Physical Therapy as Effective as Surgery for Meniscal Tear
Patients with knee osteoarthritis and a meniscal tear who received physical therapy without surgery had good functional improvement 6 months later, and outcomes did not differ significantly from patients who underwent arthroscopic partial meniscectomy, a new clinical trial shows.
In the Meniscal Tear in Osteoarthritis Research (METEOR) trial, both groups of patients improved substantially in function and pain. This finding, presented at the American Academy of Orthopaedic Surgeons 2013 Annual Meeting and published online simultaneously in the New England Journal of Medicine, provides "considerable reassurance regarding an initial nonoperative strategy," the investigators report.
Patients with a meniscal tear and osteoarthritis pose a treatment challenge because it is not clear which condition is causing their symptoms," principal investigator Jeffrey Katz, MD, from Brigham and Women's Hospital in Boston, Massachusetts, told Medscape Medical News. "These data suggest that there are 2 reasonable pathways for patients with knee arthritis and meniscal tear," Dr. Katz explained. "We hope physicians will use these data to help patients understand their choices."
In an accompanying editorial, clinical epidemiologist Rachelle Buchbinder, PhD, from the Monash University School of Public Health and Preventive Medicine in Victoria, Australia, said that "these results should change practice. Currently, millions of people are being exposed to potential risks associated with a [surgical] treatment that may or may not offer specific benefit, and the costs are substantial."
These results should change practice. The METEOR trial enrolled 351 patients from 7 medical centers in the United States. Eligible patients were older than 45 years, had osteoarthritic cartilage change documented with magnetic resonance imaging, and had at least 1 symptom of meniscal tear, such as knee clicking or giving way, that lasted at least 1 month despite drug treatment, physical therapy, or limited activity. In this intent-to-treat analysis, investigators randomly assigned 174 patients to arthroscopic partial meniscectomy plus postoperative physical therapy and 177 to physical therapy alone.
The physical therapy in both regimens was a standardized 3-stage program that allowed patients to advance to the next intensity level at their own pace, Dr. Katz explained. The program involved 1 or 2 sessions a week for about 6 weeks and home exercises. The average number of physical therapy visits was 7 in the surgery group and 8 in the nonsurgery group. Investigators evaluated patients 6 and 12 months after randomization. The primary outcome was the between-group difference in change in physical function score from baseline to 6 months, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). At baseline, demographic characteristics and WOMAC physical function scores were similar in the 2 groups.
At 6 months, improvement in the WOMAC function score was comparable in the 2 groups. There was also no significant difference between groups in pain improvement or frequency of adverse events. The 12-month results were similar to the 6-month results. In addition, by 12 months, outcomes for the crossover patients and for those in the original surgery group were similar.
Meeting delegate John Mays, MD, an orthopaedic surgeon practicing in Bossier City, Louisiana, who was asked by Medscape Medical News to comment on the findings, said most patients don't choose physical therapy. "In the real world, most people want a quick fix" and choose surgery, he noted. Dr. Mays said he would have liked to have seen a group of patients who underwent surgery but did not receive postoperative physical therapy. He explained that his patients with osteoarthritis and meniscal tear rarely get physical therapy after arthroscopic meniscectomy; they most often do home-based exercises.
N Engl J Med. Published online March 19, 2013. Abstract
The Effects of Myofascial Release with Foam Rolling on Performance
In the last decade self myofascial release (SMR) has become an increasingly common modality to supplement traditional methods of massage. However, there is limited clinical data demonstrating the efficacy or mechanism of this treatment on athletic performance . Researchers from the Human Performance Laboratory, Department of Kinesiology, University of Rhode Island, studied whether the use of myofascial rollers before athletic tests can enhance performance.
Twenty-six (13 men and 13 women) healthy college aged individuals (21.56±2.04 years, 23.97±3.98 body mass index (BMI), 20.57±12.21 percent body fat) were recruited. The study design was a randomized, crossover design in which subject performed a series of planking exercises or foam rolling exercises then performed a series of athletic performance tests (vertical jump height and power, isometric force, and agility.) Fatigue, soreness, and exertion were also measured.
The results showed that there were no statistical significant differences between foam rolling and planking for all four of the athletic tests. However, there was a significant difference between genders on all of the athletic tests.
As expected there were significant increases from pre to post during both trials for fatigue, soreness, and exertion. Post-exercise fatigue after foam rolling was significantly less than after the subjects performed planking. The reduced feeling of fatigue may allow participants to extend acute workout time and volume, which can lead to chronic performance enhancements. However, foam rolling had no effect on performance.
J Strength Cond Res. 2013 Apr 12. [Epub ahead of print] The Effects of Myofascial Release with Foam Rolling on Performance. Healey KC, Hatfield DL, Blanpied P, Dorfman LR, Riebe
Exercise is as effective as massage for sore muscles
It’s a common belief that massage is the best for treating post-workout pain. However a new research published in the Journal of Strength and Conditioning Research has found that massage and exercise had the same benefits. Lars Andersen, the lead author of the study and a professor at the National Research Center for the Working Environment in Copenhagen, and his colleagues asked 20 women to do a shoulder exercise while hooked up to a resistance machine. The women shrugged their shoulders while the machine applied resistance, which engaged the trapezius muscle between the neck and shoulders. Two days later, the women came back to the lab with aching trapezius muscles. On average they rated their achiness as a five on a 10 point scale, up from 0.8 before they had done the shoulder work out.
Then the women received a 10-minute massage on one shoulder and did a 10-minute exercise on the other shoulder. Some women got the massage first, while others did the exercise first. The exercise again involved shoulder shrugs; this time the women gripped an elastic tube held down by their foot to give some resistance. (Hygenic Corporation, which makes the tubing used in the study, supported the study.) Andersen’s group found that, compared to the shoulder that wasn’t getting any attention, massage and exercise each helped diminish muscle soreness. The effect peaked 10 minutes after each treatment, with women reporting a reduction in their pain of 0.8 points after the warm up exercise and 0.7 points after the massage. “It’s a moderate change,” said Andersen. He said he expects that athletes would notice a difference in having their soreness reduced by this amount. “I think that for athletes…by reducing soreness then they’re able to perform better, but we didn’t measure this. But if you are sore your movements are very stiff and it’s difficult to perform,” he said. Andersen said he’d like to see future studies track whether warming up the muscles to relieve soreness does indeed impact how well athletes perform. The study suggests that “maybe (massage or exercise) has some benefit for individuals prior to an activity, even though the benefit may be short-lasting,” said Jason Brumitt, of the School of Physical Therapy at Pacific University, who was not involved in the research. It’s not clear how massage or exercise would relieve soreness, but Brumitt said that it’s thought that they help to clear out metabolic byproducts associated with tissue damage. Andersen recommends that people try light exercise to ease their pain. The effect is moderate, and only offers temporary relief, but the benefit of using exercise, Andersen said, is that it doesn’t require a trained therapist or travel time. “If people go out and exercise and get sore they can find some relief in just warming up the muscles,” he said.
Reference: J Strength Cond Res. 2013 Mar 21. Acute effects of massage or active exercise in relieving muscle soreness: Randomized controlled trial. http://www.ncbi.nlm.nih.gov/
Pain is contagious
One in three people can feel pain when they see others experience it. The pain sensations of others can be felt by some people, just by witnessing their agony, according to new research.
A Monash University study into the phenomenon known as somatic contagion found almost one in three people could feel pain when they see others experience pain. It identified two groups of people that were prone to this response - those who acquire it following trauma, injury such as amputation or chronic pain, and those with the condition present at birth, known as the congenital variant.
Presenting her findings at the Australian and New Zealand College of Anaesthetists’ annual scientific meeting in Melbourne earlier this week, Dr Melita Giummarra, from the School of Psychology and Psychiatry, said in some cases people suffered severe painful sensations in response to another person’s pain. “My research is now beginning to differentiate between at least these two unique profiles of somatic contagion,” Dr Giummarra said. “While the congenital variant appears to involve a blurring of the boundary between self and other, with heightened empathy, acquired somatic contagion involves reduced empathic concern for others, but increased personal distress. “This suggests that the pain triggered corresponds to a focus on their own pain experience rather than that of others."
Most people experience emotional discomfort when they witness pain in another person and neuroimaging studies have shown that this is linked to activation in the parts of the brain that are also involved in the personal experience of pain. Dr Giummarra said for some people the pain they ‘absorb’ mirrors the location and site of the pain in another they are witnessing and is generally localised. “We know that the same regions of the brain are activated for these groups of people as when they experience their own pain. First in emotional regions but then there is also sensory activation. It is a vicarious – it literally triggers their pain, Dr Giummarra said” Dr Giummarra has developed a new tool to characterise the reactions people have to pain in others that is also sensitive to somatic contagion – the Empathy for Pain Scale.
Effect of massage on the efficacy of the mental and incisive nerve block
The purpose of this trial was to assess the effect of soft tissue massage on the efficacy of the mental and incisive nerve block (MINB).
Thirty-eight volunteers received MINB of 2.2 mL of 2% lidocaine with 1 : 80,000 epinephrine on 2 occasions. At one visit the soft tissue overlying the injection site was massaged for 60 seconds (active treatment). At the other visit the crowns of the mandibular premolar teeth were massaged (control treatment). Order of treatments was randomized. An electronic pulp tester was used to measure pulpal anesthesia in the ipsilateral mandibular first molar, a premolar, and lateral incisor teeth up to 45 minutes following the injection. The efficacy of pulp anesthesia was determined by 2 methods: (a) by quantifying the number of episodes with no response to maximal electronic pulp stimulation after each treatment, and (b) by quantifying the number of volunteers with no response to maximal pulp stimulation (80 reading) on 2 or more consecutive tests, termed anesthetic success.
Anesthetic success was 52.6% for active and 42.1% for control treatment for lateral incisors, 89.5 and 86.8% respectively for premolars, and 50.0 and 42.1% respectively for first molars.
There were no significant differences in the number of episodes of negative response to maximum pulp tester stimulation between active and control massage. A total of 131 episodes were recorded after both active and control massage in lateral incisors, 329 (active) versus 316 (control) episodes in the premolars, and 119 (active) versus 109 (control) episodes respectively for first molars. Speed of anesthetic onset and discomfort did not differ between treatments.
The authors concluded concluded that soft tissue massage after MINB does not influence anesthetic efficacy.
Effect of massage on the efficacy of the mental and incisive nerve block. Jaber A, Whitworth JM, Corbett IP, Al-Baqshi B, Jauhar S, Meechan JG. Anesth Prog. 2013 Spring;60(1):15-20. doi: 10.2344/12-00024.1.
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