Peter A. Huijbregts

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Interrater Reliability of Palpation of Myofascial Trigger Points in Three Shoulder Muscles

This observational study included both asymptomatic subjects (n=8) and patients with unilateral or bilateral shoulder pain (n=32). Patient diagnoses provided by the referring medical physicians included subacromial impingement, rotator cuff disease, tendonitis, tendinopathy, and chronic subdeltoid-subacromial bursitis. Three raters bilaterally palpated the infraspinatus, the anterior deltoid, and the biceps brachii muscles for clinical characteristics of a total of 12 myofascial trigger points (MTrPs) as described by Simons et al. The raters were blinded to whether the shoulder of the subject was painful. In this study, the most reliable features of trigger points were the referred pain sensation and the jump sign. Percentage of pair-wise agreement (PA) was ≥ 70% (range 63–93%) in all but 3 instances for the referred pain sensation. For the jump sign, PA was ≥ 70% (range 67–77%) in 21 instances. Finding a nodule in a taut band (PA = 45–90%) and eliciting a local twitch response (PA = 33–100%) were shown to be least reliable. The best agreement about the presence or absence of MTrPs was found for the infraspinatus muscle (PA = 69–80%). This study provides preliminary evidence that MTrP palpation is a reliable and, therefore, potentially useful diagnostic tool in the diagnosis of myofascial pain in patients with non-traumatic shoulder pain

Momentary temperature and differences in temperature over one week between the hands in reflex sympathetic dystrophy: A pilot study

A difference in temperature between the affected and normal extremity is one sign or symptom of reflex sympathetic dystrophy. Both patients and the literature report that the temperature can change over time. The aims of this pilot study were to investigate changes in the temperature of the extremities perceived over 1 week, and to assess whether temperature changes perceived during the previous week can be scored retrospectively by patients. The relationship with infrared outcomes was also investigated. Nine patients with reflex sympathetic dystrophy of one upper extremity were included. Using a visual analogue scale (VAS), the temperature of the extremities when completing the VAS (VAS(now)) and remembered differences in temperature in the preceding week (VAS(min) and VAS(max)) were recorded. Local infrared readouts were also obtained from both hands on entry to the study. There was no significant correlation between the VAS and infrared results. In most patients, temperature differences scored with a VAS changed considerably over time. The subjective range of differences in temperature could be scored adequately in retrospect using VAS(min) and VAS(max) scores. Further research is needed to confirm this observation and to examine the degree to which a VAS for temperature adequately represents the construct under consideration

Objective and subjective assessments of temperature differences between the hands in reflex sympathetic dystrophy

Objective: A difference in temperature between the affected and normal extremity is one of the signs or symptoms of reflex sympathetic dystrophy (RSD). These temperature differences are scored anamnestically, by palpation, or by measurements. We investigated the relationship between objective and subjective differences in skin temperature between the hands. Subjects and design: Fifty-one patients with RSD of one upper extremity participated (mean age 55 years, range 18-80). In the first 16 we investigated the reliability of the visual analogue scale (VAS) for recording perceived differences in skin temperature. In the remaining 35 patients the relationship between the VAS and objective infrared radiometry of the hands was investigated. Setting: Outpatients clinics of two university hospitals. Results: The VAS was found to be reliable in terms of response stability. There was no significant correlation between the objective and subjective outcomes. Conclusions: There is lack of correspondence between objective and subjective temperature measurements, which may be due to a normal discrepancy between objective and percieved temperature, and/or to alterations in perception due to RSD

Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: A systematic review of randomized clinical trials

Objective. To review the effectiveness of exercise therapy in patients with osteoarthritis (OA) of the hip or knee. Methods. A computerized literature search of Medline, Erabase, and Cinahl was carried out. Randomized clinical trials on exercise therapy for OA of the hip or knee were selected if treatment had been randomly allocated and if pain, self-reported disability, observed disability, or patient's global assessment of effect had been used as outcome measures. The validity of trials was systematically assessed by independent reviewers. Effect sizes and power estimates were calculated. A best evidence synthesis was conducted, weighting the studies with respect to their validity and power. Results. Six of the 11 assessed trials satisfied at least 50% of the validity criteria. Two trials had sufficient power to detect medium-sized effects. Effect sizes indicated small-to-moderate beneficial effects of exercise therapy on pain, small beneficial effects on both disability outcome measures, and moderate-to-great beneficial effects according to patient's global assessment of effect. Conclusion. There is evidence of beneficial effects of exercise therapy in patients with OA of the hip or knee. However, the small number of good studies restricts drawing firm conclusions

Muscle strength, pain and disability in patients with osteoarthritis

Objective: Reduced muscle strength is regarded as a risk factor for pain and disability in osteoarthritis (OA). Currently, various indices for muscle strength are used when assessing determinants of pain and disability. The goal of the present study was to evaluate these indices of muscle strength. Design: Isometric muscle strength was measured for 16 muscle actions around the knees and hips in 52 patients with OA of the hip and 70 patients with OA of the knee. Various indices of muscle strength were derived from these measurements, applying five alternative approaches. These approaches ranged from a single overall index to a set of 16 separate indices. The internal consistency of these indices was determined (Cronbach's α), and it was determined to what extent they could reveal the association between reduced muscle strength on the one hand and pain and disability on the other hand. Results: Internal consistency was satisfactory for all indices (Cronbach's α > 0.74). As expected, reduced muscle strength was associated with increased disability, but no clear relationship could be established between muscle weakness and pain. The strength of these associations did not depend on the approach used to derive the indices for muscle strength. Conclusions: The indices did not show major differences with regard to internal consistency or the extent to which the association with pain and disability could be revealed. For reasons of parsimony, approaches resulting in few indices appear to be most useful. However, muscle strength was found to be significantly reduced around affected joints, compared with muscle strength around unaffected joints. Therefore, the most suitable approach for reducing muscle strength data into indices is one that results in as few indices as possible, but with separate indices for muscle strength around affected and unaffected joints

Signs and symptoms in complex regional pain syndrome type I/reflex sympathetic dystrophy: Judgment of the physician versus objective measurement

Objective: To assess the relation between the subjectively assessed and objectively measured diagnostic signs and symptoms in complex regional pain syndrome type I (CRPS I) and to quantify their severity. Design: Diagnostic signs and symptoms were recorded in patients suffering from CRPS I of one upper extremity for less than I year. Independent assessors measured (a) pain by using four visual analog scales (VAS) and the McGill Questionnaire list of adjectives (MPQ), (b) edema with a hand volumeter, (c) skin temperature with an infrared thermometer, and (d) active range of motion (AROM) with goniometers. Setting: Two university hospitals. Patients: Ninety-five women and 40 men with CRPS I of one upper extremity. Results: Four signs and symptoms were diagnosed in 50 patients, and five in the remaining 85 patients. The mean score for present pain intensity was 31.5 mm and that for pain resulting from exertion of the affected extremity was 71.9 mm. A median of 11.5 words was chosen from the MPQ, with the highest number from its evaluative part. The difference in volume between both hands was 30.4 ml. The mean difference in temperature between the two hands was 0.78°C dorsally and 0.66°C palmarly. The largest decrease in mobility was seen in the wrist and fingers; the thumb was relatively less affected and the little finger relatively more affected than the other fingers. Conclusions: Bedside evaluation of CRPS I with Veldman's criteria was in good accord with psychometric or laboratory testing of these criteria

One-time physical therapist consultation in primary health care

Background and Purpose. One-time physical therapist consultation, prior to possible referral for physical therapy intervention, may enhance the quality of patient care, particularly if the referring physician is uncertain as to whether intervention by a physical therapist will be beneficial. The purpose of this study was to describe the use of consultation by a group of primary care physicians (PCPs) who could refer patients for a one-time consultation. Subjects and Methods. A 7-month observational study was conducted in the Netherlands with 59 pairs of randomly selected PCPs and physical therapists practicing in primary health care. Data were collected for the PCPs, the physical therapists, and the patients. Self-administered questionnaires (completed at the start and at the completion of the study), consultation request and report forms, and treatment referral records from health insurance agencies were used to obtain data. National reference data on patients referred by PCPs for intervention by a physical therapist were used to compare the data of patients referred by PCPs for a one-time consultation. The number and nature of consultation requests were determined as well as patient characteristics. The PCPs' satisfaction with the outcome and process of a one-time consultation and its impact on PCPs' management decisions also were described. Results. The number of referrals for a one-time consultation was 352 (X̄=5.9 per PCP, SD=5.4, range=0-20), resulting in a mean referral rate of 4.7 per 1,000 patients (SD=4.6). Characteristics of patients referred for a one-time consultation differed from national reference data of patients referred by their PCP for intervention by a physical therapist. Discussion and Conclusion. The results show that PCPs used the opportunity for a one-time physical therapist consultation and were satisfied with the outcome and process of consultation. The findings suggest that a one-time consultation is an appropriate and beneficial component of PCPs' patient management process. [Hendriks EJM, Kerssens JJ, Dekker J, et al. One-time physical therapist consultation in primary health care

Rehabilitacja medyczna i fizjoterapia oparte na wiarygodnych i aktualnych publikacjach - ocena krytyczna

Evidence-based medicine is the current undisputed predominant paradigm within medicine and allied health care. Guidelines for standardized reporting of research findings have facilitated critical evaluation of the relevant research literature. In addition, systematic reviews of the literature made available through computerized databases allow even busy clinicians and researchers rapid access to current best evidence. Despite the potential benefits of Evidence-Based Medicine (EBM) to clinical practice, over the years various points of criticism with respect to EBM have been formulated. This article provides a critical appraisal of the EBM paradigm discussing perceptions of EBM as cookbook medicine, inconsistency and contradiction in research findings, a proposed research pyramid not necessarily emphasizing the randomized controlled trial, a conceptual framework more relevant to the clinical and research needs of rehabilitation medicine and physiotherapy, the role of and impact on patients within the EBM paradigm, implementation of EBM, but also the current lack of evidence for increased efficacy of patient management based on EBM. The research base used in the EBM paradigm to support clinical decision-making is still far from complete. Demonstrating scientific evidence for EBM is a difficult task. Yet the EBM movement is of great importance for rehabilitation and physiotherapy to allow for increased transparency of care. The purpose of promoting this paradigm is optimum quality of care with conservation of professional autonomy