95%), and were primarily employed within another profession such as nursing or teaching. Respondents perceived reflexology to have a positive effect on relieving LBP (94.3%) and to provide more benefit than simply relaxation. Practitioners also commented on other treatment effects, e.g. improving sleep patterns, decreasing anxiety and stress. It was reported that other healthcare practitioners, including general practitioners, referred patients to reflexologists for treatment. DISCUSSION: Respondents considered reflexology to be an effective therapy for LBP. Further work is warranted to investigate the potential role of such treatment in the management of this prevalent and intractable condition.

Tender point count and total myalgic score in fibromyalgia: changes over a 28-day period.

Tender point count (TPC) is central to fibromyalgia syndrome (FMS), and with total myalgic score (TMS) is often used to monitor the patient's condition. This study aimed to determine the stability of TPC and TMS over time, and to examine how well these measures reflected patients' perceptions of their condition. Twenty-four patients with FMS completed the Fibromyalgia Impact Questionnaire (FIQ) and a visual analogue scale (VAS) measuring well-being, at entrance into the study, and 7 and 28 days later. There was no significant change in TPC (P = 0.074), FIQ score (P = 0.291) or VAS (P = 0.079) of well-being with time. However, mean TMS score did change over time (P = 0.021). There was no correlation between total FIQ score and the other measures (all P-values > 0.05). The significant change in TMS over time may reflect the natural fluctuation in the clinical presentation of FMS.

Caregivers of people with multiple sclerosis: experiences of support.

The aim of this phenomenological study was to gain an understanding of the experiences of a group of caregivers of people with multiple sclerosis (MS). Sixteen caregivers from Northern Ireland and the Republic of Ireland participated in focus group interviews. The theme of support, either sought or received, emerged as a major aspect of the experiences described. Caregivers' feelings about, and experiences of, support appeared to change over time. Four common phases that caregivers experienced in relation to support were identified as: 'rejecting', 'resisting, 'seeking' and 'accepting' support. This paper will present and discuss these four phases. The study findings highlight the complexity of issues surrounding a caregiver's decision to seek and accept support. It is hoped that the phases identified within this study are useful in depicting how caregivers of people with MS may progress through stages in their desire for, and acceptance of support. Findings from this study are useful to healthcare professionals who work with people with MS and their caregivers by increasing awareness that a caregiver's attitude toward and acceptance of support changes over time.

Explanations for the smoking paradox in Japan.

The prevalence of cigarette smoking among Japanese men has been consistently high compared with Western males over the past 30 years. However, during the same period, the incidence of and mortality rates for lung cancer have consistently been lower in Japan than in Western countries ('Japanese smoking paradox'). The odds ratio/relative risk of cigarette smoking for lung cancer mortality/incidence relative to the same number of cigarettes smoked per capita in Japan, were apparently lower than those in Western countries. This must be the cause driving the 'Japanese smoking paradox'. Furthermore, low carcinogenic ingredients in Japanese cigarettes and a congenitally-related resistance to smoking-related lung carcinogenesis emerged as the main factors which have brought the 'Japanese smoking paradox'.

The needs and experiences of caregivers of individuals with multiple sclerosis: a systematic review.

PRIMARY OBJECTIVE: To appraise recent studies regarding the needs and experiences of caregivers of individuals with multiple sclerosis (MS). DESIGN: The following computerized databases were searched: CINAHL, BIDS IBSS, ASSIA, MEDLINE, PSYCHINFO, British Nursing Index, ISI Web of Science, Zetoc, AMED (1990-April 2002). The computer-based search was supplemented by manual searches of the reference lists of all retrieved studies and review articles. Inclusion and exclusion criteria were formulated. RESULTS: Twenty-four studies from across the world that met the inclusion criteria were reviewed. The majority of studies were descriptive in nature. The studies covered a variety of topics, including how carers assist people with MS, the effect of providing care on a carer's physical and psychological well-being, social life, financial situation and overall quality of life, and how carers cope with the stresses of providing care. CONCLUSIONS: Providing care for a person with MS has a major impact on all areas of the caregiver's life. Perceived social support has been shown to have a beneficial impact on the caregiver. Limitations in design and variation in methodology of studies limits the generalizability of findings. There is a need for further research, in particular the development of reliable and valid disease-specific caregiver assessment instruments.

Clinical guidelines versus clinical practice in the management of low back pain.

To date, there have been limited data on the implementation of evidenced-based clinical guidelines for low back pain (LBP). The aim of this study was to assess current management of LBP and evaluate to what extent clinical practice now reflects clinical guidelines. This survey involved the collection and analysis of data from the records of 200 patients who had been referred to a large teaching hospital with LBP Analysis indicated a high use of X-rays, with little evidence of initial biopsychosocial assessment. The most popular treatments were advice, active exercises and McKenzie therapy. Manipulation was rarely used. Overall, a low use of electrotherapy was recorded. The results emphasise how little the clinical guidelines have influenced the decisions of clinicians, and highlight the need to address the barriers to adopting an evidence-based approach in this area.