Physical Therapy Intervention for the Musculoskeletal System

1. Physical Therapy Intervention for the Musculoskeletal System Jeff Robinson, PT, FAAOMPT FOCUSED PRESENTATION

2. Introduction Intervention defined in a general way is “any measure whose purpose is to improve health or alter the course of disease.”1 Intervention is at the core of what a physical therapist does. One could argue the most important part of patient interaction is intervention. Ultimately, patients seek out physical therapists for a solution to a problem. The way in which physical therapists ultimately solve a patient problem is through intervention.

3. Primary goals of presentation 1) to define intervention as it relates to the practice of physical therapy for the musculoskeletal system 2) to provide a brief history of intervention in physical therapy as it relates to the musculoskeletal system 3) to provide a general overview of the evidence of procedural interventions in physical therapy related to the musculoskeletal system

4. Secondary Goals of presentation 1) to educate the reader about how to practice using evidence to answer clinical questions 2) to summarize evidence based principles and concepts To accomplish the secondary goals, the author defines evidence based principles and concepts and shares with the reader the clinical questions asked in gathering the evidence for this work.

5. Intervention According to The Guide to Physical Therapist Practice, “intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition that are consistent with the diagnosis and prognosis.” 2

6. History of Intervention in Physical Therapy Modern day musculoskeletal interventions in physical therapy were born out of the need to treat victims of the poliomyelitis epidemic of the late 1800s and the early 1900s for the impairments of muscle weakness and decreased range of motion. 3 The various wars throughout history also resulted in many musculoskeletal injuries which further drove the need for intervention. 3 Moffett describes interventions such as exercise programs, hydrotherapy, massage, and other modalities used for veterans of World War I. 3 The first textbook written by a physical therapist was actually named after musculoskeletal interventions. The book was published in 1921 by Mary McMillan and titled, Massage and Therapeutic Exercise. 3

7. Intervention The procedural intervention category is further divided up into 9 general sub-headings: • Therapeutic exercise. • Functional Training in Self Care and Home Management • Functional Training in Work • Manual Therapy Techniques • Prescription, Application and as Appropriate, Fabrication of Devices and Equipment • Airway Clearance Techniques • Integumentary Repair and Protection Techniques • Electrotherapeutic modalities • Physical Agents and Mechanical Modalities For the most part all of these, all except for subheadings for airwar clearance and integumentary repair are applicable to musculoskeletal intervention. The Guide 2 divides interventions into 3 categories: 1) coordination, communication, and documentation 2)Patient/Client-Related Instruction and 3) procedural interventions.

8. Intervention The first 2 headings (1) coordination, communication, and documentation and (2)Patient/Client-Related Instruction will not be covered in this presentation This presentation will focus on the procedural interventions for musculoskeletal conditions

9. Intervention The highest level of evidence for intervention studies are systematic reviews of RCTs (Randomized controlled trials) Level 1a. 4 The next highest level of evidence is an individual RCT (with narrow confidence interval). Once studies are located, they need to be critically appraised to ensure validity. 4

10. Hierarchy of Evidence

11. Critically Appraising the Evidence - RCT • “Is the evidence about therapy valid?” • 1. “Was the assignment of patients to treatment randomized?” • 2. “Was the randomization concealed?” • 3. “Were the groups similar at the start of the trial?” • 4. “Was the follow-up of patients sufficiently long and complete?” • 5. “Were all patients analyzed in the groups to which they were randomized?” • 6. “Were patients, clinicians and study personnel kept blind to the treatment?” • 7. “ Were groups treated equally, apart from the experimental therapy?”

12. Critically Appraising the Evidence • “Is the valid evidence about therapy important?” • 1. “What is the magnitude of the treatment effect?” • 2. “How precise is the estimate of the treatment effect?” • “Can we apply this valid, important evidence about therapy in caring for our patient?” 1. “Is our patient so different from those in the study that its results cannot apply?” 2. “Is the treatment feasible in our setting?” 3. “What are our patient’s potential benefits and harms from the therapy?” 4. “What are our patient’s values and expectations for both the outcome we are trying to prevent and the treatment we are offering?

13. Foreground Question Foreground questions were generated throughout the presentation using the PICO method. P – Patient I – Intervention C – Comparison O - Outcome

14. Procedural InterventionsTherapeutic Exercise • Smidt et al. 7 concluded that exercise is effective for several musculoskeletal conditions including: knee osteoarthritis, ankylosingspondylitis, hip osteoarthiritis. They concluded that there was not enough evidence to support or not the support the effectiveness for neck pain, shoulder pain, and repetitive strain injury. • The authors concluded that exercise is not effective for acute low back pain. • The general conclusion by the authors was, that “exercise therapy is effective for a wide range of chronic disorders.”

15. Procedural InterventionsTherapeutic Exercise Taylor et al. 8 found evidence for effectiveness of therapeutic exercise for arthritis, low back and neck pain, fractures, and lower and upper limb disorders. Overall conclusions on therapeutic exercise: There is robust evidence supporting the effectiveness of therapeutic exercise for musculoskeletal conditions.

16. Procedural InterventionsFunctional Training in Self – Care and Home Management • Observations • Dearth of evidence evaluating the use of functional training in self care and home management for patients with musculoskeletal dysfunction • Most of research on functional training in physical therapy is in the realm of back schools, but the evidence is lacking for the effectiveness of back schools in the non-occupational setting • Much of research on back schools is on multidisciplinary treatment not specific physical therapy functional training interventions

17. Procedural InterventionsFunctional Training in Self – Care and Home Management • Best available evidence for this broad intervention category was this RCT on functional vs. strength training 9 • Functional training included sit to stand, forward reaching to opposite foot, forward and side-step walking, etc. • Study concluded subjects with functional training achieved equal strength gains compared to subjects who underwent a strength program • Functional training group had greater improvements in balance and coordination in ADLs

18. Procedural InterventionsFunctional Training in Self – Care and Home Management • Best available evidence for specific type of functional training (Back School). • Recent (2010) RCT found “functional multidisciplinary rehabilitation” (which included back school) to be better than outpatient PT in increasing function 10 • Systematic review found moderate evidence for effectiveness of back school in decreasing pain and increasing functional status (2005) 11

19. Procedural InterventionsFunctional Training in Self – Care and Home Management • Observations/Conclusions • Evidence may be lacking because in musculoskeletal patients often times we are treating at the level of impairment (through therapeutic exercises, manual therapy, etc.) which automatically results in increased function • Perhaps more of the functional training literature in physical therapy is done on neurological patients • More research is needed to evaluate the effectiveness of functional training in patients with musculoskeletal dysfunction

20. Procedural InterventionsFunctional Training in Work (job, school, play) • 2010 Cochrane review was able to efficiently answer my clinical question: • 91 page study found that there “might” be a positive effect of work hardening type program for sub-acute and chronic back pain 12 • Some of the studies reviewed did include exercise and “physical conditioning” • Even in the well done studies there were conflicting results

21. Procedural InterventionsFunctional Training in Work (job, school, play) 2010 systematic review looked at what they called “neuromuscular training” which in reading the article included sport specific training or functional training for play 13 Results concluded there is evidence that this type of training reduces the incidence of injury

22. Procedural InterventionsFunctional Training in Work (job, school, play) • Observations/Conclusions/Recommendations • There is a lack of consensus on the effectiveness of functional training in work as it relates to low back pain • There is evidence to support functional training in sports for injury prevention • Functional training done in the clinic is most likely never done solely, but rather as part of a comprehensive treatment plan that includes other interventions. • Future studies may need to compare functional training vs. individualized physical therapy intervention plus functional training.

23. Procedural InterventionsManual Therapy Techniques Bronfort et al 14 included 322 references in a 33 page report in the most comprehensive, thorough review on manual therapy found In patients with low back pain, headache, cervicogenic dizziness, spinal mobilization/manipulation is effective

24. Procedural InterventionsManual Therapy Techniques In patients with neck pain, thoracic manipulation is effective. For neck pain alone, evidence is inconclusive Also inconclusive evidence for mid back pain, sciatica, coccydinia, TMJ disorders, sciatica, tension type headache, knee OA, fibromyalgia, migraines For low back pain, massage is effective

25. Procedural InterventionsManual Therapy Techniques • Observations/Conclusions/Recommendations: • Manual therapy is effective for certain musculoskeletal dysfunctions • Studies that focus on manual therapy have increased dramatically in recent years • The profession should continue to study the various manual therapy techniques used in physical therapy practice for conditions where there is currently inconclusive evidence

26. Procedural InterventionsPrescription, Application of Equipment • Spinal orthoses in the workplace • A relatively recent systematic review 15(which included RCTs and lower quality of studies due to lack of RCTs) concluded: • No evidence to support the use of back belts in the work environment in preventing injury or decreasing lost time from work • Future research should focus on well designed RCTs

27. Procedural InterventionsPrescription, Application of Equipment Custom semi-rigid FOs are effective in treating and preventing plantar fasciitis and posterior tibial stress fractures 16 Custom semi rigid FOs show small to moderate effects for patellofemoral pain syndrome 16 Further research with high quality studies was recommended

28. Procedural InterventionsElectrotherapeutic Modalities • TENS • Results of 3 systematic reviews done by the Cochrane Collaboration provided mixed results • One of the three studies did include musculoskeletal and non-musculoskeletal conditions and could not make any definitive conclusions 17 • One study could not support its use in chronic low back pain 18 • One study could not make any definitive statements for TENS use for neck pain 19

29. Physical Agents and Mechanical Modalities 2 papers were located that offered broad summaries of the effectiveness of various physical agents Unfortunately the reviews were not systematic in nature One described a less than adequate grading system for studies included and had no regard for randomization or blindness 20 Another did not provide any information on how studies were chosen for the review and included no information on the rating system used 21 I chose the physical agent, ultrasound to search in depth

30. Ultrasound A recent Cochrane Review addressed therapeutic ultrasound for OA of the knee and found no evidence to support effectiveness22 Robertson et al agreed in their review, concluding there is little evidence that active therapeutic ultrasound is more effective than placebo in their study which looked at therapeutic ultrasound for various afflictions23

31. Procedural Interventions - Summary There is robust evidence for effectiveness of therapeutic exercise for musculoskeletal problems There is good evidence to support manual therapy for musculoskeletal problems Ultrasound is not effective for musculoskeletal problems More studies are needed to determine the effectiveness of functional training for self care and work, and TENS

32. References • The free dictionary by Farlex. Retrieved March 20, 2011, from http://medical dictionary .thefreedictionary.com/intervention. • American Physical Therapy Association. Guide to Physical Therapist Practice. Second Edition. Phys Ther. 2001;81:9-746. • Moffat M. History of physical therapy practice in the united states. J Phys Ther Ed. 2004;17:(3):15-25. • Portney LG, Watkins MP. Foundations of Clinical Research, 3rd edition. Upper Saddle River: Pearson Prentice Hall, 2009. • Straus SE. Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine How to Practice and Teach EBM, 3rd edition. Philadelphia: Elsevier Churchill Livingstone, 2005. • Evidence Based Medicine/Practice Pyramid & USD Databases. In The University of South Dakota. Retrieved March 20, 2011, from http://libguides.usd.edu/EBM. • Smidt N, deVet CW, Bouter LM, Dekker J. Effectiveness of exercise therapy: A best-evidence summary of systematic reviews. Australian Journal of Physiotherapy. 2005;51:71-85. • Taylor NF, Dodd KJ, Shields N, Bruder A. Therapeutic exercise in physiotherapy practice is beneficial: a summary of systematic reviews 2002-2005. Australian Journal of Physiotherapy. 2007;(53):7-16. • Krebs DE, Scarborough DM, McGibbon CA. Functional vs. strength training in disabled elderly outpatients. Am J Phys Med Rehabil. 2007;86(2):93-103.

33. References • Henchoz Y, deGoumoens P, So AK Paillex R. Functional multidisciplinary rehabilitation versus outpatient physiotherapy for non specific low back pain:randomized controlled trial. Swiss Medical Weekly. 2010;(140):w13133. • Heymans MW, vanTulder MW, Esmail R, Bombardier C, Koes BW. Back schools for nonspecific low back pain. Spine. 2005;30(19):2153-2163. • Schaafsma F, Schonstein E, Whelan KM, Ulvestad E, Kenny DT, Verbeek JH. Physical conditioning programs for improving work outcomes in workers with back pain. Cochrane Database Syst Rev. (1):CD001822,2010. • Hubscher M, Zech A, Pfeifer K, Hansel F, Vogt L, Banzer W. Neuromuscular training for sports injury prevention: a systematic review. Med Sci Sports Exerc. 2010 Mar;42(3):413-21. • Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy. 2010;18(3). • Ammendolia C, Kerr MS, Bombardier C. Back belt use for prevention of occupational low back pain: a systematic review. J of Manip and Phsiolog Therap. February 2005:128-134. • Hume P, Hopkins W, Rome K, Maulder P,  Coyle G, Nigg B. Effectiveness of foot orthoses for treatment and prevention of lower limb injuries: a review. Sports Medicine. 2008; 38(9):759-777. • Kroeling P, Gross A, Goldsmith CH, Burnie SJ, Haines T, Graham N, Brant A. Electrotherapy for neck pain. Cochrane Database Sys Rev. 2009;(4):CD004251.

34. References • Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low back pain. Cochrane Database Sys Rev. 2008;(4):CD003008. • Walsh DM, Howe TE, Johnson MI, Sluka KA. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database Sys Rev. 2009;(2):CD006142. • Allen R. Physical agents in the management of chronic pain by physical therapists. Phys Med Rehab Clinic of NA. 2006;17(2). • Rakel B, Barr JO. Physical modalities in chronic pain management. Nursing Clin of NA. 2003;38(3). • Welch V, Brosseau L, Peterson J, Shea B, Tugwell P, Wells G. Therapeutic ultrasound for osteoarthritis of the knee. 2010;Cochrane Database of Syst Rev. (3)CD0003132. • Robertson VJ, Baker KG. A review of therapeutic ultrasound: effectiveness studies. Phys Ther. 2001;81(7):1339-1350.

35. References • Herno A, Airaksinen O, Saari T, Luukkonen M. Lumbar spinal stenosis: a matched-pair study of operated and non-operated patients. Br J Neurosurg. Oct 1996;10(5):461-465. • Hurri H, Slatis P, Soini J, et al. Lumbar spinal stenosis: assessment of long-term outcome 12 years after operative and conservative treatment. J Spinal Disord. 1998;11(2):110-115. • Johnsson KE, Uden A, Rosen I. The effect of decompression on the natural course of spinal stenosis. A comparison of surgically treated and untreated patients. Spine. 1991;16(6):615-619. • Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Blood EA, Birkmeyer NJ, Hilibrand AS, Herkowitz H, Cammisa, FP, Albert TJ, Emery SE, Lenke LG, Abdu WA, Longley M, Errico TJ, Hu SS. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med. 2007;356(22):2257-70. • Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Blood EA, Birkmeyer NJ, Hilibrand AS, Herkowitz H, Cammisa, FP, Albert TJ, Emery SE, Lenke LG, Abdu WA, Longley M, Errico TJ, Hu SS. Surgical versus nonsurgical treatment for lumbar spinal stenosis. N Engl J Med. 2008;358:794-810. • Iversen MD, Choudhary VR, Patel SC. Therapeutic exercise and manual therapy for persons with lumbar spinal stenosis. Int J Rheumatol. 2010; 5(4):425-437.