Research Recap #1 - Telemedicine, Running Economy, Placebo, Open-Chain, Fear, and Fibromyalgia

Welcome to the first Research Recap blog post. These articles will contain brief research reviews and clinical takeaways. The original iterations of these posts go out to all PT Solutions employees as we aim to Live Clinically and provide updated evidence-based assessment and treatment to all of our patients. The original PTS newsletters contain brand-new evidence. These blog posts are older versions of the newsletters but they still contain recent and relevant research that can be applied to clinical practice.

For more recent content and a slightly deeper dive into each article, check out The Clinical Gap Podcast. For the most recent content, you will need to be a PTS employee. I may be slightly biased, but I highly recommend it. The podcast will also include Residency Roundups which are brief reviews of recent residency lectures. As you likely guessed, the most recent content is reserved for the residents. Another career path I highly recommend.

Ok, enough recruiting pitches. Here are the articles for the first Research Recap blog post:

Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Patients

We are just beginning to understand the applicability of telehealth. Primarily used as an alternative to in-person care, telehealth is often as inferior. Therapists frequently cite the inability to put their hands on patients, both for assessment and treatment. But what about the patients? Treatment should be a shared decision, and the patient experience plays a critical role in the delivery of healthcare. Would telehealth improve adherence to care? Would patients be more committed to treatment if they have the option of where to receive treatment?

This paper surveyed patients aged 16 years or older who had undergone ACL reconstruction within the past 5 years. They were invited to give their “thoughts and opinions regarding a potentially new approach to post-surgical rehab” and introduced to the possibility of telerehabilitation in addition to usual care.

Only 26% (25/96) of patients felt that they had fully recovered at the end of their PT; 77% of patients felt that they had sufficient PT. Moreover, 69% of patients stated that their physical therapy was ended by their physical therapist, whereas 51% ended physical therapy themselves (overlap likely indicates joint decision), and 39% said that travel, time commitments, and other factors were causal for ending their physical therapy. When asked in which phase they preferred to use their allocated physical therapy appointments, 60% said they preferred face-to-face in the early stages of care, 33% said they preferred to use face-to-face with the return-to-sport care, and 6% chose other.

The primary pros were telehealth can save appointments, fill gaps between phases of care or breaks, and save time and money. The cons were concerns about a difference in value between in-person and over a screen and the access to technology to facilitate a high-quality telehealth experience. The predominant theme was that telerehabilitation needed to be used as an adjunct to physical therapy rather than instead of it.

Visual Classification of Running Economy by Distance Running Coaches

Can we gauge how efficient a runner is simply by observing their mechanics? What about running coaches? This paper sought to answer that question. As most couches and clinicians do not possess specialized equipment to assess running economy (RE), visual assessment is often relied upon. Endurance coaches from high school to the international level (N = 121) viewed each video and ranked the runners on a scale from 1 (most economical) to 5 (least economical). Coaches also completed a demographic questionnaire and listed running style biomechanical observations they used in determining each ranking.

On average, the coaches had 8 years of coaching (range 1-41) and 12 years of running (range 1-50) experience. The current study evaluated the ability of distance-running coaches to correctly rank distance runners on RE through video observation during treadmill running. Findings from this investigation revealed that 35%, 47%, 12%, and 6% of coaches could identify zero, one, two, or three of the runners in the correct order, respectively. Furthermore, none of the analyzed coaching characteristics - coaching level, years of experience, certifications, or competition level as a runner - were significant predictors of RE ranking accuracy. There was little agreement on which running qualities are helpful to determine running economy (e.g. stride length, body mass, forward lean, etc.).

The Placebo and Nocebo effect on sports performance: A systematic review

Research is pretty clear that a placebo (belief effect) can enhance interventions while nocebo can be detrimental. Even in the world of sports, an athlete's performance can be affected by placebo and nocebo. What is unknown, is the magnitude of the influence. Past reviews have only assessed nutritional aids while this review took a broader approach. small to moderate effect sizes were found for nutritional and mechanical ergogenic aids. Larger placebo effects were found when participants were led to believe they were given banned performance-enhancing ergogenic aids and Transcutaneous Nerve Stimulation. Moderate effects were found in studies investigating placebo effects of caffeine, amino acids, and modified tennis rackets.

The magnitude of the placebo effect varies depending on the type of placebo and on how the effects are induced. Pre-conditioning procedures lead to larger placebo effects than positive and negative expectations This is consistent with meta-analyses in other research domains.

Who's Afraid of the Big Bad Wolf? Open-Chain Exercises After Anterior Cruciate Ligament Reconstruction

Let's get right to it. Open chain exercises are not dangerous. Furthermore, knee extension exercises are not dangerous. They are not detrimental to any knee rehabilitation, whether it be a tendinopathy or ACL rehabilitation. Similar to the "text neck" fear-mongering of increased stress, using relative terms fails to account for absolute forces. Just as "poor" posture causes increased forces and subsequent stress on the spine, open chain exercises create increased stress at the patellar tendon. But the level of stress does not cause harm. Regarding the ACL, the stresses are minor. In fact, walking creates more strain on the ACL graft than open chain exercises. Studies assessing open chain exercises a mere 4 weeks post-op demonstrate no change in tensile strength or laxity.

The argument that open chain is unnecessary because closed chain exercises are superior fails to hold water. Open chain exercises often elicit greater EMG activity and allow for the isolation of muscle groups. Closed chain exercises allow for compensatory action and emphasis on other muscle groups. A knee extension exercise will isolate and rapidly hypertrophy the quadriceps - vital for ACL rehabilitation - while the squat heavily emphasizes gluteals and lumbar paraspinals (if using a barbell). Squats are immensely valuable, as are open-chain exercises. Furthermore, all exercises do not need to replicate a single "functional" movement. Controlling a limp in space, rapidly producing force, and building muscle all contribute to function.

Making Sense of Low Back Pain and Pain-Related Fear

The Fear-Avoidance Model has been validated and adopted in the pain and physical therapy literature. It explains how the experience of low back pain can initiate negative cognitive, emotional, and behavioral responses. Fear of pain leads to catastrophizing and subsequent fear of movement. This creates a vicious cycle as the lack of activity contributes to further pain and disability, adding fuel to the fear-induced fire. This clinical commentary assesses the Fear-Avoidance Model and how clinicians can better help pains with chronic pain, catastrophizing, and pain-related fear.

Key contributors to pain-related fear are as follows: Radiological reports, negative explicit and implicit advice from clinicians, cultural beliefs about the structural vulnerability of the spine, the belief that pain is a sign of damage poor pain-control coping strategies, the perception that pain is uncontrollable, repeated failed attempts to control pain and frequent worry about pain. Pain-related fear can be lessened by gaining control over the pain. This can be accomplished through cognitive reframing and addressing the previously mentioned concerns.

Our past experiences and beliefs about pain influence how we will experience and respond to pain. As clinicians, we must understand these variables. Every patient is unique. If we do not know how they conceptualize pain, we can not hope to fully address the patient's concerns and help them on a path to recovery. Our job is not to fix patients, but rather, our job is to coach them. We must fully understand the problem in order to help patients address their pain and build self-efficacy for improved health and long-term outcomes.

Top down or bottom up? An observational investigation of improvement in fibromyalgia symptoms following hip and knee replacement

‘Top down' mechanisms of central sensitization refer to pain amplification that exists independent of peripheral inflammation and other nociceptive input. This concept is supported by the frequent disagreement between the degree of damage or inflammation in the joint and the severity of symptoms reported by the patient. Conversely, a 'bottom-up' mechanism would indicate peripheral sources of nociceptive input such as joint inflammation and damage sensitize the CNS to pain. According to this view, chronic injury and/or inflammation, such as that due to OA, drives central nervous system sensitization. If a patient with chronic pain has surgery to address a peripheral issue, such as a fibromyalgia patient receiving a TKA, would pain symptoms improve? In this study, only 48 of 150 patients improved. The patients who stayed the same or worsened had higher levels of fatigue, depression, and surgical site pain at baseline. This study highlights the importance of assessing 'top down' drivers of pain in cases emphasizing a 'bottom up' approach.


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