Systematic review of distal biceps tendon rupture in athletes: treatment and rehabilitation

by ptfadmin | Jul 26, 2024 | Health Tips

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction: 

Distal biceps tendon rupture is an injury resulting in the complete tearing of the distal biceps tendon.  The mechanism of biceps tendon rupture often involves a forceful eccentric contraction of the bicep.  Though rare, treatment for distal biceps tendon rupture is usually surgical, as non-operative treatment generally results in a loss of functional strength with elbow flexion and radioulnar supination. 

          Bicep tendon repair surgeries have two common approaches: single incision and double incision.  There are multiple factors influencing a patient’s surgical approach such as mechanism of injury and surgeon preference. 

          Athletes who sustain a distal biceps tendon rupture are generally younger and more active than the average patient population that receives this surgery and they usually require more intensive rehabilitation to reach their prior level of function and return to sport. 

          The purpose of this article was to assess multiple rehabilitation approaches to compare their effectiveness in functional outcomes and return to sport. 

Methods: 

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.  The search was performed using the MEDLINE, Cochrane, Web of Science and Scopus databases for articles referring to treatment and rehabilitation of distal biceps tendon rupture in athletes. 

          The initial search yielded 1254 results.  Those results were then scanned for duplicates, accessibility and exclusion criteria, leaving 10 articles that were ultimately included in this review. 

Results: 

This systematic review demonstrated that the return to sport rate of athletes following distal biceps tendon rupture was 97.5%, interestingly this figure as well as the recovery time seem to be independent of postoperative immobilization times and strengthening protocols used.  Although return to work is expected in 3-4 months, return to sport time for athletes ranged from 7-15 months.  The authors attributed this to the increased demands that athletes place on their biceps. 

          Although there is no consensus on optimal rehabilitation or strengthening protocols, most studies focused on early mobilization followed by a graded strengthening protocol.  Most of the rehabilitation protocols featured in these studies included a 2-week post-operative period of immobilization with strengthening exercises beginning at the fourth post-operative week.  No differences in return to sport time were noted between differing rehabilitation protocols. 

Discussion/Clinical Utility: 

This systematic review is useful because it allows us to look at a collection of the current best evidence regarding the rehabilitation of distal biceps tendon rupture.  Though there was no noted difference in recovery times between different rehabilitation protocols, it is important to note that there are similarities in the overall course of treatment for this type of pathology. 

          Based on the evidence presented, it is important to start with a short period of immobilization to allow the injured tissue to begin healing.  After this, the next stage in the rehabilitation process is to regain range of motion in the affected arm.  Next at around 4-weeks post-surgery, strengthening of the injured muscle can begin.  Although this doesn’t give any specific recommendations in terms of a strengthening or stretching protocol, it does provide a basic timeline and methodology to guide treatment for athletes who are hoping to return to sport. Due to the variable nature of human anatomy and recovery times in the population, specific protocols can have limited utility in the clinic.  It is instead preferable to allow basic concepts paired with continual assessment of a patient’s progress and pain state to guide the course of rehabilitation. 

          One of the limitations of this study is that it focused specifically on athletes, a relatively small portion of the population.  Though the data cannot be blindly generalized to the entire population, this is still useful data because the overall course of treatment is likely to remain mostly unchanged.  The main difference in the athletic population is the higher level of function that is required to get back to.  Keeping this in mind, a non-athletic member of the population without comorbidities is likely to actually have a faster recovery due to the lower demands that will be placed on their bicep muscles. 

References

Pitsilos, C., Gigis, I., Chitas, K., Papadopoulos, P., & Ditsios, K. (2022). Systematic review of distal biceps tendon rupture in athletes: Treatment and Rehabilitation. Journal of Shoulder and Elbow Surgery, 31(8), 1763–1772. https://doi.org/10.1016/j.jse.2022.02.027

Effects of virtual reality exercises and routine physical therapy on pain intensity and functional disability in patients with chronic low back pain

by ptfadmin | Apr 3, 2024 | Health Tips

Reviewed by: Zachary Stango, SPT; Bridget Collier, PT, DPT

The increase in virtual reality and gamification has been implemented in numerous aspects of our daily lives, and the area of rehab is one realm in which advancements in technology have the possibility to make tremendous impacts on patient outcomes. The randomized controlled trial conducted by Afzal et al. (2022) aimed to analyze the effects of implementing virtual reality exercises into a physical therapy routine, on pain and perceived disability, in patients with chronic low back pain.

The inclusion criteria for this study consisted of participants aged 25-50 with a history of chronic low back pain, which the study defined as pain persisting for greater than 12 weeks. Patients were randomly assigned to a group receiving conventional physical therapy, consisting of a moist heat pack, hamstring stretching, and loading and stretching of the lumbar spine musculature. The experimental group underwent the same therapeutic interventions, with the addition of two virtual reality interventions: the reflex ridge and body ball game. The reflex ridge made participants complete movements such as trunk side bending, sitting, and jumping to avoid obstacles on the screen. The body ball game included arm movements while kicking a ball displayed on the device. Each group underwent their respective interventions three times a week for a total of 12 weeks, with metrics analyzed after every quarter completion of the study. The 84 participants had their pain levels  measured using the Visual Analogue Scale (VAS) and their perceived disability measured through the Modified Oswestry Disability Index (MODI). Both of the groups displayed significant improvements in their levels of pain and subjective disability, with the group undergoing the additional virtual reality interventions exhibited significant reductions in their scores compared to the conventional group, correlating with better outcomes.

Clinical Bottom Line:

Virtual reality allows for the participants to dive into their own world of adventure, and the rehabilitative world can use this tool to allow patients the opportunity to actively complete tasks in their animated realm, which could translate to completion of these tasks in everyday life. Even though the activities in this study that were completed in virtual reality did not necessarily mimic activities of daily living for every participant, the motions can serve as a starting point to progress these to add in loading of the lower back. Individuals with chronic low back pain often show signs of fear avoidance of specific movements and the results of this study suggest that virtual reality can aid in helping these individuals regain the confidence to complete previously avoided movements and return to their prior level of function.

References:

Afzal MW, Ahmad A, Mohseni Bandpei MA, Gilani SA, Hanif A, Waqas MS. Effects of virtual reality exercises and routine physical therapy on pain intensity and functional disability in patients with chronic low back pain. J Pak Med Assoc. 2022;72(3):413-417. doi:10.47391/JPMA.3424

Unwrapping the “black box” of balance training in people with multiple sclerosis – A descriptive systematic review of intervention components, progression, and intensity

by ptfadmin | Mar 27, 2024 | Health Tips

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction:

Neuromuscular disorders that result in the demyelination of neurons, like multiple sclerosis (MS), experience several motor, sensory, and cognitive deficits over the disease’s progression. Reduction in balance capabilities is common among this population and is a major reason for these patients to seek out physical therapists to combat the degeneration that occurs over time. It is well understood and recommended that all older adults with chronic health conditions like MS participate in moderate to high-intensity balance training at least 2-3 times per week to avoid increasing their risk of falls. This review looked to synthesize how training frequency, intensity, time components, duration, and progression in balance training can be best completed for people living with MS.

Methods:

This review included 40 eligible studies which had to be of randomized control/clinical trial or systematic review in origin. Inclusion criteria required all participants to be adults with a diagnosis of MS, a severity level of 7.5 or lower on the Expanded Disability Status Scale, be able to transfer from one seated position to another independently, and at least 50% of exercise interventions used in the trials must have been directly relate to challenging balance control.

Conclusions of the Study:

This study effectively synthesized the major components of designing a balance training program. The majority of the exercises performed challenged general motor and sensory deficits commonly seen in MS, but fewer studies included training of reactive motor strategies, and even less challenged tasks requiring cognitive dual tasking. This aspect was surprising as cognitive dual-tasking ability is a strong indicator of potential fall risk for patients with MS. The balance training progression among each of the studies also had no specific method and seemed to be specific to the clinician treating the patient. The researchers stated that the exact order in which progression is made does not matter whether that is through changing the base of support, the cognitive demand of the task, or the somatosensory deficit being targeted as long as the task is challenging the patient’s specific deficits. Balance training intensity also had no common system among any of the studies and was oddly not measured often. Two studies utilized visual displacement of the center of mass and the excessive corrective upper limb movements as indicators of failure of an exercise, while others cited the patient’s perception of difficulty as their marker for intensity. The researchers concluded that there is a current lack of evidence providing clinicians with specific parameters to program and progress their patients and that future research should be performed to determine better guidelines for treating MS patients.

Clinical Implications:

Based on this review, the current state of evidence on exercise programming specifics for balance training in patients living with MS is mostly inconclusive. The best method of proceeding with treating individuals with MS would be to first identify what systems have been affected most by the MS, whether it is more motor, sensory, or cognitive. The second step would be to determine your progression model based on how the patient presents and their goals. For example, deciding when to incorporate cognitive dual tasks or to reduce the patient’s base of support first. Furthermore, when gauging the intensity of balance exercise it is recommended to determine the patient’s perception of intensity, such as with an RPE scale, and to also gauge the patient’s difficulty through observing the visual displacement of the patient’s center of mass and any excessive corrective upper limb movement. Combining the use of both these factors should improve the reliability of determining the patient’s exercise intensity. By taking these components into account a PT should be able to effectively program and progress a patient’s balance training program and tailor it to their goals.

References:

Brincks, J., Dalgas, U., Franzén, E., Callesen, J., Wallin, A., & Johansson, S. (2023). Unwrapping the “Black Box” of balance training in people with multiple sclerosis – a descriptive systematic review of intervention components, progression, and intensity. Multiple Sclerosis and Related Disorders, 69, 104412. https://doi.org/10.1016/j.msard.2022.104412

Pragmatic application of manipulation versus mobilization to the upper segments of the cervical spine plus exercise for treatment of cervicogenic headache: a randomized clinical trial

by ptfadmin | Mar 20, 2024 | Health Tips

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction:

Cervicogenic headaches are a common form of headache that impacts up to 20% of the population. These headaches commonly come from the musculoskeletal components surrounding the cervical spine and are exacerbated by neck movements. Current clinical practice guidelines suggest manual technique usage in conjunction with exercise as the best course of treatment, with some of the most common manual techniques utilized being mobilizations and manipulations. This study intended to determine which method is more effective in reducing patient discomfort and improving function in patients who have cervicogenic headaches.

Methods:

The study was a randomized pragmatic clinical trial that required all patients to be diagnosed with cervicogenic headaches, have tenderness to palpation in at least one joint in the upper cervical spine region, a neck disability index (NDI) of at least 20% or greater, and at least a 2/10 level of pain on the NPRS pain scale. All patients completed several self-report measures including the NDI, Headache impact test, and NPRS pain scale. The study compared upper cervical spine (C0-C3) mobilizations versus manipulations of the same area.

Conclusions of the Study:

The study concluded there was no difference in the patient’s perceived improvements in pain and function and objective ROM. This contradicts previous evidence stating that manipulations provided greater improvements in patient-reported outcomes than mobilizations. However, many previous studies utilized a prescriptive approach that had all manipulations and mobilizations performed at the same location, whereas this study utilized a pragmatic approach that allowed the treating therapists to use their own clinical judgment to determine where to perform manual techniques. It can be concluded from this study that despite there being some limitations, especially the smaller sample size of 45 people, that when treating patients with cervicogenic headaches both manipulations and mobilizations are viable options to improve patient pain and disability.  

Clinical Implications:

This study provides some evidence for the idea that manipulation or mobilization for cervicogenic headache patients can have nearly the same effect on patient perceived functionality. Given the increased risks of performing upper cervical spine manipulations it may be better to defer to mobilizations when deciding on manual treatments for patients with cervicogenic headaches, unless mobilizations have otherwise been unsuccessful. The similar improvements seen may be due to the neurophysiological input to the brain that is improving patient functionality, rather than any increases in motion after mobilization or manipulation. The key part of this study that differs from previous research is its allowance of the PT’s clinical judgment to determine what the patient needs during treatment. This highlights the importance of reassessing from session to session to determine exactly what the patient may benefit from more, it is important to keep in mind the differences in the methods of this study compared to previous iterations.

Reference

Lerner-Lentz, A., O’Halloran, B., Donaldson, M., & Cleland, J. A. (2020). Pragmatic application of manipulation versus mobilization to the upper segments of the cervical spine plus exercise for treatment of cervicogenic headache: A randomized clinical trial. Journal of Manual & Manipulative Therapy, 29(5), 267–275. https://doi.org/10.1080/10669817.2020.1834322

Supervised Training Compared With No Training or Self-training in Patients With Subacromial Pain Syndrome: A Systematic Review and Meta-analysis

by ptfadmin | Mar 15, 2024 | Health Tips

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction:

Shoulder pain is incredibly common among the general population with a prevalence of between 7-26%. Most of this shoulder pain is attributed to the generalized term of Subacromial pain syndrome (SAPS), subacromial impingement syndrome, rotator cuff tendinopathy, or some other variant of these. This dysfunction is traditionally linked to overuse or dysfunction of underlying structures in the area of glenohumeral joint, altered kinematics of the shoulder, or slouched posture. This meta-analysis looks to compare patient treatment outcomes when they take part in an intensive supervised exercise program, a home training program, and no training at all.

Methods:

The systematic review included studies with populations of non-traumatic event related shoulder pain with pain lasting at least 1 month before seeking professional help and no other clear diagnosis at hand. Supervised training was defined as training instructed by a healthcare professional two or more times. Home Training included a take home leaflet from a healthcare professional or one time instruction, but no other instruction, and no training received was no instruction at all and were left to heal without therapy. The study lengths ranged from being 6 weeks to 6 months long and used multiple patient reporting handouts to determine patient pain and functionality.

Conclusions of the Study:

The review determined that having supervised training was better than no training at all and improved pain at rest and during movement, shoulder function, and patient perceived effect. However, supervised training and home training had equal effects on pain and shoulder function. The researchers stated that supervised training saw greater benefits in patients with higher pain levels and disability levels at baseline, as well as greater adherence to the training protocol. This suggests that the clinician will have to use their clinical judgement to determine which patients will benefit from more of a home based exercise program, and which will require more in person supervision to recover from SAPS or other similar conditions.

Clinical Implications:

This paper gives insight to the necessity of a PT’s judgement when treating their patient’s. The improvements in pain and shoulder function patient’s receive from exercise can be seen regardless of whether it is supervised for multiple visits per week within clinic or unsupervised at home. The key is to take into account the patient’s stage of healing, irritability levels, baseline level of function, and attitude toward exercise to decide if they can make progress on their own. If the patient happens to be in a high irritability state incorporating several sessions of supervised therapy may be greatly beneficial to build the patient’s confidence and comfort with performing exercises on their own, in conjunction with manual techniques to desensitize the painful areas. This may allow the therapist to eventually transition the patient to a self-management home exercise program. The goal should be to educate and empower patients to understand the benefits of the exercise and be able to manage their own rehabilitation at home when treating individuals with SAPS or other similar conditions.

Reference:

 Liaghat, B., Ussing, A., Petersen, B. H., Andersen, H. K., Barfod, K. W., Jensen, M. B., Hoegh, M., Tarp, S., Juul-Kristensen, B., & Brorson, S. (2021). Supervised training compared with no training or self-training in patients with Subacromial Pain Syndrome: A systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 102(12). https://doi.org/10.1016/j.apmr.2021.03.027