BackgroundThe convergence of rising health care costs and physician shortages have made health care transformation a priority in many countries resulting in the emergence of new models of care that often involve the extension of the scope of practice for allied health professionals. Physiotherapists in advanced practice/extended scope roles have emerged as key providers in such new models, especially in settings providing services to patients with musculoskeletal disorders. However, evidence of the systematic evaluation of advance physiotherapy practice (APP) models of care is scarce. A systematic review was done to update the evaluation of physiotherapists in APP roles in the management of patients with musculoskeletal disorders.MethodsStructured literature search was conducted in 3 databases (Medline, Cinahl and Embase) for articles published between 1980 and 2011. Included studies needed to present original quantitative data that addressed the impact or the effect of APP care. A total of 16 studies met all inclusion criteria and were included. Pairs of raters used four structured quality appraisal methodological tools depending on design of studies to analyse included studies.ResultsIncluded studies varied in designs and objectives and could be categorized in four areas: diagnostic agreement or accuracy compared to medical providers, treatment effectiveness, economic efficiency or patient satisfaction. There was a wide range in the quality of studies (from 25% to 93%), with only 43% of papers reaching or exceeding a score of 70% on the methodological quality rating scales. Their findings are however consistent and suggest that APP care may be as (or more) beneficial than usual care by physicians for patients with musculoskeletal disorders, in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction.ConclusionsThe emerging evidence suggests that physiotherapists in APP roles provide equal or better usual care in comparison to physicians in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction. There is a need for more methodologically sound studies to evaluate the effectiveness APP care.

BackgroundDifferent diagnostic imaging modalities, such as ultrasonography (US), MRI, MR arthrography (MRA) are commonly used for the characterisation of rotator cuff (RC) disorders. Since the most recent systematic reviews on medical imaging, multiple diagnostic studies have been published, most using more advanced technological characteristics. The first objective was to perform a meta-analysis on the diagnostic accuracy of medical imaging for characterisation of RC disorders. Since US is used at the point of care in environments such as sports medicine, a secondary analysis assessed accuracy by radiologists and non-radiologists.MethodsA systematic search in three databases was conducted. Two raters performed data extraction and evaluation of risk of bias independently, and agreement was achieved by consensus. Hierarchical summary receiver-operating characteristic package was used to calculate pooled estimates of included diagnostic studies.ResultsDiagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears was high with overall estimates of sensitivity and specificity over 0.90. As for partial RC tears and tendinopathy, overall estimates of specificity were also high (>0.90), while sensitivity was lower (0.67–0.83). Diagnostic accuracy of US was similar whether a trained radiologist, sonographer or orthopaedist performed it.ConclusionsOur results show the diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears. Since full thickness tear constitutes a key consideration for surgical repair, this is an important characteristic when selecting an imaging modality for RC disorder. When considering accuracy, cost, and safety, US is the best option.

The ultrasound measure of AHD is reliable and sensitive. Although a distinct pattern of AHD variation in SIS patients could not be confirmed, a strong positive relationship was found between the reduction of AHD narrowing and functional improvement following rehabilitation. Ultrasound measurement of AHD might help identify SIS patients who will benefit from rehabilitation.

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BackgroundIn Canada, new models of orthopaedic care involving advanced practice physiotherapists (APP) are being implemented. In these new models, aimed at improving the efficiency of care for patients with musculoskeletal disorders, APPs diagnose, triage and conservatively treat patients. Formal validation of the efficiency and appropriateness of these emerging models is scarce. The purpose of this study is to assess the diagnostic agreement of an APP compared to orthopaedic surgeons as well as to assess treatment concordance, healthcare resource use, and patient satisfaction in this new model.Methods120 patients presenting for an initial consult for hip or knee complaints in an outpatient orthopaedic hospital clinic in Montreal, Canada, were independently assessed by an APP and by one of three participating orthopaedic surgeons. Each health care provider independently diagnosed the patients and provided triage recommendations (conservative or surgical management). Proportion of raw agreement and Cohen’s kappa were used to assess inter-rater agreement for diagnosis, triage, treatment recommendations and imaging tests ordered. Chi-Square tests were done in order to compare the type of conservative treatment recommendations made by the APP and the surgeons and Student t-tests to compare patient satisfaction between the two types of care.ResultsThe majority of patients assessed were female (54%), mean age was 54.1 years and 91% consulted for a knee complaint. The raw agreement proportion for diagnosis was 88% and diagnostic inter-rater agreement was very high (κ=0.86; 95% CI: 0.80-0.93). The triage recommendations (conservative or surgical management) raw agreement proportion was found to be 88% and inter-rater agreement for triage recommendation was high (κ=0.77; 95% CI: 0.65-0.88). No differences were found between providers with respect to imaging tests ordered (p≥0.05). In terms of conservative treatment recommendations made, the APP gave significantly more education and prescribed more NSAIDs, joint injections, exercises and supervised physiotherapy (p<0.05). Patient satisfaction was significantly higher for APP care than for the surgeons care (p<0.05).ConclusionThe diagnoses and triage recommendations for patients with hip and knee disorders made by the APP were similar to the orthopaedic surgeons. These results provide evidence supporting the APP model for orthopaedic care.

There is limited evidence to support the efficacy of therapeutic exercise and manual therapy to treat impingement syndrome. More methodologically sound studies are needed to further evaluate these interventions.

® T t STUDY DESIGN:Systematic review and metaanalysis. T t OBJECTIVES:To evaluate the efficacy of manual therapy (MT) for patients with rotator cuff (RC) tendinopathy. T t BACKGROUND:Rotator cuff tendinopathy is a highly prevalent musculoskeletal disorder, for which MT is a common intervention used by physical therapists. However, evidence regarding the efficacy of MT is inconclusive. T t METHODS:A literature search using terms related to shoulder, RC tendinopathy, and MT was conducted in 4 databases to identify randomized controlled trials that compared MT to any other type of intervention to treat RC tendinopathy. Randomized controlled trials were assessed with the Cochrane risk-of-bias tool. Meta-analyses or qualitative syntheses of evidence were performed. T t RESULTS:Twenty-one studies were included.The majority had a high risk of bias. Only 5 studies had a score of 69% or greater, indicating a moderate to low risk of bias. A small but statistically significant overall effect for pain reduction of MT compared with a placebo or in addition to another intervention was observed (n = 406), which may or may not be clinically important, given a mean difference of 1.1 (95% confidence interval: 0.6, 1.6) on a 10-cm visual analog scale. Adding MT to an exercise program (n = 226) significantly decreased pain (mean difference, 1.0; 95% confidence interval: 0.7, 1.4), as reported on a 10-cm visual analog scale, which may or may not be clinically important. Based on qualitative analyses, it is unclear whether MT used alone or added to an exercise program improves function. T t CONCLUSION:For patients with RC tendinopathy, based on low-to moderate-quality evidence, MT may decrease pain; however, it is unclear whether it can improve function. More methodologically sound studies are needed to make definitive conclusions. T t LEVEL OF EVIDENCE:Therapy, level 1a-. Ther 2015;45(5):330-350. Epub 26 Mar 2015. doi:10.2519/jospt.2015 T t KEY WORDS: mobilization, physical therapy, shoulder impingement syndrome, shoulder pain S houlder pain is highly prevalent and among mus culoskeletal disorders is the third most common reason for visiting a primary care physician. 16,33,46 As many as two thirds of people who have shoulder complaints receive a diagnosis of rotator cuff (RC) tendinopathy. 46 Rotator cuff tendinopathy often leads to decreased function, 34 lower health related quality of life, 34 poor sleep quality, 47 and work absenteeism. J Orthop Sports Phys 40Rotator cuff tendinopathy is a broad diagnosis, and mounting evidence suggests that diagnoses such as shoulder impingement syndrome, RC tendinitis/ tendinosis, as well as subacromial bursitis may be considered as the same clinical entity. 19 Conservative treatment of RC tendinopathy generally includes rest, nonsteroidal anti-inflammatory drugs, and rehabilitation interventions such as exercise.19 High-level evidence supports exercise as an effective treatment. 20 In conjunction with exercise, physical therapists often add manual therapy (MT) interventions to address impairm...

Purpose Kinematic alignment technique for TKA aims to restore the individual knee anatomy and ligament tension, to restore native knee kinematics. The aim of this study was to compare parameters of kinematics during gait (knee lexion-extension, adduction-abduction, internal-external tibial rotation and walking speed) of TKA patients operated by either kinematic alignment or mechanical alignment technique with a group of healthy controls. The hypothesis was that the kinematic parameters of kinematically aligned TKAs would more closely resemble that of healthy controls than mechanically aligned TKAs. Methods This was a retrospective case-control study. Eighteen kinematically aligned TKAs were matched by gender, age, operating surgeon and prosthesis to 18 mechanically aligned TKAs. Post-operative 3D knee kinematics analysis, performed with an optoelectronic knee assessment device (KneeKG®), was compared between mechanical alignment TKA patients, kinematic alignment TKA patients and healthy controls. Radiographic measures and clinical scores were also compared between the two TKA groups. ResultsThe kinematic alignment group showed no signiicant knee kinematic diferences compared to healthy knees in sagittal plane range of motion, maximum lexion, abduction-adduction curves or knee external tibial rotation. Conversely, the mechanical alignment group displayed several signiicant knee kinematic diferences to the healthy group: less sagittal plane range of motion (49.1° vs. 54.0°, p = 0.020), decreased maximum lexion (52.3° vs. 57.5°, p = 0.002), increased adduction angle (2.0-7.5° vs. − 2.8-3.0°, p < 0.05), and increased external tibial rotation (by a mean of 2.3 ± 0.7°, p < 0.001). The post-operative KOOS score was signiicantly higher in the kinematic alignment group compared to the mechanical alignment group (74.2 vs. 60.7, p = 0.034). Conclusions The knee kinematics of patients with kinematically aligned TKAs more closely resembled that of normal healthy controls than that of patients with mechanically aligned TKAs. This may be the result of a better restoration of the individual's knee anatomy and ligament tension. A return to normal gait parameters post-TKA will lead to improved clinical outcomes and greater patient satisfaction. Level of evidence III.