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Objective: To determine the effectiveness of exercise and soft tissue massage either in isolation or in combination for the treatment of non-specific shoulder problems. Methods: Database searches for articles from 1966 to December 2011 were performed. Studies were eligible if they investigated ‘hands on’ soft tissue massage performed locally to the shoulder or exercises aimed at improving strength, range of motion or coordination; non-surgical painful shoulder disorders; included participants aged 18–80 years and outcomes measured included pain, disability, range of motion, quality of life, work status, global perceived effect, adverse events or recurrence. Results: Twenty-three papers met the selection criteria representing 20 individual trials. We found low-quality evidence that soft tissue massage was effective for producing moderate improvements in active flexion and abduction range of motion, pain and functional scores compared with no treatment, immediately after the cessation of treatment. Exercise was shown by meta-analysis to produce greater improvements than placebo, minimal or no treatment in reported pain (weighted mean=9.8 of 100, 95% CI 0.6 to 19.0) but these changes were of a magnitude that was less than that considered clinically worthwhile. Exercise did not produce greater improvements in shoulder function than placebo, minimal or no treatment (weighted mean=5.7 of 100, 95% CI −3.3 to 14.7). Conclusion: There is low-quality evidence that soft tissue massage is effective for improving pain, function and range of motion in patients with shoulder pain in the short term. Exercise therapy is effective for producing small improvements in pain but not in function or range of motion. [ABSTRACT FROM AUTHOR]

Question: What is the clinical course of a new episode of non-specific neck pain in people who are treated with multimodal physical therapies in a primary care setting? Design: Observational study with 3-month follow-up, run in conjunction with a randomised trial. Participants: 181 adults who consulted a physiotherapist or chiropractor for a new episode of nonspecific neck pain. Outcome measures: Time to recover from the episode of neck pain, time to recover normal activity, and pain and neck-related disability at three months. Clinical and demographic characteristics were investigated as potential predictors of recovery. Results: Within 3 months, 53% of participants reported complete recovery from the episode of neck pain. On a scale from 0 (none) to 10 (worst), pain improved from 6.1 (SD 2.0) at baseline to 2.5 (SD 2.1) at 2 weeks and to 1.5 (SD 1.8) at 3 months. On a scale from 0 (none) to 50 (worst), disability improved from 15.5 (SD 7.4) at baseline to 5.4 (SD 6.4) at 3 months. Faster recovery was independently associated with better self-rated general health, shorter duration of symptoms, being a smoker, and absence of concomitant upper back pain or headache. Higher disability at 3 months was independently associated with higher disability at baseline, concomitant upper or lower back pain, older age, and previous sick leave for neck pain. Conclusion: People who seek physical treatments for a new episode of neck pain in this primary care setting typically have high pain scores that improve rapidly after commencing treatment. Although almost half of those who seek treatment do not recover completely within three months, residual pain and disability in this group is relatively low. Physiotherapists should reassure people with a new episode of neck pain that rapid improvement in symptoms is common, modifying this advice where applicable based on risk factors. [ABSTRACT FROM AUTHOR]

Background. The evidence that exercise intervention is effective for treatment of chronic low back pain comes from trials that are not placebo-controlled. Objective. The purpose of this study was to investigate the efficacy of motor control exercise for people with chronic low back pain. Design. This was a randomized, placebo-controlled trial. Setting. The study was conducted in an outpatient physical therapy department in Australia. Patients. The participants were 154 patients with chronic low back pain of more than 12 weeks' duration. Intervention. Twelve sessions of motor control exercise (ie, exercises designed to improve function of specific muscles of the low back region and the control of posture and movement) or placebo (ie, detuned ultrasound therapy and detuned short-wave therapy) were conducted over 8 weeks. Measurements. Primary outcomes were pain intensity, activity (measured by the Patient-Specific Functional Scale), and patient's global impression of recovery measured at 2 months. Secondary outcomes were pain; activity (measured by the Patient-Specific Functional Scale); patient's global impression of recovery measured at 6 and 12 months; activity limitation (measured by the Roland-Morris Disability Questionnaire) at 2, 6, and 12 months; and risk of persistent or recurrent pain at 12 months. Results. The exercise intervention improved activity and patient's global impression of recovery but did not clearly reduce pain at 2 months. The mean effect of exercise on activity (measured by the Patient-Specific Functional Scale) was 1.1 points (95% confidence interval [CI]=0.3 to 1.8), the mean effect on global impression of recovery was 1.5 points (95% CI=0.4 to 2.5), and the mean effect on pain was 0.9 points (95% CI=-0.01 to 1.8), all measured on 11-point scales. Secondary outcomes also favored motor control exercise. Limitation. Clinicians could not be blinded to the intervention they provided. Conclusions. Motor control exercise produced short-term improvements in global impression of recovery and activity, but not pain, for people with chronic low back pain. Most of the effects observed in the short term were maintained at the 6- and 12-month follow-ups. [ABSTRACT FROM AUTHOR]

Question: What predicts short- and medium-term activity limitation in people after ankle fracture? Design: Inception cohort observational study. Participants: Adults with ankle fracture recruited within days following cast removal from physiotherapy departments of teaching hospitals in Sydney, Australia. Outcome measures: The predictive value of variables that were injury-related (fracture management, fracture severity, angle of the ankle during cast immobilisation, and time from cast removal to baseline) and performance-related (activity limitation, pain, mobility, and dorsiflexion range of motion measured soon after cast removal) were examined in one dataset (n = 150) using univariate linear regression. Significant variables (p ≤ 0.20) were further examined with a multivariate linear model. A clinical prediction rule was derived then validated using data from an independent dataset (n = 94). Results: Fracture management, fracture severity, baseline activity limitation, pain, mobility, and dorsiflexion had significant but weak univariate associations with activity limitation. Only pain and dorsiflexion range of motion contributed independently to the clinical prediction rule. When applied to the validation data, the rule explained 12% of the short-term and 9% of the medium-term variance in activity limitation. Conclusion: Performance-related variables were stronger predictors than injury-related variables. A clinical prediction rule consisting of pain and dorsiflexion range of motion explained a small amount of the variance in short- and medium-term activity limitation, suggesting that it may be appropriate to identify people with high levels of pain and restricted dorsiflexion after ankle fracture and target intervention accordingly. [ABSTRACT FROM AUTHOR]

Anterior cruciate ligament (ACL) rupture is a common sporting injury, often managed surgically with patella-tendon or hamstrings-gracilis autograft. Some people who sustain the injury, request information about their prognosis if they choose to forgo surgery and opt for conservative management. Numerous studies provide data on the prognosis of conservatively managed ACL injuries. These studies have not been systematically reviewed. Thus, the aims of this systematic review are to describe the natural history and clinical course of function and proprioception in the conservatively managed ACL-deficient knee, and to identify prognostic factors. We searched MEDLINE, CINAHL, EMBASE, SportDiscus, PEDro and the Cochrane Central Register of Clinical Trials without language restrictions from the earliest record available up to July 2006. We also searched the Science Citation Index, and iteratively searched bibliographies for prospective studies of outcomes (>6 months follow-up) of conservatively managed complete ACL tears. Six criteria were used to assess the methodological quality of included studies. The main outcome measures were self-reported measures of knee function, activity level, performance in functional tasks and knee proprioception. Fifteen studies of variable methodological quality were included in the review. On average, patients with mixed or isolated ACL-deficient knees reported good knee function (87/100 Lysholm knee scale) at follow-up duration of 12-66 months. On average, functional performance assessed with the hop-for-distance test, was in the normal range. From pre-injury to follow-up there was a reduction in Tegner activity level of 21.3%. According to the methods used in the assessed studies, conservatively managed ACL-deficient knees have a good short-to mid-term prognosis in terms of self-reported knee function and functional performance. However, subjects reduced their activity levels on average by 21% following injury. [ABSTRACT FROM AUTHOR]

Background: Manipulation is a common treatment for non-specific neck pain. Neck manipulation, unlike gentler forms of manual therapy such as mobilisation, is associated with a small risk of serious neurovascular injury and can result in stroke or death. It is thought however, that neck manipulation provides better results than mobilisation where clinically indicated. There is long standing and vigorous debate both within and between the professions that use neck manipulation as well as the wider scientific community as to whether neck manipulation potentially does more harm than good. The primary aim of this study is to determine whether neck manipulation provides more rapid resolution of an episode of neck pain than mobilisation. Methods/Design: 182 participants with acute and sub-acute neck pain will be recruited from physiotherapy, chiropractic and osteopathy practices in Sydney, Australia. Participants will be randomly allocated to treatment with either manipulation or mobilisation. Randomisation will occur after the treating practitioner decides that manipulation is an appropriate treatment for the individual participant. Both groups will receive at least 4 treatments over 2 weeks. The primary outcome is number of days taken to recover from the episode of neck pain. Cox regression will be used to compare survival curves for time to recovery for the manipulation and mobilisation treatment groups. Discussion: This paper presents the rationale and design of a randomised controlled trial to compare the effectiveness of neck manipulation and neck mobilisation for acute and subacute neck pain. [ABSTRACT FROM AUTHOR]

Background and Purpose. Depression is a condition that worsens the prognosis of low back pain (LBP) and is under-recognized and undertreated in primary care. The purpose of this study was to evaluate the accuracy with which physical therapists screen for depressive symptoms among their patients with LBP. Subjects. Sixty-eight physical therapists and 232 patients with nonspecific LBP from 40 physical therapy clinics participated. Methods. Patients completed the reference standard (Depression Anxiety Stress Scales [DASS]) and a 2-item screening test for depression taken from the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD). Treating physical therapists used a 0 to 10 scale to judge whether each patient was depressed. Based on the short-form Depression Anxiety Stress Scales (DASS-21) depression scale score, each patient was categorized as exhibiting normal, mild, moderate, severe, or extremely severe depression symptoms, and receiver operating characteristic (ROC) curves were generated to describe test accuracy. Results. The 2-item screening test was more accurate in screening for depressive symptoms than the physical therapists' ratings were; for example, in detecting moderate depressive symptoms in the 2 areas under the ROC curve, values were 0.66 versus 0.79. Discussion and Conclusion. Because the therapists did not accurately identify symptoms of depression, even symptoms of severe depression, despite the common presentation in their clinics, we recommend that physical therapists managing patients with LBP use the 2-item depression screening test. Administration of this screening test would improve physical therapists' ability to screen for symptoms of depression and would enable referral for appropriate management. [Haggman S, Maher CG, Refshauge KM. Screening for symptoms of depression by physical therapists managing low back pain. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effect of conservative interventions on clinically relevant outcome measures for patients with subacute low back pain. This is particularly important because effective treatment for subacute low back pain will prevent the transition to chronic low back pain, a condition that is largely responsible for the high health care costs of low back pain. Design: Systematic review of randomized controlled trials. Main outcome measures: Methodological quality of each trial was assessed. Effect sizes and 95% confidence intervals were calculated for pain and disability and risk ratios for return to work. Results: Thirteen trials were located, evaluating the following interventions: manipulation, back school, exercise, advice, transcutaneous electrical nerve stimulation (TENS), hydrotherapy, massage, corset, cognitive behavioural treatment and co-ordination of primary health care. Most studies were of low quality and did not show a statistically significant effect of intervention. For the strict duration of low back pain (six weeks to three months), no evidence of high internal validity was found but when other methodological criteria were considered, evidence was found for the efficacy of advice. Furthermore, there is evidence that when a broader view is taken of the duration of subacute low back pain (seven days to six months), other treatments (e.g.manipulation, exercise, TENS) may be effective. Conclusions: Our review identified a major gap in the evidence for interventions that are currently recommended in clinical practice guidelines for the treatment of subacute low back pain. Lack of a uniform definition of subacute low back pain further limited current evidence. [ABSTRACT FROM AUTHOR]