Active Physiotherapy Research Articles

Comparison the Effect of Active Cyclic Breathing Technique and Routine Chest Physiotherapy on Pain and Respiratory Parameters After Coronary Artery Graft Surgery: A Randomized Clinical Trial.

BackgroundThere are limited reports available on preferred chest physiotherapy methods in patients with coronary artery graft (CABG) surgery.ObjectivesThe aim of this study was to compare the effect of active cyclic breathing technique (ACBT) and routine chest physiotherapy on pain and respiratory parameters in patients undergoing CABG surgery.MethodsThis randomized clinical trial was carried out from July to November 2018. Seventy patients were selected randomly after CABG according to inclusion criteria and then assigned in two groups (35 in ACBT and 35 in routine physiotherapy) by random minimization method. The arterial blood gas levels, pain, heart rate, and respiratory rate were measured for both groups before and after the intervention on two consecutive days after surgery. Data were analyzed by SPSS software V.22, at a significance level of 0.05.ResultsThe two groups were similar in terms of demographic variables. In within group comparison in the physiotherapy group, the level of PaO2, HR, RR, and pain increased significantly on both days (P = 0.001), SaO2 on the first day (P = 0.005) and second day (P = 0.001), and PaCO2 on the first day (P = 0.02). In ACBT group, the level of SaO2, HR, RR, and pain increased significantly on both days (P = 0.001), HCO3 on the first day (P = 0.021), and PaO2 on the second day (P = 0.001) post intervention. In between group comparison, on the first day, the level of PH (P = 0.034), and on the second day HCO3 (P = 0.032) decreased, while RR (P = 0.011) increased significantly in the physiotherapy group, at post-intervention phase.ConclusionsACBT and routine physiotherapy had similar effects on arterial oxygenation, HR, and pain perception following CABG surgery. The physiotherapy on the second day increased the RR to an abnormal range.

Functional outcome of surgical management of distal end humerus fractures in adults: A prospective study

Introduction: Distal humerus fractures are uncommon injuries that account for fewer than 2%of all adult fractures. The aim of the study is to evaluate the functional outcome of the surgical management of distal humerus fractures in adults treated by various methods using the postoperative functional criteria by Riseborough and Radin.Materials and Methods: A Prospective clinical study was conducted over a period of 2 years which included 20 patients in tertiary care centre. The patients were treated with primary open reduction and internal fixation.Results: The average age of the patients in our study was 35.8 years with a range of 23-53 years. In our series, according the Riseborough and Radin criteria, the results were good in 50% patients, Fair in 35% and Poor in 15% patients.Conclusion: Operative treatment with rigid anatomical internal fixation should be the first line of treatment for all grades of Riseborough Radin intercondylar fractures, more so in young adults as it gives best chance to achieve good elbow function. Vigorous, active physiotherapy is a must for good results. Stable fixation allows early, active and aggressive post-operative mobilization.

Concentrated Bone Marrow Aspirate Injection for Hallux Sesamoid Disorders

Category:Midfoot/Forefoot, SportsIntroduction/Purpose:Sesamoidectomy is the most common surgical procedure for the treatment of hallux sesamoid pathology, including fracture, acute separation of bipartite sesamoid, sesamoiditis, and avascular necrosis (AVN). However, there is a concern of complications following sesamoidectomy, such as the development of hallux valgus/varus and transfer metatarsalgia due to the altered mechanical loading on the forefoot. Recent systematic review showed high complication rate of 22.5% following sesamoidectomy, prompting surgeons to find alternative methods. Concentrated bone marrow aspirate (CBMA) may have the potential to treat sesamoid disorders with avoidance of sesamoid resection. However, there is no studies investigating the effect of CBMA for sesamoid disorders. The purpose of this study was to evaluate the functional outcomes following the use of CBMA for hallux sesamoid disorders.Methods:A retrospective cohort study investigating consecutive patients treated with CBMA injection for the treatment of sesamoid disorders were performed. The sesamoid disorders included sesamoiditis, symptomatic bipartite or chronic nonunited sesamoid and AVN. The CBMA injection was indicated for patients with failed a minimum of 3 months non-surgical management including activity limitation, customized orthotics, physiotherapy and extracorporeal shockwave therapy. Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS), Short-Form 12 (SF-12), and visual analog scale (VAS) scores preoperatively and at final follow-up.Results:Total of 13 feet were included. The mean age was 26.9 years and mean follow-up time was 19.1 months. Patient demographic is shown in Table 1. Mean symptoms, pain, daily activities, sports activities and quality of life scores in FAOS significantly improved from 63.9, 55.4, 68.4, 37.3, and 30.9 preinjection to 91.2, 84.1 92.9, 72.7, and 64.8 postinjection, respectively at final follow-up (p<0.001). The mean SF-12 and VAS score significantly improved (34.3 to 62.5, 5.7 to 1.5, respectively, p<0.001). Of 9 patients played sports at preinjection, 7 patients returned to play at previous level. Two patients failed the treatment. One had second-CBMA injection and final VAS score was 1.0. Another one required subsequent shockwave-therapy followed by platelet-rich plasma injection with final VAS score of 1.5.Conclusion:No complications and adverse effects were reported in this cohort. In addition, no patients had any signs of progression or new emerge of AVN on plain radiographs. The current study demonstrates that CBMA injection is a safe and effective treatment for hallux sesamoid disorders when conservative treatment fails, with avoidance of sesamoid resection. CBMA injection can be a valid alternative for the treatment of sesamoid disorders, as it permits preservation of the biomechanical stability provided by the sesamoids which is an element inevitably vital for long-term quality of life. Further studies investigating long-term effects of this treatment should be warranted.

Efficacy and early results after combining laparoscopic harvest of double gastroepiploic lymph node flap and active physiotherapy for lower extremity lymphedema.

Lymph node flap transfer has gradually gained popularity for the treatment of upper and lower limb lymphedema. The aim of this study is to present the outcomes of an integrated treatment protocol based on double gastroepiploic lymph node flap (DG-VLN) and active physiotherapy in patients affected by Stage II and III lower extremity lymphedema. All Stage II and III lower limb lymphedema patients operated between September 2015 and December 2017 were retrospectively identified and only those treated with an integrated approach of DG-VLN flap and active physiotherapy were included. Outcomes were assessed clinically with limb circumference measurement and radiologically with lymphoscintigraphy. Flap viability was evaluated through indocyanine green lymphography. Lymphedema related quality of life was evaluated preop and at 1 year follow up through LYMQOL questionnaire. Sixteen patients met inclusion criteria. Mean follow up was 26.2 months. Significant reduction in lower limb volume was observed for all patients from pre to post intervention. At 3 months of follow up, the mean CRR was 42.4% at below knee (BK) level and 25.4% at above knee (AK) level. At 12 months of follow up, the mean CRR was 58.3% at BK level (p = .001*) and 43.4% at AK level (p < .04*). LYMQOL metrics showed significantly better scores in all domains. Patients with lower limb lymphedema can benefit from combined DG-VLN flap and active physiotherapy, as this approach seem to fasten the onset of improvement and to have a positive impact on patients' quality of life.

Pragmatic cluster randomised double-blind pilot and feasibility trial of an active behavioural physiotherapy intervention for acute non-specific neck pain: a mixed-methods protocol

IntroductionNon-specific neck pain causes pain and disability and contributes substantial socioeconomic burden internationally. Up to 50% of adults experience neck pain annually, leading to reduced the quality of life. An...

Distraction osteogenesis in the management of mandibular hypoplasia secondary to temporomandibular joint ankylosis. Long term follow up

PurposeThe aim of this retrospective study was to evaluate the short-term and long-term skeletal and soft-tissue stability after MDO with or without genioplasty, as well as the stability of the achieved maximum inter-incisal opening (MIO) in patients with mandibular hypoplasia secondary to TMJ ankylosis. Patients and methodsTwenty patients with mandibular hypoplasia secondary to TMJ ankylosis were managed by a two-stage surgical protocol, gap arthroplasty as the first stage, followed by MDO. The patients were analyzed for skeletal and soft-tissue stability as well as the maintenance of the achieved MIO. Lateral cephalograms were evaluated at four time intervals: pre-distraction (T1), after a consolidation period with or without genioplasty (T2), after one year following consolidation (T3), and at the longest follow-up (T4). Statistical analyses compared the skeletal and soft-tissue changes at different intervals in every group. ResultsAll the ankylosed joints except three were treated with gap arthroplasty without costochondral graft. The MIO was increased from 8.2 ± 2.1 mm preoperatively to 40.2 ± 1.7 mm postoperatively. After the consolidation period, MIO decreased to 23 ± 6.5 mm. The patients were instructed to restart active physiotherapy after removal of the distractors to regain the pre-distraction MIO, which was maintained during the short-term follow-up. The mean follow-up period was 8.5 ± 1.5 years. At the end of the follow-up, two patients showed recurrence of ankylosis. Cephalometric analysis revealed great improvements in the hard- and soft-tissue structures after MDO with or without genioplasty. Several significant long-term relapses could be observed in all groups; however, they did not reach their pre-operative values. ConclusionTMJ ankylosis leads to severe, multidirectional mandibular hypoplasia, which is significantly corrected with the MDO. The MDO provides a stable short-term improvement in the facial esthetics at the first postoperative year, but a significant relapse occurs during the long term follow-up. Nevertheless, a satisfied facial esthetic is maintained for up to seven to 12 years postoperatively. During the activation period, the MDO minimizes the gained MIO after release of ankylosis, but the MIO is successfully restored with physiotherapy.

Exercise for improving outcomes after osteoporotic vertebral fracture.

Exercise for improving outcomes after osteoporotic vertebral fracture.

A cluster randomised, double-blind pilot and feasibility trial of an active behavioural physiotherapy intervention for acute whiplash-associated disorder (WAD)II

Whiplash-associated disorder (WAD) causes substantial social and economic burden, with ≥70% patients classified as WADII (neck complaint and musculoskeletal sign(s)). Effective management in the acute stage is required to prevent development of chronicity; an issue for 60% of patients. An Active Behavioural Physiotherapy Intervention (ABPI) was developed to address both physical and psychological components of WAD. The ABPI is a novel complex intervention designed through a rigorous sequential multiphase project to prevent transition of acute WAD to chronicity. An external pilot and feasibility cluster randomised double-blind (assessor, participants) parallel two-arm clinical trial was conducted in the UK private sector. The trial compared ABPI versus standard physiotherapy to evaluate trial procedures and feasibility of the ABPI for managing acute WADII in preparation for a future definitive trial. Six private physiotherapy clinics were recruited and cluster randomised using a computer-generated randomisation sequence. Twenty-eight (20 ABPI, 8 standard physiotherapy) participants [median age 38.00 (IQR = 21.50) years] were recruited. Data were analysed descriptively with a priori establishment of success criteria. Ninety-five percent of participants in the ABPI arm fully recovered (Neck Disability Index ≤4, compared to 17% in the standard physiotherapy arm); required fewer treatment sessions; and demonstrated greater improvement in all outcome measures (pain intensity, Cervical Range of Motion, Pressure Pain Threshold, EuroQol-5 Dimensions) except for the Impact of Events Scale and Fear Avoidance Beliefs Questionnaire. The findings support the potential value of the ABPI, and that an adequately powered definitive trial to evaluate effectiveness (clinical, cost) is feasible with minor modifications to procedures.

Management of distal femoral fractures treated with locking compression plate: a prospective study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Distal femoral fractures are extremely common and represent 6-8% of all the femoral fractures treated by orthopaedic surgeons. Near anatomical reduction is most important in these fractures to obtain near good functional results. A variety of treatment options are proposed for distal femoral fractures of the treatment with distal femoral LCP has yielded good results. In this study we did a prospective study of 30 patients treated with locking compression plates.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; There were 30 patients both male and female of different age groups treated by plate. All the patients were followed up in orthopaedic department prospectively for 12 months between November 2017 to November 2018. The functional and radiological outcomes were assessed.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The study included 30 patients both male and female in age group between 20 and above 60. Average follow up was 12 months using Neer’s scoring system we had excellent 60%, good 26.6%, fair 6.7%, poor 6.7%.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The locking compression plate along with active physiotherapy proved to be better for distal femoral fractures.&lt;/p&gt;

Current evidence for nonpharmacological interventions and criteria for surgical management of persistent acromioclavicular joint osteoarthritis: A systematic review.

The primary aim of this systematic review was to investigate the individual/combined effectiveness of nonpharmacological interventions in individuals with persistent acromioclavicular joint osteoarthritis. The secondary aims were to investigate the comparative effectiveness of nonpharmacological versus surgical interventions, and to identify the criteria used for defining failure of conservative interventions in individuals who require surgery for persistent acromioclavicular joint osteoarthritis. Major electronic databases were searched from inception until October 2018. Studies involving adults aged 16 years and older, diagnosed clinically and radiologically with isolated acromioclavicular joint osteoarthritis for at least three months or more were included. Studies must explicitly state the type and duration of conservative interventions. Methodological risk of bias was assessed using the Modified Downs and Black checklist. Ten surgical intervention studies were included for final synthesis. No studies investigated the effectiveness of nonpharmacological interventions or compared them with surgical interventions. Common nonpharmacological interventions trialed from the 10 included studies were activity modification (n = 8) and physiotherapy (n = 4). Four to six months was the most often reported timeframe defining failure of conservative management (range 3-12 months). Currently, there is no evidence to guide clinicians about the individual or combined effectiveness of nonpharmacological interventions for individuals with persistent acromioclavicular joint osteoarthritis.

Effect of Blood Flow Restriction Training on Quadriceps Muscle Strength, Morphology, Physiology, and Knee Biomechanics Before and After Anterior Cruciate Ligament Reconstruction: Protocol for a Randomized Clinical Trial.

Despite best practice, quadriceps strength deficits often persist for years after anterior cruciate ligament reconstruction. Blood flow restriction training (BFRT) is a possible new intervention that applies a pressurized cuff to the proximal thigh that partially occludes blood flow as the patient exercises, which enables patients to train at reduced loads. This training is believed to result in the same benefits as if the patients were training under high loads. The objective is to evaluate the effect of BFRT on quadriceps strength and knee biomechanics and to identify the potential mechanism(s) of action of BFRT at the cellular and morphological levels of the quadriceps. This will be a randomized, double-blind, placebo-controlled clinical trial. The study will take place at the University of Kentucky and University of Texas Medical Branch. Sixty participants between the ages of 15 to 40 years with an ACL tear will be included. Participants will be randomly assigned to (1) physical therapy plus active BFRT (BFRT group) or (2) physical therapy plus placebo BFRT (standard of care group). Presurgical BFRT will involve sessions 3 times per week for 4 weeks, and postsurgical BFRT will involve sessions 3 times per week for 4 to 5 months. The primary outcome measure was quadriceps strength (peak quadriceps torque, rate of torque development). Secondary outcome measures included knee biomechanics (knee extensor moment, knee flexion excursion, knee flexion angle), quadriceps muscle morphology (physiological cross-sectional area, fibrosis), and quadriceps muscle physiology (muscle fiber type, muscle fiber size, muscle pennation angle, satellite cell proliferation, fibrogenic/adipogenic progenitor cells, extracellular matrix composition). Therapists will not be blinded. The results of this study may contribute to an improved targeted treatment for the protracted quadriceps strength loss associated with anterior cruciate ligament injury and reconstruction.

Postoperative pain relief in general surgery - recommendations of the Association of Polish Surgeons, Polish Society of Anaesthesiology and Intensive Therapy, Polish Association for the Study of Pain and Polish Association of Regional Anaesthesia and Pain Treatment.

It is estimated that there are over 310 million surgeries performed in the world every year. Appropriate analgesic management in the perioperative period constitutes a fundamental right of every patient, significantly reducing the number of postoperative complications and the time and costs of hospitalization, particularly in the high-risk group of patients (ASA III-V) subject to extensive surgical procedures and hospitalized in intensive care units. Despite such significant arguments speaking for the conduct of effective analgesia in the perioperative period, nearly 79% of patients operated in hospitalization settings and 71% of patients operated in outpatient settings (so-called first day surgery) experienced postoperative pain of moderate, strong or extreme intensity. Hence, effective relief of postoperative pain should constitute one of the priorities of integrated, modern perioperative management, the components of which apart from adequate analgesia involve early nutrition through the alimentary canal, early patient activation and active physiotherapy. In the currently published "Guidelines", a team of authors has updated the previous "Recommendations" primarily in terms of methods for optimizing postoperative pain relief and new techniques and drugs introduced for postoperative pain therapy in recent years. The algorithms of postoperative pain management in different treatment categories were also updated.

Ultrasound-guided adductor canal block using levobupivacaine versus periarticular levobupivacaine infiltration after totalknee arthroplasty: a randomized clinical trial

Both postoperative pain control and range of motion are important in total knee arthroplasty (TKA). However, in the literature, there is little comparison of peripheral nerve blocks and periarticular infiltration techniques using levobupivacaine. The aim of our study was to measure pain with visual analogue scale (VAS) and knee range of motion (ROM) between in patients undergoing adductor canal block (ACB) for TKA using levobupivacaine compared to periarticular levobupivacaine infiltration (PAI-L). Prospective randomized clinical trial in a university hospital. Patients aged 40-85 years who underwent unilateral TKA were included; 39 were treated withperiarticular infiltration using 40 ml (0.125 mg) of levobupivacaine (PAI-L group); and 40 were treated with ACB using 20 ml of 0.25% levobupivacaine (ACB-L group). Postoperative pain scores at rest and during active physical therapy were assessed using a VAS, along with knee ROM in flexion and extension. In addition, 100-foot walking time results, total morphine consumption and time of first analgesia requirement were recorded postoperatively. VAS scores at rest and during active physical therapy and the total amount of morphine consumed were lower in the ACB-L group than in the PAI-L group (P < 0.05). In contrast, knee ROM in flexion and extension and 100-foot walking times were greater in the PAI-L group than in the ACB-L group (P < 0.05). ACB-L was superior to PAI-L regarding pain treatment after TKA; however, PAI-L was superior to ACB-L regarding postoperative ROM and walking ability. ACTRN-12618000438257.

Awake and fully mobile patients on cardiac extracorporeal life support.

Early mobilization of critically ill patients is increasingly being recognized as not only safe and feasible, but also as a potential means of optimizing outcomes in the intensive care unit (ICU). With the rapidly expanding use of extracorporeal life support (ECLS) for severe cardiopulmonary failure, there is a growing interest in the application of early mobilization to this patient population, which has been shown to be safe and feasible in select patient populations. However, some patients receiving ECLS support may benefit more than others. For instance, early mobilization may be particularly beneficial in patients awaiting heart or lung transplantation, as maintenance of physical conditioning may be an important component of a patient's transplant candidacy. The ability to engage critically ill patients in active physical therapy and early mobilization necessarily involves minimization of sedation and is often further facilitated by a strategy that favors endotracheal extubation. Whether an awake, extubated and mobile strategy can be applied in any given patient is often dictated by the severity of the underlying disease and the amount of extracorporeal support required. Additionally, whether this approach is superior to usual care, which patients might benefit or be harmed, and which patient characteristics are most likely to predict success of this strategy, are areas of ongoing investigation.

Barriers and facilitators of loaded self-managed exercises and physical activity in people with patellofemoral pain - a UK qualitative study

Purpose: There is an emergent body of evidence supporting exercise therapy and physical activity in the management of musculoskeletal pain. The purpose of this study was to explore potential barriers and facilitators with patients and physiotherapists with patellofemoral pain involved in a feasibility randomised controlled trial (RCT) study. The trial investigated a loaded self-managed exercise intervention, which included education and advice on physical activity versus usual physiotherapy as the control.

Virtual reality analgesia for burn joint flexibility: A randomized controlled trial.

We conducted a randomized controlled study to determine the effects of virtual reality (VR) distraction on pain and range of motion (ROM) in patients hospitalized for burn care during active physical therapy exercises. Thirty-nine participants aged 15 to 66 (M = 36) years with significant burn injuries (mean burn size = 14% TBSA) participated. Under therapist supervision, using a within-subjects design, participants performed unassisted active ROM exercises both with and without VR distraction in a randomized order. Therapists provided participants with instructions but did not physically assist with stretches. Maximum active ROM was measured using a goniometer. A 0-100 Graphic Rating Scale (GRS) was used to assess the cognitive, affective, and sensory components of pain. A GRS rating of the amount of "fun" during stretching served as a measure of positive experience. Participants reported lower mean GRS ratings during VR, relative to No VR, for worst pain, pain unpleasantness, and time spent thinking about pain. They also reported having a more positive experience during VR than during No VR. However, patients did not show greater ROM during VR. Immersive VR reduced pain during ROM exercises that were under the control of the patient. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Physical activity and physiotherapy: perception of women breast cancer survivors

Physical activity levels seem to play an important role on musculoskeletal disorders in women diagnosed with breast cancer. However, the effects of physical activity after diagnosis are not fully understood. Our purpose was to understand the importance of physical activity and physiotherapy on musculoskeletal disorders as a sequela of treatment in breast cancer survivor women. For this cross-sectional study, a sample of 94 breast cancer survivor women fulfilled a self-completed questionnaire with questions on clinical and functional variables, and levels of physical activity before and after breast cancer diagnosis. All 94 women, aged between 23 and 72years, reported at least one or more post-cancer musculoskeletal disorders. More active women reported fewer changes than the less active women (p < 0.05). For the majority of women who underwent physiotherapy after breast cancer, this intervention was perceived as helpful in the treatment of post-cancer disorders. Physical activity habits and physiotherapy treatments contributed for the perception of lower number of musculoskeletal disorders. This practice should be advocated among women with breast cancer.

Barriers to implementing expert safety recommendations for early mobilisation in intensive care unit during mechanical ventilation: A prospective observational study

BackgroundEarly mobilisation in the intensive care unit (ICU) has been consistently reported as feasible and safe with minimal adverse events; however, invasive mechanical ventilation patients are rarely actively mobilised. An expert consensus group developed and published recommendations using a traffic light system on safety criteria to promote active mobilisation of invasive mechanical ventilation patients. ObjectivesThe aim of this study was to determine whether, in clinical practice, the safety consensus recommendations resulted in (1) increased early mobilisation in patients assessed as appropriate to mobilise based on the risk classification and (2) early mobilisation without adverse events. MethodsA prospective observational study of 100 patients requiring invasive mechanical ventilation (IMV) for greater than 24 h admitted to the ICU at The Alfred Hospital. Patients were assessed daily (Monday to Friday) to determine their ability to perform early mobilisation. ResultsData were collected on 100 patients, resulting in 280 physiotherapy–patient interactions during IMV. Of the 100 patients, five patients actively mobilised out of bed during IMV. No adverse event occurred during active physiotherapy–patient interactions. There were 15 physiotherapy–patient interactions that had a low risk of an adverse event, and on nine (60.0%) of these physiotherapy–patient interactions, patients were actively mobilised out of bed with the main reported barrier being time constraints. Of 208 physiotherapy–patient interactions where there were significant potential risks of an adverse event identified for mobilising, active out of bed mobilisation did not occur, with sedation being reported as the main barrier in 170 (82%) patients. ConclusionsThe translation of expert consensus recommendations for early mobilisation into clinical practice was poor. Clinicians were safe and conservative in the implementation of early mobilisation during IMV.

Feasibility study for the generalization of early management of low back pain in work stoppage after a work-related injury

A considerable proportion of work absence is attributed to low back pain (LBP), with high lost productive time and health spending, specially after a work-related injury. The French Health Insurance try to improve the return-to-work for these patient with a early care in rehabilitation center. The objective of this study is to determinate if a early care three months after a work stoppage after a work-related injury improve the return to work three months after, and to determinate factors that influence the return-to-work. Five center in France took part in this protocol, in an open prospective study; 147 LBP patients (handler) were included in 2016, three months after the work-related injury. The intervention was a multidisciplinary functional restoration program for 67 patients. The others were follow-up about the return-to-work. The outcome was the return-to-work rate three months after the intervention. In the 52 remaining patients, 26 (50%) were at work at 3 months: 16 in full time at the same job. Nine patients were in occupational retraining. For the other 80 patients, 70 (87.5%) were at work at three months. Active physiotherapy, TAMPA, FABQ, DALLAS, Visual Analog Scale (VAS) after the programs were found to have relationships with the outcome. LBP background and being sportive before or after the program, were not found to have relationship with the outcome. Unfortunately, we fund an adverse effect of the multidisciplinary functional restoration program from patients with low back pain in work stoppage after a work-related injury in our study. Maybe the overmedication, or the drama caused by this program in hospitalization, must influence the situation of workers. Surprisingly, sports practice did not show any influence on the results. Active physiotherapy should be offered to any patient in this situation to promote the return to work.

Divergent dislocation of the carpometacarpal joints: a case report

BackgroundDivergent carpometacarpal joint dislocations of the fingers are very rare. Due to severe swelling and overlapping of bones on a radiograph of the wrist and hand, dislocations are missed. The purpose of this clinical case report is to highlight this unusual injury to avoid missing diagnosis.Case presentationWe report a case of a 24-year-old Moroccan man, an athlete, who presented divergent carpometacarpal joint fracture-dislocations of the ulnar four fingers after a fall during a national cycling competition. Radiographs showed divergent dislocation and associated fractures. He underwent open reduction and fixation with percutaneous Kirschner wires followed by 6 weeks of immobilization. Active physiotherapy was started and the results were satisfactory after a 2-year follow-up.ConclusionsDivergent carpometacarpal joint dislocations of the fingers are exceptional; their diagnosis is sometimes difficult and may go unnoticed especially in a patient with polytrauma. The functional prognosis depends on the precocity of diagnosis and the quality of the reduction and rehabilitation.