Top POEMs of 2014: Musculoskeletal Disease

Top 20 POEMs of 2014

Strength Training Better Than Stretching for Plantar Fasciitis

Clinical question
Is strength training more effective than stretching for patients with plantar fasciitis?

Bottom line
A regimen of strength training (specifically, heel raises) improves pain and function in patients with plantar fasciitis faster than a typical stretching regimen. Over time, though, patients who stretch will continue to improve and have similar improvement. (LOE = 1b-)

Reference
Rathleff MS, Molgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports 2014 (e-publication). doi: 10.1111/sms.12313

Study design: Randomized controlled trial (nonblinded)

Funding source: Foundation

Allocation: Uncertain

Setting: Outpatient (specialty)

Synopsis
These Danish researchers recruited 48 consecutive patients referred for physical therapy for the treatment of plantar fasciitis. All patients had heel pain for at least 3 months and had ultrasound-confirmed plantar fascia thickness of at least 4.00 mm. All patients received Tuli's Polar Bears gel heel cups and were then randomized, concealed allocation uncertain, to plantar-specific stretching or strength training. The stretching regimen consisted of crossing the affected heel over the opposite knee and pulling the toes back for 10 seconds, repeated in sets of 10 three times a day. The strength-training group performed heel lifts from a raised platform (eg, a step), with a rolled towel placed under the toes to cause maximum dorsiflexion (see a picture at http://tinyurl.com/plantarstrength). The regimen is progressive and rigorous (see outline below). The Function Foot Index, a measure of self-reported pain, disability, and function ranging from 0 to 230, was used to measure benefit. After 3 months, scores in the strength-training group were 29 points better than in the stretching group (95% CI 6 - 52). However, at 6 months and 12 months the stretching group continued to improve and their scores were not significantly different from the strength-training group’s scores. High-load strength training: Heel raises are performed on a raised platform with a rolled-up towel under the toes to cause maximum dorsiflexion. Raise the heels over 3 seconds, hold for 2 seconds, and then lower over 3 seconds. Complete 3 sets of 12 repetitions every other day using one leg unless 12 cannot be performed. After 2 weeks, increase the load by wearing a backpack filled with books, reduce the repetitions to 10 per set, and increase to 4 sets After 2 more weeks, increase the load again (add more books to your backpack) and perform 8 repetitions, 5 sets.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Injection = PT for Shoulder Impingement

Clinical question
Is corticosteroid injection more effective than physical therapy in the management of non-traumatic shoulder pain?

Bottom line
Both physical therapy and corticosteroid injection decrease pain and disability by about 50% within one month of beginning treatment. However, average scores won't improve beyond that over the course of the year, and the average person will have pain, disability, and change to their quality of life one year later. Let patients know that neither treatment is a silver bullet for functional shoulder pain and they are likely to some long-term problems no matter which treatment they select. (LOE = 1b)

Reference
Rhon DI, Boyles RB, Cleland JA. One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: A pragmatic randomized trial. Ann Intern Med. 2014;161:161-169. doi:10.7326/M13-2199

Study design: Randomized controlled trial (nonblinded)

Funding source: Industry

Allocation: Concealed

Setting: Outpatient (specialty)

Synopsis
The investigators enrolled 104 adults referred for physical therapy from family medicine or orthopedic clinics. The patients had shoulder pain without evidence of trauma, rotator cuff tear, or cervical spine-related symptoms, and were loosely defined as having "shoulder impingement syndrome." The patients (65% male, mean age 42 years) were randomized, using concealed allocation, to receive either 6 twice-weekly sessions of physical therapy or up to 3 subacromial injection of triamcinolone acetonide 40 mg over the course of a year. The physical therapy consisted of mobilization, stretching, and exercising based on an assessment of the patients weakness, mobility, and pain. Home exercises were also prescribed. Patients in both groups improved quickly, with an approximately 50% improvement in shoulder pain and function as measured by the Shoulder Pain and Disability Index by one month, which was maintained in both groups over new subsequent 11 months. Similarly, pain scores and quality of life scores were improved. Unfortunately, the average patient in either group still had residual pain and/or disability. Thirty-eight percent of patients in the corticosteroid group had more than one injection.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Opioids for Chronic Back Pain: Short-Term Effectiveness, Long-Term Uncertain

Clinical question
Are opioids effective in the treatment of chronic low-back pain?

Bottom line
Overall, in patients with chronic low-back pain, opioids are moderately more effective than placebo in the short term for pain relief and slightly more effective in the short term for improving function. However, data for long term use are pretty much nonexistent. The long-term use of opioids for patients with chronic low-back pain is controversial. Physicians are asked to provide comfort to patients, yet the regulatory and safety concerns of long-term use are a sobering counterpoint. (LOE = 1a-)

Reference
Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC. Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane review. Spine 2014;39(7):556-563.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Synopsis
This is an update to a Cochrane Review published in 2007. The authors systematically searched several databases to identify randomized trials comparing opioids with placebo or other drugs. The studies had to have masked outcome assessments and evaluated at least one of the following: pain, function, global improvement, or the proportion of patients reporting 30% or 50% pain relief. Two authors independently assessed studies for inclusion, reconciling disagreements by discussion. Additionally, 3 authors independently extracted data from included studies. Finally, they used an explicit approach to assess the quality of each study and to assess the role of publication bias. Eventually, these authors included 15 trials with 5540 participants. For the most part, the reviewed trials had low to moderate quality, high drop-out rates, short duration, and limited interpretability of functional improvement. Six studies evaluated tramadol alone or in combination with acetaminophen (5 compared with placebo, 1 as an active comparator against a centrally acting nonopioid); 2 studies compared buprenorphine with placebo; and 7 studies assessed strong opioids (morphine, oxymorphone, hydromorphone, oxycodone). Of the 7 trials of strong opioids, 3 were not really designed to assess opioid efficacy. Twelve of the 15 total studies were at low risk of bias. The 5 studies comparing tramadol with placebo generally had more methodologic bias and showed greater overall pain relief than placebo and greater improvement in functional outcomes than placebo. In the 2 studies of buprenorphine, the authors found very-low-quality evidence that this agent reduces pain more than placebo and that it does anything for function. The studies of strong opioids found small reductions in pain and small improvements in function.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

Advertisement