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Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association

by | Aug 16, 2024 | Health Tips

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

Article:

Neck Pain:  Revision 2017 Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association

Introduction:

The orthopaedic section of the American Physical Therapy Association (APTA) published these clinical practice guidelines in 2017 to give recommendations to clinicians in the differential diagnosis, assessment and treatment of neck pain. 

              These recommendations are designed to fit into the International Classification of Functioning, Disability, and Health (ICF model) that was introduced by the World Health Organization (WHO) to improve clinician’s ability to appropriately treat and communicate with patients by including pathoanatomical, psychosocial and societal factors when assessing a patient’s wants and needs. 

Methods: 

Content experts were appointed by the orthopedic section of the APTA to search the current literature for articles relating to the treatment, assessment and diagnosis of neck pain.  Articles included were taken from PubMed, Cochrane Library, Web of Science, CINAHL, ProQuest Dissertations and Abstracts, PEDro, ProQuest Nursing and Allied Health Sources, and Embase with dates ranging from 2007 to 2016. 

              The chosen articles were then categorized based on level of evidence where I represented the highest quality evidence and V represented expert opinion.  After the evidence was reviewed and ranked, the experts developed and ranked recommendations utilizing the information.  A ranked recommendations were based on strong evidence while F ranked recommendations were based on expert opinion.  These recommendations were further categorized into the following content areas; pathoanatomical features/differential diagnosis, Imaging, Examination, Diagnosis/classification, and interventions.  These recommendations are further divided based on the type of neck pain the patient is presenting with; neck pain with mobility deficits, neck pain with movement coordination impairments, neck pain with headaches, and neck pain with radiating pain.    

Results: 

After reviewing the available literature, the authors made the following recommendations: 

              Clinicians should perform assessments on patients to screen for serious pathology and refer to other providers when necessary. 

              Clinicians should use validated self-reported outcome measures to assess and track patient pain, status, and physical/psychological function throughout an episode of care. 

              Clinicians should use easily reproducible activity limitation and participation restriction measures to assess patient function throughout an episode of care.

              Clinicians should use assessments of body impairments to determine if a patient has one of the following; (1)neck pain with mobility deficits (cervical active range of motion), (2)neck pain with headache (cervical active range of motion, the cervical flexion-rotation test, upper cervical segmental mobility testing), (3)neck pain with radiating pain (neurodynamic testing, spurling’s test, distraction test, the Valsalva test), (4)neck pain with movement coordination impairments (cranial cervical flexion and neck flexor endurance test.)

              To effectively classify patients into one of the 4 neck pain designations, clinicians should use cervical motion limitations, thoracic motion limitations, presence of cervicogenic headache, history of trauma and referred or radiating pain into an upper extremity.

Interventions for neck pain with mobility deficits:

              For patients with acute neck pain clinicians should use thoracic manipulation, a program to improve neck ROM, and scapulothoracic and upper extremity strengthening.  Clinicians may provide cervical manipulations and/or mobilization.

              For patients with subacute neck pain clinicians should use neck and shoulder girdle endurance exercises and may provide thoracic and cervical manipulations/mobilizations.

              For patients with chronic neck pain clinicians should employ a multimodal approach including thoracic and cervical manipulations/mobilizations, mixed exercises for the cervical and scapulothoracic regions, dry needling, laser therapy, and intermittent manual or mechanical traction. 

              Clinicians may provide neck, shoulder girdle and trunk endurance exercises and patient education.  Patients should be encouraged to have an active lifestyle and to address psychosocial factors.

Interventions for neck pain with movement coordination impairments

              For patients with acute neck pain clinicians should educated their patients on returning to normal, nonprovocative pre-accident activities as soon as possible, minimize the use of a cervical collar, and perform postural and mobility exercises to decrease pain and increase range of motion.  Patients should be advised that recovery is expected within the first 2-3 months. 

              Clinicians should employ a multimodal approach including manual interventions and exercise programs.  For patients at low risk of developing chronic symptoms, clinicians may provide a single session consisting of education, a detailed exercise program and TENS treatment.  Clinicians should monitor recovery status for signs of chronicity.

              For patients with chronic neck pain clinicians may provide manual interventions, patient education focused on encouragement and exercise programs that utilize concepts from cognitive behavioral therapy. 

Interventions for neck pain with headaches

              For patients with acute neck pain clinicians should provide active mobility exercises as well as C1/C2 self-sustained natural apophyseal glide (SNAG) exercises. 

              For patients with subacute neck pain clinicians should provide cervical manipulation/mobilization as well as SNAG exercises. 

              For patients with chronic neck pain clinicians should provide cervical or cervicothoracic manipulation/mobilization combined with exercises for range of motion, strength and endurance.

Interventions for neck pain with radiating pain

              For patients with acute neck pain clinicians may provide mobilizing and stabilizing exercises, laser treatments, and short-term use of a cervical collar.

              For patients with chronic neck pain clinicians should employ a multimodal approach including mobilization/manipulation, exercise interventions and mechanical intermittent traction.  Clinicians should encourage participation in occupational and exercise activities. 

Discussion and clinical utility: 

This CPG does and excellent job of providing different intervention approaches based on different patient presentations.  Neck pain is variable and sometimes inconsistent, therefore it is important to adjust interventions based on a patient’s current presentation. 

              It is also important to note the emphasis on educating patients to remain active.  Many of the stated interventions involve increasing range of motion in the apophyseal joints of the cervical and thoracic spine.  The challenge is that when in pain, it can be counterintuitive for patients to continue mobilizing those areas.  Encouraging an active lifestyle is a good way of ensuring that benefits introduced during a therapy session continue to have carry over into a patient’s day to day life.

References

Neck Pain: Revision 2017 Peter R. Blanpied, Anita R. Gross, James M. Elliott, Laurie Lee Devaney, Derek Clewley, David M. Walton, Cheryl Sparks, and Eric K. Robertson Journal of Orthopaedic & Sports Physical Therapy 2017 47:7, A1-A83

An Evidence-Based Clinical Commentary for Treating Patients with Hypermobile Ehlers-Danlos Syndrome or a Hypermobility Spectrum Disorder

by | Aug 8, 2024 | Health Tips

Reviewed by Maggie McPherson, SPT

Article:

An Evidence-Based Clinical Commentary for Treating Patients with Hypermobile Ehlers-Danlos Syndrome or a Hypermobility Spectrum Disorder published in Orthopaedic Physical Therapy Practice

Dr. Joseph Signorino, DPT, DSc, Dr. Samuel Bikkers, DPT, and Dr. Kate Divine, DPT put together this clinical commentary to guide physical therapy treatment of individuals with Ehlers-Danlos Syndrome (EDS) or Hypermobility Spectrum Disorder (HSD). They worked to combine evidence-based interventions with their own clinical expertise and clinical reasoning to provide coherent guidelines. The main principles of their commentary included options for monitoring and addressing common symptoms and deficits seen in individuals with EDS and HSD, the importance of education and empathy, the incorporation of the pelvic floor, and some helpful insights into the role of manual therapy for individuals with EDS or HSD.

Some of the common barriers to efficient and pain free movement patterns for individuals with EDS or HSD are identified by the authors as pain, fear of movement, fatigue, and decreased proprioception. Advised interventions to modulate pain perception and decrease fear of movement included education and empathy, graded exposure, progressive resistive exercise (PRE) beginning with gentle isometrics, and aerobic exercise between 40-75% VO2max or at a Borg RPE rating of 13. Aerobic exercise and PRE with isometrics were also recommended as interventions to address fatigue. The authors underlined that since fatigue and pain are common side effects of both resistive and aerobic exercise, clinicians should ensure they are properly dosing exercise interventions, and may need to considerably scale down their resistance depending on how the individual presents. Hence, these authors recommend graded exposure: a gradual progression from isometrics, to multi angle isometrics, to isotonics with gradual progression to resisted movements in multiple planes according to the functional needs of the individual. Additionally, the authors note it is important to be aware of vascular presentations of EDS that need to be seriously considered when dosing any sort of exercise.

Another intervention the authors addressed was manual therapy. While traditionally manual therapy is seen as a means to improve joint mobility and flexibility, which is typically not the goal for the individual with EDS or HSD, the authors identify other potential benefits. They highlight commonly cited effects of manual therapy including changes in pain perception and modulation of the autonomic nervous system which could be beneficial to address pain and kinesiophobia. Regarding proprioception deficits, the authors mention taping, compression garments,  and motor control interventions as potential options for treatment.

Pelvic floor dysfunction is another common symptom that these individuals experience. The authors discussed interventions such as scheduled voiding, urgency strategies, education, and pelvic floor strengthening to mitigate organ prolapse. Here the authors also took time to talk about the importance of education and empathy. They found that individuals with EDS consistently report feeling that their health care providers do not have a good understanding of their condition and do not empathize with their symptoms. Each individual with EDS has a unique presentation, but a solid understanding of the nature of syndrome can help guide clinicians to appropriate treatment strategies.

Clinical Bottom Line:

These authors emphasize a personalized approach, carefully considering graded exposure and pain modulation to address kinesiophobia, pain and fatigability, using a variety of interventions that include gradual progressive resisted exercise starting from isometrics, aerobic exercise, manual therapy, taping, education, and empathy. Additionally, they highlighted the need for pelvic floor interventions as prolapse and incontinence can be concerns for individuals with EDS and HSD.

References:

Signorino JA, Bikkers SJ, Divine K. An Evidenced-Based Clinical Commentary for Treating Patients with Hypermobile Ehlers-Danlos Syndrome or a Hypermobility Spectrum Disorder. Orthopaedic Physical Therapy Practice. 2023;35(3):28-36. Accessed July 16, 2024. https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=164775891&site=eds-live

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

by | 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

Shoulder Pain and Mobility Deficits: Adhesive Capsulitis

by | Jul 9, 2024 | Health Tips

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

Article: 

Shoulder Pain and Mobility Deficits: Adhesive Capsulitis Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther 2013;43(5):A1-A31. doi:10.2519/jospt.2013.0302

Introduction: 

The purpose of this clinical practice guideline (CPG) is to review the current best evidence regarding the treatment, and diagnosis of adhesive capsulitis for orthopedic physical therapists.  The goal of CPGs is to provide a reference for currently practicing clinicians and students to utilize when treating common orthopedic conditions.  The goal of this CPG is not to give a blueprint or exact protocol for treatment.  Evidence should always be viewed through the lens of clinical reasoning and patient care before it is utilized in a clinical setting. 

Methods: 

A group of content experts was chosen by the orthopedic academy of the American Physical Therapy Association (APTA) to describe the treatment and assessment of adhesive capsulitis using language consistent with he International Classification of Functioning, Disability and Health (ICF) model. 

              These content experts performed a literature review using CINHAL, MEDLINE and the Cochrane Database of Systematic Reviews.  Sources were collected from 1966 to 2011.  The selected sources were then ranked in order of quality and given grades I-V where I is considered as being of higher quality and V is considered as being expert opinion.  The experts then used the available evidence to create recommendations that were assigned grades A-F; A representing strong evidence and F representing expert opinion. 

Results: 

The writers made recommendations regarding; pathoanatomical features, risk factors, clinical course, diagnosis/classification, differential diagnosis, imaging, outcome measures, activity limitations, physical impairment measures, and various treatment interventions. 

              For pathoanatomical features, a recommendation is to look for various range of motion impairments consistent with the capsular pattern of the glenohumeral joint, primarily a decrease in external rotation and abduction. 

              For risk factors, a recommendation is to look for diabetes mellitus or thyroid disease.  The condition is more prevalent in female patients aged 40-65 with a previous episode of adhesive capsulitis in the contralateral upper extremity. 

              Cor clinical course, it is recommended that clinicians consider that adhesive capsulitis occurs as a continuum of pathology with varying levels of pain, range of motion and functional limitations. 

For diagnosis/classification, clinicians should recognize that adhesive capsulitis presents as a gradual loss of function, passive range of motion and active range of motion that is often accompanied by pain. 

For examination and outcome measures, the authors recommend using validated outcome measures such as the SPADI and the DASH.  Activity limitation and participation restrictions should be determined based on the patient’s pain state and functional ability.  As for physical impairment measures, Active and passive range of motion and arthrokinematics motion are useful for predicting functional limitations. 

The treatment options with the highest level of evidence backing them are corticosteroid injections, patient education and stretching exercises.  Other less supported interventions include modalities, joint mobilization and translational manipulation. 

Discussion/Clinical Utility: 

This paper and CPGs in general are useful resources for clinicians and students.  As stated in the introduction, this CPG is not intended to make decisions for clinicians, but rather to serve as a reference and snapshot into what the research has been saying. 

              This CPG is useful because it lays out a great guideline for treatment, so clinicians have a starting point for planning treatment sessions.  It was especially helpful to have treatment recommendations based on the stage of this pathology and level of tissue irritability.  Being able to assess patients and determine their pain/irritability state is an important step in determining the most appropriate course of treatment so that we can provide the best care and optimize results.

References

Shoulder Pain and Mobility Deficits: Adhesive Capsulitis
Martin J. Kelley, Michael A. Shaffer, John E. Kuhn, Lori A. Michener, Amee L. Seitz, Tim L. Uhl, Joseph J. Godges, and Philip McClure.  Journal of Orthopaedic & Sports Physical Therapy 2013 43:5, A1-A31

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

by | 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 | 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