Management Of Musculoskeletal Conditions Research Articles

Diagnosis and Management of Knee Arthrofibrosis and Associated Pain-Related Fear Using Multidimensional Clinical Reasoning and Exposure In Vivo Concept: A Case Report

BACKGROUND: A plethora of treatment approaches are used to manage persistent pain, disability, and fear associated with restricted knee range of motion following knee surgery. We used the pain and disability driver model and exposure in vivo concepts to manage pain-related fear and disability. CASE PRESENTATION: A 68-year-old male who underwent arthroscopic partial meniscectomy presented to physical therapy with a medical diagnosis of Complex Regional Pain Syndrome Type I and knee range-of-motion restriction. Despite extensive medical care and physical therapy for 3 years (202 visits), he continued to experience debilitating knee pain and demonstrated a high level of fear. To ambulate, he wore a knee brace and used a trekking pole. OUTCOME AND FOLLOW UP: Interventions to address the knee stiffness included combined tibiofemoral joint mobilization and high-velocity low-amplitude thrust manipulation targeting tibial internal rotation and low-load long-duration sustained capsular stretching using total end range time principle for extension. His fear was managed using techniques inspired by in vivo exposure concepts. Total knee range of motion improved 110 degrees and the patient was able to ambulate for 30 minutes (0.5 mile) without an assistive device with <2/10 pain intensity. DISCUSSION: Outside-the-box clinical reasoning suggested that poor outcomes with previous interventions were likely due to hypervigilance and pain-related fear. This case delineates the value of nonreductionist clinical reasoning in diagnosis and management of musculoskeletal conditions. It also outlines how the exposure in vivo approach helped the patient overcome his long-established avoidance behaviors. JOSPT Cases 2024;4(3):121-132. Epub 2 July 2024. doi:10.2519/josptcases.2024.0034

Randomized-controlled trial assessing a digital care program versus conventional physiotherapy for chronic low back pain

Low back pain (LBP) is the world’s leading cause of years lived with disability. Digital exercise-based interventions have shown great potential in the management of musculoskeletal conditions, promoting access and easing the economic burden. However, evidence of their effectiveness for chronic LBP (CLBP) management compared to in-person physiotherapy has yet to be unequivocally established. This randomized controlled trial (RCT) aims to compare the clinical outcomes of patients with CLBP following a digital intervention versus evidence-based in-person physiotherapy. Our results demonstrate that patient satisfaction and adherence were high and similar between groups, although a significantly lower dropout rate is observed in the digital group (11/70, 15.7% versus 24/70, 34.3% in the conventional group; P = 0.019). Both groups experience significant improvements in disability (primary outcome), with no differences between groups in change from baseline (median difference: −0.55, 95% CI: −2.42 to 5.81, P = 0.412) or program-end scores (−1.05, 95% CI: −4.14 to 6.37; P = 0.671). Likewise, no significant differences between groups are found for secondary outcomes (namely pain, anxiety, depression, and overall productivity impairment). This RCT demonstrates that a remote digital intervention for CLBP can promote the same levels of recovery as evidence-based in-person physiotherapy, being a potential avenue to ease the burden of CLBP.

The impact of the COVID-19 pandemic on referrals to musculoskeletal services from primary care and subsequent incidence of inflammatory rheumatic musculoskeletal disease: an observational study.

The aim was to describe the impact of the COVID-19 pandemic upon referral patterns and incident diagnosis of inflammatory rheumatic and musculoskeletal diseases (iRMDs). UK primary care data were used to describe referral patterns for patients with musculoskeletal conditions. Trends in referrals to musculoskeletal services and incident diagnoses of iRMDs (specifically, RA and JIA) were described using Joinpoint Regression and comparisons made between key pandemic time periods. The incidence of RA and JIA reduced by -13.3 and -17.4% per month, respectively, between January 2020 and April 2020, then increased by 1.9 and 3.7% per month, respectively, between April 2020 and October 2021. The incidence of all diagnosed iRMDs was stable until October 2021. Referrals decreased between February 2020 and May 2020 by -16.8% per month from 4.8 to 2.4% in patients presenting with a musculoskeletal condition. After May 2020, referrals increased significantly (16.8% per month) to 4.5% in July 2020. The time from first musculoskeletal consultation to RA diagnosis and from referral to RA diagnosis increased in the early pandemic period [rate ratio (RR) 1.11, 95% CI 1.07, 1.15 and RR 1.23, 95% CI 1.17, 1.30, respectively] and remained consistently higher in the late pandemic period (RR 1.13, 95% CI 1.11, 1.16 and RR 1.27, 95% CI 1.23, 1.32, respectively), compared with the pre-COVID-19 pandemic period. Patients with underlying RA and JIA that developed during the pandemic might be yet to present or might be in the referral and/or diagnostic process. Clinicians should remain alert to this possibility, and commissioners should be aware of these findings, enabling the appropriate planning and commissioning of services.

Telerehabilitation versus face-to-face rehabilitation in the management of musculoskeletal conditions: a systematic review and meta-analysis

Background Musculoskeletal conditions such as spinal pain and osteoarthritis are among the leading causes of years lived with disability worldwide. With the COVID-19 pandemic forcing many healthcare providers to change the way in which care for chronic conditions is delivered, telehealth is an alternative to face-to-face consultations that can be used for both assessment and provision of therapy and support. Objectives To identify, appraise and synthesise findings from all randomised controlled trials (RCTs) that compared telehealth to face-to-face consultations for patients with any type of musculoskeletal condition. Methods Systematic review and meta-analysis. We used the GRADE approach to assess the quality of evidence related to all outcomes. We searched three electronic databases (PubMed, Embase, CENTRAL), clinical trial registries and citing-cited references of included studies. Results Five RCTs were includable: one in patients with osteoarthritis of the knee, one in patients with osteoarthritis of the knee or hip in preparation for a total joint arthroscopy and three after total knee replacement. Telehealth was conducted by video in four trials and by phone in one. A total of 402 participants were analysed across the five trials. There were no significant differences in pain outcomes (WOMAC) between telehealth and face-to-face therapy immediate post-intervention (mean difference (MD): 0.12 (95% CI −2.3 to 2.6, p = .92) or two months post-intervention (MD): 1.2, (95% CI: −2.7 to 5.1, p = .55). Similarly, outcomes related to function, quality of life and satisfaction were comparable between the two modes of delivery immediate post-intervention, with no significant differences reported. Conclusion There is limited low quality evidence that there is no significant differences between telehealth-based delivery of rehabilitation to patients with osteoarthritis or following knee surgery and face-to-face therapy for pain, function, quality of life and satisfaction. These findings should be should be interpreted with caution due to the small number of included studies and small sample size.

The state of the art in telerehabilitation for musculoskeletal conditions

BackgroundGiven the rapid advances in communication technology and the need that emerged from the COVID-19 pandemic, telehealth initiatives have been widely used worldwide. This masterclass aims to provide an overview of telerehabilitation for musculoskeletal conditions, synthesizing the different terminologies used to describe telehealth and telerehabilitation, its effectiveness and how to use it in clinical practice, barriers and facilitators for the implementation in health services, and discuss the need of a curriculum education for the near future.Main bodyTelerehabilitation refers to the use of information and communication technologies provided by any healthcare professionals for rehabilitation services. Telerehabilitation is a safe and effective option in the management of musculoskeletal conditions in different models of delivery. There are many technologies, with different costs and benefits, synchronous and asynchronous, that can be used for telerehabilitation: telephone, email, mobile health, messaging, web-based systems and videoconferences applications. To ensure a better practice of telerehabilitation, the clinician should certify safety and access, and appropriateness of environment, communication, technology, assessment, and therapeutic prescription. Despite the positive effect of telerehabilitation in musculoskeletal disorders, a suboptimal telerehabilitation implementation may have happened due to the COVID-19 pandemic, especially in countries where telehealth was not a reality, and clinicians lacked training and guidance. This emphasizes the need to identify the necessary curriculum content to guide future clinicians in their skills and knowledge for telerehabilitation. There are some challenges and barriers that must be carefully accounted for to contribute to a health service that is inclusive and relevant to health professionals and end users.ConclusionsTelerehabilitation can promote patient engagement in health care and plays an important role in improving health outcomes in patients with musculoskeletal conditions. Digital health technologies can also offer new opportunities to educate patients and facilitate the process of behavior change to a healthy lifestyle. Currently, the main needs in telerehabilitation are the inclusion of it in health curriculums in higher education and the development of cost-effectiveness and implementation trials, especially in low- and middle-income countries where access, investments and digital health literacy are limited.

Evolution and Clinical Advances of Platelet-Rich Fibrin in Musculoskeletal Regeneration.

Over the past few decades, various forms of platelet concentrates have evolved with significant clinical utility. The newer generation products, including leukocyte-platelet-rich fibrin (L-PRF) and advanced platelet-rich fibrin (A-PRF), have shown superior biological properties in musculoskeletal regeneration than the first-generation concentrates, such as platelet-rich plasma (PRP) and plasma rich in growth factors. These newer platelet concentrates have a complete matrix of physiological fibrin that acts as a scaffold with a three-dimensional (3D) architecture. Further, it facilitates intercellular signaling and migration, thereby promoting angiogenic, chondrogenic, and osteogenic activities. A-PRF with higher leukocyte inclusion possesses antimicrobial activity than the first generations. Due to the presence of enormous amounts of growth factors and anti-inflammatory cytokines that are released, A-PRF has the potential to replicate the various physiological and immunological factors of wound healing. In addition, there are more neutrophils, monocytes, and macrophages, all of which secrete essential chemotactic molecules. As a result, both L-PRF and A-PRF are used in the management of musculoskeletal conditions, such as chondral injuries, tendinopathies, tissue regeneration, and other sports-related injuries. In addition to this, its applications have been expanded to include the fields of reconstructive cosmetic surgery, wound healing in diabetic patients, and maxillofacial surgeries.

Effectiveness of biofeedback-assisted asynchronous telerehabilitation in musculoskeletal care: A systematic review.

Musculoskeletal conditions are the leading cause of disability worldwide. Telerehabilitation may be a viable option in the management of these conditions, facilitating access and patient adherence. Nevertheless, the impact of biofeedback-assisted asynchronous telerehabilitation remains unknown. To systematically review and assess the effectiveness of exercise-based asynchronous biofeedback-assisted telerehabilitation on pain and function in individuals with musculoskeletal conditions. This systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search was conducted using three databases: PubMed, Scopus, and PEDro. Study criteria included articles written in English and published from January 2017 to August 2022, reporting interventional trials evaluating exercise-based asynchronous telerehabilitation using biofeedback in adults with musculoskeletal disorders. The risks of bias and certainty of evidence were appraised using the Cochrane tool and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE), respectively. The results are narratively summarized, and the effect sizes of the main outcomes were calculated. Fourteen trials were included: 10 using motion tracker technology (N = 1284) and four with camera-based biofeedback (N = 467). Telerehabilitation with motion trackers yields at least similar improvements in pain and function in people with musculoskeletal conditions (effect sizes: 0.19-1.45; low certainty of evidence). Uncertain evidence exists for the effectiveness of camera-based telerehabilitation (effect sizes: 0.11-0.13; very low evidence). No study found superior results in a control group. Asynchronous telerehabilitation may be an option in the management of musculoskeletal conditions. Considering its potential for scalability and access democratization, additional high-quality research is needed to address long-term outcomes, comparativeness, and cost-effectiveness and identify treatment responders.

Machine learning approaches for early detection and management of musculoskeletal conditions

Machine learning approaches for early detection and management of musculoskeletal conditions

How to report parameters and procedures for shockwave therapy in musculoskeletal disorders: A narrative review.

Shockwave therapy (SWT) has been successful in the management of musculoskeletal conditions. The limitations of the use of SWT in clinical practice regard a lack of familiarity with the device and the lack of uniformity in information reported in scientific publications. Standardization in the reporting of these parameters could facilitate the reproduction and interpretation of data in future studies. Most studies fail to offer a detailed description of the parameters. Therefore, the aim of the present paper is to prepare a report on how to standardize the presentation of this information and serve a reference guide to report physical parameters and procedures of SWT when used on patients with musculoskeletal disorders. The terms were selected from the Medical Subject Headings database of controlled vocabulary. An extensive process of systematic searching of databases was performed, after which experts met and discussed on the main findings, and a consensus was achieved. SWT parameters were described, including the physiological meaning and clinical relevance of each parameter. Also, the description of patient and equipment positioning was added. The consensus-based guideline on how to report SWT parameters for the treatment of musculoskeletal conditions was developed to help clinicians and researchers.

“MUCH BETTER THAN I THOUGHT IT WAS GOING TO BE”: TELEHEALTH DELIVERED GROUP-BASED EDUCATION AND EXERCISE-THERAPY IS ACCEPTABLE AMONG PEOPLE WITH KNEE OSTEOARTHRITIS

Purpose: Management of musculoskeletal conditions through one-on-one telehealth services is generally acceptable to patients and provides pain and disability outcomes that are comparable to in-person care, including in people with osteoarthritis. However, the effectiveness of telehealth delivered group-based education and exercise-therapy for osteoarthritis is unknown. To purpose of this study was to understand patient perceived acceptability of participating in a telehealth delivered group-based education and exercise-therapy program for knee osteoarthritis.

Multi-disciplinary rehabilitation for management of diabetes mellitus related neurological and musculoskeletal complications.

Diabetes Mellitus (DM) is one of the most common metabolic disorders in the world. It can result in several neurological and musculoskeletal (MSK) conditions. These conditions adversely affect the mobility, community functioning and quality of life for the patient with DM. Rehabilitation Medicine Physicians (Physiatrists) can offer both diagnostic and therapeutic interventions for the accurate diagnosis and optimal management of neurological and MSK conditions associated with DM. These include diagnostic tests such as Nerve Conduction Studies and Electromyography, therapeutic interventions in form of pharmacological management of symptoms, prescription of appropriate physical therapy, occupational therapeutic exercise, injections, as well as psychosocial and cognitive interventions. A physiatrist can provide expert advice on musculoskeletal disorders in patients with DM, as they are formally trained in the evaluation, diagnosis, and management of MSK conditions. A multidisciplinary team for DM should include a physiatrist as one of the key members. This can help effectively address neurological and MSK disorders related to DM.

Infrared Radiation in the Management of Musculoskeletal Conditions and Chronic Pain: A Systematic Review.

Infrared radiation (IR) is a promising complementary treatment for musculoskeletal conditions and chronic pain. By means of a systematic review, we evaluated the contribution of IR to the management of these ailments. PubMed-MEDLINE, Scopus, and Cochrane Library–Cochrane Central Register of Controlled Trials were systematically searched until 20 December 2021. The literature search yielded 233 relevant records. Following the screening of titles and abstracts, 42 full-texts were evaluated. As per inclusion/exclusion criteria, 13 publications were entered into the qualitative assessment. These studies described the effects of IR in humans: three studies focused on osteoarthritis, four studies on fibromyalgia, and six encompassed a wider range of diseases (ankylosing spondylitis, recovery from sports injuries, myofascial pain syndrome). Based on the findings of our systematic review, we noted a decrease in pain levels, as evaluated by the visual analog scale (VAS), in patients suffering from musculoskeletal disorders treated with IR. In addition, IR use led to a decrease in Fibromyalgia Impact Questionnaire (FiQ) scores in subjects diagnosed with fibromyalgia. Nevertheless, IR has failed to facilitate muscle recovery following athletic injuries.

Exploring the effectiveness of immersive Virtual Reality interventions in the management of musculoskeletal pain: a state-of-the-art review

Background Virtual Reality (VR) is an immersive technology, which transports the user to a three-dimensional ‘virtual world’ and is increasingly used as an innovative treatment modality in various aspects of healthcare. The use of immersive VR in the management of musculoskeletal conditions is relatively new and research is required to demonstrate its effectiveness in this field. Aim The aim of this narrative review is to explore the effectiveness of immersive VR interventions in the management of musculoskeletal conditions. Methods A literature search was carried out on the following databases: Pubmed, Scopus and Medline using the following keywords: Virtual Reality and Pain. Studies of any design were included if they reported clinical outcomes following an immersive VR intervention for individuals with musculoskeletal pain. Results Thirteen studies which investigated the effectiveness of immersive VR in the management of musculoskeletal conditions were identified. Studies included people with various musculoskeletal conditions: neck pain (5), low back pain (1), complex regional pain syndrome (4), peripheral nerve injury (1), fibromyalgia (1) and total knee replacement (2). Only five randomized controlled trials were found. Outcome measures included but were not limited to pain, range of motion and disability. Conclusion Although the current findings are promising and demonstrate that immersive VR interventions may have a useful role in musculoskeletal management and rehabilitation, no conclusive clinical recommendations can be made based on the low quality of available research. Future research should follow a framework with clear standards leading to robust and meaningful outcomes that will guide clinical practice using immersive VR.

Recommendations of Polarized Polychromatic Non-Coherent Light (Bioptron Light) in the Management of Musculoskeletal Conditions

Recommendations of Polarized Polychromatic Non-Coherent Light (Bioptron Light) in the Management of Musculoskeletal Conditions

Value-based Healthcare: Not Going Anywhere-Why Orthopaedic Surgeons Will Continue Using Telehealth in a Post-COVID-19 World.

Value-based Healthcare: Not Going Anywhere-Why Orthopaedic Surgeons Will Continue Using Telehealth in a Post-COVID-19 World.

Preparation Methods and Clinical Outcomes of Platelet-Rich Plasma for Intra-articular Hip Disorders: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

Background:Despite its increasing use in the management of musculoskeletal conditions, questions remain regarding the preparation methods of platelet-rich plasma (PRP) and its clinical applications for intra-articular hip disorders, including femoroacetabular impingement syndrome (FAIS), labral pathology, and osteoarthritis (OA).Purpose:To systematically review and assess the preparation methods and clinical outcomes from randomized clinical trials (RCTs) on the use of PRP for intra-articular hip disorders.Study Design:Systematic review; Level of evidence, 2.Methods:A systematic review in accordance with the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed in September 2019. The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Ovid Medline, and Embase were queried for studies regarding the use of PRP to treat intra-articular hip disorders. Qualifying articles were English-language RCTs describing the use of PRP for intra-articular hip disorders, either as standalone treatment or surgical augmentation. Two authors independently assessed article eligibility. Data pertaining to patient characteristics, indication for treatment, PRP preparation method, follow-up period, and clinical outcomes were extracted. Study results were qualitatively reported and quantitatively compared using meta-analysis when appropriate.Results:Seven RCTs met inclusion criteria. Four studies described the use of PRP for hip OA and 3 utilized PRP at arthroscopy for FAIS and labral tears. Outcomes after PRP for OA demonstrated improvement in validated patient-reported outcome measures for up to 1 year; however, pooled effect sizes found no statistically significant difference between PRP and hyaluronic acid (HA) regarding pain visual analog scale scores at short-term (≤2 months; P = .27), midterm (4-6 months; P = .85), or long-term (1 year; P = .42) follow-up. When injected at arthroscopy, 1 study reported improved outcomes, 1 reported no difference in outcomes, and 1 reported worse outcomes compared with controls. The meta-analysis demonstrated no statistically significant difference on the modified Harris Hip Score (mHHS) between PRP and control cohorts at a minimum 1-year follow-up. There were considerable deficiencies and heterogeneity in the reporting of PRP preparation methods for both indications.Conclusion:Treatment of OA with PRP demonstrated reductions in pain and improved patient-reported outcomes for up to 1 year. However, there was no statistically significant difference between PRP and HA in pain reduction. Likewise, for FAIS and labral surgery there was no statistically significant difference in mHHS outcomes between patients treated with PRP and controls. Given the limited number of studies and variability in PRP preparations, additional high-quality randomized trials are warranted.

Profile of acupuncture use among primary care physicians working in the Brazilian public healthcare system.

An introductory acupuncture course has been offered to primary health care physicians and family medicine residents in southern Brazil since 2011. To analyze the profile of acupuncture utilization of primary care physicians who completed an introductory course of acupuncture between 2011 and 2018. A survey using an electronic questionnaire was sent to all 119 physicians who completed the course. Fifty-five physicians answered the questionnaire. The majority of them reported continuation of the practice of acupuncture in scheduled appointments and on spontaneous demand. The most commonly used principles of point selection were traditional acupuncture point function, myofascial trigger point needling and point protocols. As barriers to the practice of acupuncture, time limitation and inadequate physical space were predominant. The participants described the problem-solving potential of the procedure and good patient acceptance as facilitators. The most common problems treated with acupuncture were musculoskeletal pain, and mood and anxiety disorders. A reduction in referrals to specialists and reduced prescription of pain medications were also reported. Most physicians answered that they often combined acupuncture with other medications or associated acupuncture with other complementary practices. The main adverse events reported by the participants were vascular trauma and fainting. Most primary care physicians who completed the introductory course and answered the survey still used acupuncture in their routine, primarily for the management of musculoskeletal conditions and mental health conditions. These physicians reported reductions in specialist referrals and prescription of pain medication after integrating basic acupuncture skills into primary care practice.

The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice.

While advances in assessment and management of musculoskeletal conditions have improved care for many people, there have been other, less beneficial developments in the provision of care for people with musculoskeletal pain conditions, one of which is the worrying tendency to provide too much medicine. Too much medicine occurs when the provision of either investigation or intervention (or both) is unjustifiably excessive. Another concern in musculoskeletal health care is medicalizing normality-when a normal human function or condition is labeled as abnormal. In this Viewpoint, the authors argue that medicalizing normality creates health concerns where none exist, while too much medicine involves provision of care where benefits do not outweigh harms, and wastes precious health care resources. The authors (1) list 2 common examples of too much medicine, and 2 examples of medicalizing normality, relevant to physical therapy practice; (2) outline the drivers of too much medicine and medicalizing normality; and (3) make suggestions for change. J Orthop Sports Phys Ther 2020;50(1):1-4. doi:10.2519/jospt.2020.0601.

Health promotion in physiotherapy services using NHS health and diabetes checks

Several public health initiatives have been launched in England including NHS Health Checks and the National Diabetes Prevention programme; however, uptake has been suboptimal. Musculoskeletal problems are a large health burden and there are increasing links identified between musculoskeletal disorders and metabolic and cardiovascular disorders, which are influenced by lifestyle factors. Physiotherapists have a key role to play in public health and are an untapped resource. Methods: An enhanced health promotion service, using support staff, was implemented into a physiotherapy-led musculoskeletal service including the provision of NHS Health Checks and diabetes checks. Evaluation included descriptive statistical analysis, documentary analysis and qualitative review. Results: In total, 1550 health assessments were completed with 43% eligible for a HbA1c test and 17% were eligible for an NHS Health Check. Service evaluation feedback from patients and GPs was wholly positive and social prescribing increased. Discussion: This service describes a successful model for embedding NHS Health Checks and diabetes checks into a musculoskeletal service, providing opportunistic health promotion and behaviour change interventions and reducing the duplication of different public health initiatives. This service uses an untapped allied health professional public health workforce to support an identification of disease, behaviour change, self-care and social prescribing within the holistic management of musculoskeletal conditions.

Staying focused: Ultrasound guided extracorporeal shockwave therapy in the management of musculoskeletal conditions

The effects of shockwaves were first observed during the Second World War with human lungs cracking from waterbomb explosions without signs of external injuries. In 1966, Claude Dornier observed cavitations on the surface of aircrafts approaching the sound barrier, this subsequently led to the development of the first extracorporeal shockwave lithotripser used on kidney and gall bladder stones. Over the last 30 years, applications of extracorporeal shockwave therapy (ESWT) for musculoskeletal conditions pathologies have emerged. There is strong basic science research and clinical evidence for the use of ESWT for tendinopathies and bone pathologies. The capabilities of ultrasound in locating musculoskeletal pathology adds another dimension to the use of focused ESWT. Ultrasound allows the identification of specific areas of tendon pathology such as tendon swelling, fibre disarray, calcifications, micro-tears and neo-vascularisation as targets for shockwave treatment, in addition to palpation, skin markings and patient feedback. This non-invasive and low risk modality has proven to be highly effective with predictable outcomes and has high patient acceptance. As such, ultrasound guided focused ESWT has been the cornerstone in the management of recalcitrant tendon pathologies around the heel, knee, elbow and shoulder in my practice.