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A preliminary study of potential indicators of standardised exercise program success in individuals with knee osteoarthritis: Is self-report enough?
Thursday 16 October Posters / Journal of Science and Medicine in Sport 18S (2014) e72–e107
role in maintaining foot stability and arch and contributes to many pathologies and syndromes common in podiatric medical practice. Background: Plantar fasciopathy is a common foot disorder encountered in the outpatient clinic. It is a chronic recalcitrant condition which is frequently encountered cause of heel pain and restricted activities of daily living in a significant population among athletes. Athletes have a demanding lifestyle and when injured, require a rapid return to optimum activity level with resolution of symptoms. The purpose of this study was to compare the results of ESWT and LASER in the treatment of chronic plantar fasciopathy in athletes resistant to conservative measures for a minimum of 6 months. Objective: To compare the efficacy of Extracorporeal Shock Wave Lithotripsy with LASER for the treatment of plantar fasciopathy after 6 months of follow up. Methodology: Study design: A randomized prospective, comparative clinical study was done on 150 patients of chronic heel pain diagnosed as plantar fasciopathy. Case Selection: Patients of either sex between 20 to 60 years of age attending the Sports Injury OPD with the diagnosis of plantar fasciopathy and ≥Grade 2 tenderness over medial calcaneal tuberosity were included in the study after informed consent. Patients were randomly divided into two groups: group 1 with 75 patients who received ESWT along with two weeks supervised exercise program and group 2 with 75 patients who received Low Intensity LASER Therapy along with same supervised exercise program. All patients were advised Aceclofenac 200 mg daily for 1 week and assessed with regard to pain and functional abilities at the baseline, after 2 weeks, 4 weeks, 12 weeks and 24 weeks of commencement of therapy. Protocol: Our management included stretching exercises of gastrocnemius and soleus muscle and plantar fascia performed thrice a day for 2 weeks and transverse friction massage at medial calcaneal tuberosity to be started after 1 week of commencement of treatment. Strengthening of the foot intrinsic muscles and avoidance of high impact activities and sports for a minimum of 2 weeks was advised. Also patients were advised appropriate footwear before returning to previous activity level. Observations and results: Conservative management relieved pain in all of our patients. Few patients reported transient increase in pain after ESWT and discontinued therapy. There was no loss to follow up and no patient reported any other adverse reaction with therapy. First follow up did not reveal any significant difference in pain scale and functional abilities on comparison among both the groups. Second follow up revealed better outcomes in relation to pain and functional abilities in patients who received ESWT. Higher rate of recurrence of heel pain was observed in patients who received LASER therapy at third and fourth follow up with statistically significant relief from pain on VAS scale in patients who received ESWT. Discussion: In sportspersons, conservative treatment provides significant relief from pain due to plantar fasciopathy and hence help in rapid return to sports. ESWT provides significantly better relief from pain and prevents recurrence after resuming sports as compared with LASER therapy. Our study emphasizes the role of comprehensive conservative management for the treatment of plantar fasciopathy. http://dx.doi.org/10.1016/j.jsams.2014.11.348
e89
43 Neuromuscular upper limb training reduces major shoulder injury rate in elite Rugby League Players C. Ball Background: Major shoulder injuries are common in elite level Rugby League Players. Upper limb neuromuscular training is evidenced as a preventative intervention in several sports; however no evidence has been reported in the rugby codes which have a unique injury profile. This study retrospectively assessed the effect of a specific shoulder neuromuscular training program on the occurrences of major shoulder injuries in an elite level rugby league club. Materials and methods: A retrospective review of major shoulder injury rates was conducted at an elite level rugby league club over a six-year period between 2007 and 2012. A specific preventative neuromuscular shoulder exercise program was introduced during the 2010 season. An age-adjusted comparison between the 2007–2009 seasons (pre-neuromuscular training period) and 2010–2012 seasons (neuromuscular training period) was conducted. Results: Overall, the observed major shoulder injury rates dropped significantly (p = 0.011; exact binomial test) by more than 50% after the introduction of the neuromuscular training program (from 15.8%/anno to 7.7%/anno). Age was generally inversely associated with injury risk and the achieved preventative effect size of training. Younger athletes aged less than 20 years profited most with an observed reduction by more than 80%. Conclusion: Specific neuromuscular shoulder training seems able to substantially reduce major shoulder injury rates in elite level Rugby League Players. http://dx.doi.org/10.1016/j.jsams.2014.11.349 44 A preliminary study of potential indicators of standardised exercise program success in individuals with knee osteoarthritis: Is self-report enough? K. Mills 1,∗ , S.T. Osis 2 , M. Martin 3 , B.A. Hettinga 2 , R. Ferber 2 1 Discipline of Physiotherapy, Faculty of Human Sciences, Macquarie University, Australia 2 Running Injury Clinic, University of Calgary, Canada 3 Research School of Finance, Actuarial Studies and Applied Statistics, The Australian National University, Australia
Introduction: Identifying individuals who require a more tailored approach to OA management is an increasing focus of conservative care models. There are an increasing number of assessment tools being employed to assist in this clinical decisionmaking. These range in technology, time and expense requirements from 3-dimensional (3D) movement analysis to patient-reported outcomes. The additional predictive value of more time- and costdemanding tools is unknown. The aim of this preliminary study was to compare the predictive ability of variables gained from 3D gait analysis and the Knee Osteoarthritis Outcome Scale (KOOS) based on outcomes from an exercise intervention. Methods: A pilot sample of 38 community dwelling individuals with mild-to-moderate knee OA (males = 9, age = 55.08 ± 8.88 years, BMI = 25.94 ± 3.66 kg/m2 ) was recruited. At baseline, partic-
e90
Thursday 16 October Posters / Journal of Science and Medicine in Sport 18S (2014) e72–e107
ipants completed a 100 mm knee pain visual analogue scale (0 = no pain), the KOOS, lower limb strength dynamometry and 3D gait analysis during treadmill walking (speed = 1.1 m/s). Twenty-three participants completed a progressive 6-week standardised exercise program of hip and knee strengthening. On completion, participants were dichotomised based on reporting a successful outcome. “Success” was defined as pain improving by ≥50% and absolute change of ≥20 mm. Three classification and regression tree (CART) analyses were used to identify which baseline characteristics were best able to differentiate between successful and non-successful participants. The first CART examined the KOOS, the second examined joint excursions of the pelvis, hip and knee and the third examined peak range of motion of these joint during the first 25% of stance. Results: Nine participants met the criteria for success. In the KOOS CART, reporting a score of <45/100 of the “other symptoms” subscale and exhibiting a BMI > 31 kg/m2 predicted success. These variables successfully classified 66% of successful and 100% of nonsuccessful cases. For the joint excursion CART, exhibiting frontal plane knee range of motion >8.9◦ was the only variable that could successfully classify participants. This correctly classified 55.55% of successful and 100% of non-successful cases. Conclusion: This preliminary study demonstrated the potential for baseline characteristics to distinguish between individuals who experienced a successful outcome from a standardised exercise programs from those who did not. It also found that a combination of patient-reported other symptoms of knee OA and BMI had similar predictive ability as the more technologically demanding 3D gait analysis. Therefore, preliminary evidence suggests that patient-reported outcomes may be enough to guide clinical decision-making regarding exercise prescription for individuals with mild-to-moderate knee OA. http://dx.doi.org/10.1016/j.jsams.2014.11.350 45 Prolotherapy for sacroiliac joint pain – 12 months outcomes B. Mitchell ∗ , R. Rose, A. Barnard Metro Pain Clinic, Australia Introduction: Prolotherapy is a non-surgical treatment for chronic musculoskeletal pain in damaged ligaments or tendons. Prolotherapy involves injecting a soluble solution such as dextrose into the ligament and tendon sites, inducing a localized inflammatory response, tissue. A previous study of 25 sacroiliac joint (SIJ) pain patients reported a functional improvement of 76% following prolotherapy. Methods: Over a 3-year period, we assessed 131 patients who underwent prolotherapy treatment around the SIJ. This process involved outlining the deep interosseuos ligament with contrast material under direct fluoroscopy, which was then injected with 1.5 ml Narapin 0.75% and 10 ml 50% glucose over multiple sites. This procedure was repeated on average three times, at 6-week intervals. Patients were assessed at 6 months and 12 months following their last treatment. Outcome measures included pain relief, back/hip/pelvic strength, Oswestry disability index (ODI), patient satisfaction and analgesic use. Results: Half the patients reported improved stability of 71.6 ± 23.1%. Similarly, one-third of patients described pain relief of 74.5 ± 21.4%. Pain relief is dependent on improved stability r = 0.61 (p = 0.00). Whilst no patients reported pain relief without improved stability, 10/70 patients reported improved stability without pain relief. Where patients reported an improvement in both pain relief
and strength, percentage of improvements directly correlated with one another r = 0.82 (p = 0.00). A trend depicting a reduction in ODI was observed with patients reporting pain relief also scoring lower on their post-prolotherapy ODI questionnaire r = 0.74, p = 0.024. Discussion: These findings suggest that prolotherapy can be an effective treatment for increasing stability and strength and decreasing pain in patients with SIJ pain. http://dx.doi.org/10.1016/j.jsams.2014.11.351 46 Comparison of the Lactate Pro 2 and i-Stat1 portable blood lactate analysers D. Whyte ∗ , G. Rowe, S. Cormack Australian Catholic University, Australia Background: Blood lactate is routinely used by athletes, coaches and researchers to evaluate exercise intensity and predict performance. Lactate testing is generally performed in the field using portable lactate analysers and capillary blood samples. More recently, the i-Stat portable analyser (Abbott Laboratories, USA) has expanded the range of haematological parameters that can be measured using capillary blood outside of the laboratory, including pH, HCO3 − and blood gases. While the i-Stat has been shown to be reliable, the level of agreement between it and other portable lactate analysers has not been determined. Therefore, the purpose of this study was to compare the level of agreement in blood lactate readings between the i-Stat and a commonly used lactate analyser, the Lactate Pro 2 (Arkray Inc., Japan). Methods: Fingertip blood samples (N = 241) were taken from 19 subjects during either intermittent running or incremental cycling protocols. Blood flow was promoted by placing the participant’s hand in warm water immediately prior to skin puncture. After discarding the first drop, blood was collected into two heparinised capillary tubes and immediately transferred to an i-Stat1 CG4+ cartridge for analysis. Blood from the same puncture site was applied directly to the Lactate Pro 2 test strip. Pearson correlation analysis and Bland–Altman plots were used to evaluate the relationship and level of agreement between the analysers, respectively. Results: Lactate levels in the blood samples ranged between 0.4 and 18.2 mM. A significant relationship was observed between the two analysers for lactate levels <4 mM (r = 0.930, n = 108, p < 0.001), >4 mM (r = 0.944, n = 133, p < 0.001), as well as overall (r = 0.977, n = 241, p < 0.001). However, the i-Stat analyser consistently reported higher values (1.43 ± 1.3 mM, n = 241, p < 0.001), especially when lactate exceeded 4 mM (2.2 ± 1.0 mM, n = 133, p < 0.001). This was reflected in the Bland–Altman plots which revealed a marked disparity between the analysers with increasing lactate levels. Discussion: While there was a strong correlation between the Lactate Pro 2 and i-Stat analysers the level of agreement deteriorated once lactate levels exceeded 4 mM, with the i-Stat analyser consistently providing a higher reading compared to the Lactate Pro 2. These data further highlight the need for caution when interpreting or comparing lactate data obtained using different analysers. http://dx.doi.org/10.1016/j.jsams.2014.11.352
role in maintaining foot stability and arch and contributes to many pathologies and syndromes common in podiatric medical practice. Background: Plantar fasciopathy is a common foot disorder encountered in the outpatient clinic. It is a chronic recalcitrant condition which is frequently encountered cause of heel pain and restricted activities of daily living in a significant population among athletes. Athletes have a demanding lifestyle and when injured, require a rapid return to optimum activity level with resolution of symptoms. The purpose of this study was to compare the results of ESWT and LASER in the treatment of chronic plantar fasciopathy in athletes resistant to conservative measures for a minimum of 6 months. Objective: To compare the efficacy of Extracorporeal Shock Wave Lithotripsy with LASER for the treatment of plantar fasciopathy after 6 months of follow up. Methodology: Study design: A randomized prospective, comparative clinical study was done on 150 patients of chronic heel pain diagnosed as plantar fasciopathy. Case Selection: Patients of either sex between 20 to 60 years of age attending the Sports Injury OPD with the diagnosis of plantar fasciopathy and ≥Grade 2 tenderness over medial calcaneal tuberosity were included in the study after informed consent. Patients were randomly divided into two groups: group 1 with 75 patients who received ESWT along with two weeks supervised exercise program and group 2 with 75 patients who received Low Intensity LASER Therapy along with same supervised exercise program. All patients were advised Aceclofenac 200 mg daily for 1 week and assessed with regard to pain and functional abilities at the baseline, after 2 weeks, 4 weeks, 12 weeks and 24 weeks of commencement of therapy. Protocol: Our management included stretching exercises of gastrocnemius and soleus muscle and plantar fascia performed thrice a day for 2 weeks and transverse friction massage at medial calcaneal tuberosity to be started after 1 week of commencement of treatment. Strengthening of the foot intrinsic muscles and avoidance of high impact activities and sports for a minimum of 2 weeks was advised. Also patients were advised appropriate footwear before returning to previous activity level. Observations and results: Conservative management relieved pain in all of our patients. Few patients reported transient increase in pain after ESWT and discontinued therapy. There was no loss to follow up and no patient reported any other adverse reaction with therapy. First follow up did not reveal any significant difference in pain scale and functional abilities on comparison among both the groups. Second follow up revealed better outcomes in relation to pain and functional abilities in patients who received ESWT. Higher rate of recurrence of heel pain was observed in patients who received LASER therapy at third and fourth follow up with statistically significant relief from pain on VAS scale in patients who received ESWT. Discussion: In sportspersons, conservative treatment provides significant relief from pain due to plantar fasciopathy and hence help in rapid return to sports. ESWT provides significantly better relief from pain and prevents recurrence after resuming sports as compared with LASER therapy. Our study emphasizes the role of comprehensive conservative management for the treatment of plantar fasciopathy. http://dx.doi.org/10.1016/j.jsams.2014.11.348
e89
43 Neuromuscular upper limb training reduces major shoulder injury rate in elite Rugby League Players C. Ball Background: Major shoulder injuries are common in elite level Rugby League Players. Upper limb neuromuscular training is evidenced as a preventative intervention in several sports; however no evidence has been reported in the rugby codes which have a unique injury profile. This study retrospectively assessed the effect of a specific shoulder neuromuscular training program on the occurrences of major shoulder injuries in an elite level rugby league club. Materials and methods: A retrospective review of major shoulder injury rates was conducted at an elite level rugby league club over a six-year period between 2007 and 2012. A specific preventative neuromuscular shoulder exercise program was introduced during the 2010 season. An age-adjusted comparison between the 2007–2009 seasons (pre-neuromuscular training period) and 2010–2012 seasons (neuromuscular training period) was conducted. Results: Overall, the observed major shoulder injury rates dropped significantly (p = 0.011; exact binomial test) by more than 50% after the introduction of the neuromuscular training program (from 15.8%/anno to 7.7%/anno). Age was generally inversely associated with injury risk and the achieved preventative effect size of training. Younger athletes aged less than 20 years profited most with an observed reduction by more than 80%. Conclusion: Specific neuromuscular shoulder training seems able to substantially reduce major shoulder injury rates in elite level Rugby League Players. http://dx.doi.org/10.1016/j.jsams.2014.11.349 44 A preliminary study of potential indicators of standardised exercise program success in individuals with knee osteoarthritis: Is self-report enough? K. Mills 1,∗ , S.T. Osis 2 , M. Martin 3 , B.A. Hettinga 2 , R. Ferber 2 1 Discipline of Physiotherapy, Faculty of Human Sciences, Macquarie University, Australia 2 Running Injury Clinic, University of Calgary, Canada 3 Research School of Finance, Actuarial Studies and Applied Statistics, The Australian National University, Australia
Introduction: Identifying individuals who require a more tailored approach to OA management is an increasing focus of conservative care models. There are an increasing number of assessment tools being employed to assist in this clinical decisionmaking. These range in technology, time and expense requirements from 3-dimensional (3D) movement analysis to patient-reported outcomes. The additional predictive value of more time- and costdemanding tools is unknown. The aim of this preliminary study was to compare the predictive ability of variables gained from 3D gait analysis and the Knee Osteoarthritis Outcome Scale (KOOS) based on outcomes from an exercise intervention. Methods: A pilot sample of 38 community dwelling individuals with mild-to-moderate knee OA (males = 9, age = 55.08 ± 8.88 years, BMI = 25.94 ± 3.66 kg/m2 ) was recruited. At baseline, partic-
e90
Thursday 16 October Posters / Journal of Science and Medicine in Sport 18S (2014) e72–e107
ipants completed a 100 mm knee pain visual analogue scale (0 = no pain), the KOOS, lower limb strength dynamometry and 3D gait analysis during treadmill walking (speed = 1.1 m/s). Twenty-three participants completed a progressive 6-week standardised exercise program of hip and knee strengthening. On completion, participants were dichotomised based on reporting a successful outcome. “Success” was defined as pain improving by ≥50% and absolute change of ≥20 mm. Three classification and regression tree (CART) analyses were used to identify which baseline characteristics were best able to differentiate between successful and non-successful participants. The first CART examined the KOOS, the second examined joint excursions of the pelvis, hip and knee and the third examined peak range of motion of these joint during the first 25% of stance. Results: Nine participants met the criteria for success. In the KOOS CART, reporting a score of <45/100 of the “other symptoms” subscale and exhibiting a BMI > 31 kg/m2 predicted success. These variables successfully classified 66% of successful and 100% of nonsuccessful cases. For the joint excursion CART, exhibiting frontal plane knee range of motion >8.9◦ was the only variable that could successfully classify participants. This correctly classified 55.55% of successful and 100% of non-successful cases. Conclusion: This preliminary study demonstrated the potential for baseline characteristics to distinguish between individuals who experienced a successful outcome from a standardised exercise programs from those who did not. It also found that a combination of patient-reported other symptoms of knee OA and BMI had similar predictive ability as the more technologically demanding 3D gait analysis. Therefore, preliminary evidence suggests that patient-reported outcomes may be enough to guide clinical decision-making regarding exercise prescription for individuals with mild-to-moderate knee OA. http://dx.doi.org/10.1016/j.jsams.2014.11.350 45 Prolotherapy for sacroiliac joint pain – 12 months outcomes B. Mitchell ∗ , R. Rose, A. Barnard Metro Pain Clinic, Australia Introduction: Prolotherapy is a non-surgical treatment for chronic musculoskeletal pain in damaged ligaments or tendons. Prolotherapy involves injecting a soluble solution such as dextrose into the ligament and tendon sites, inducing a localized inflammatory response, tissue. A previous study of 25 sacroiliac joint (SIJ) pain patients reported a functional improvement of 76% following prolotherapy. Methods: Over a 3-year period, we assessed 131 patients who underwent prolotherapy treatment around the SIJ. This process involved outlining the deep interosseuos ligament with contrast material under direct fluoroscopy, which was then injected with 1.5 ml Narapin 0.75% and 10 ml 50% glucose over multiple sites. This procedure was repeated on average three times, at 6-week intervals. Patients were assessed at 6 months and 12 months following their last treatment. Outcome measures included pain relief, back/hip/pelvic strength, Oswestry disability index (ODI), patient satisfaction and analgesic use. Results: Half the patients reported improved stability of 71.6 ± 23.1%. Similarly, one-third of patients described pain relief of 74.5 ± 21.4%. Pain relief is dependent on improved stability r = 0.61 (p = 0.00). Whilst no patients reported pain relief without improved stability, 10/70 patients reported improved stability without pain relief. Where patients reported an improvement in both pain relief
and strength, percentage of improvements directly correlated with one another r = 0.82 (p = 0.00). A trend depicting a reduction in ODI was observed with patients reporting pain relief also scoring lower on their post-prolotherapy ODI questionnaire r = 0.74, p = 0.024. Discussion: These findings suggest that prolotherapy can be an effective treatment for increasing stability and strength and decreasing pain in patients with SIJ pain. http://dx.doi.org/10.1016/j.jsams.2014.11.351 46 Comparison of the Lactate Pro 2 and i-Stat1 portable blood lactate analysers D. Whyte ∗ , G. Rowe, S. Cormack Australian Catholic University, Australia Background: Blood lactate is routinely used by athletes, coaches and researchers to evaluate exercise intensity and predict performance. Lactate testing is generally performed in the field using portable lactate analysers and capillary blood samples. More recently, the i-Stat portable analyser (Abbott Laboratories, USA) has expanded the range of haematological parameters that can be measured using capillary blood outside of the laboratory, including pH, HCO3 − and blood gases. While the i-Stat has been shown to be reliable, the level of agreement between it and other portable lactate analysers has not been determined. Therefore, the purpose of this study was to compare the level of agreement in blood lactate readings between the i-Stat and a commonly used lactate analyser, the Lactate Pro 2 (Arkray Inc., Japan). Methods: Fingertip blood samples (N = 241) were taken from 19 subjects during either intermittent running or incremental cycling protocols. Blood flow was promoted by placing the participant’s hand in warm water immediately prior to skin puncture. After discarding the first drop, blood was collected into two heparinised capillary tubes and immediately transferred to an i-Stat1 CG4+ cartridge for analysis. Blood from the same puncture site was applied directly to the Lactate Pro 2 test strip. Pearson correlation analysis and Bland–Altman plots were used to evaluate the relationship and level of agreement between the analysers, respectively. Results: Lactate levels in the blood samples ranged between 0.4 and 18.2 mM. A significant relationship was observed between the two analysers for lactate levels <4 mM (r = 0.930, n = 108, p < 0.001), >4 mM (r = 0.944, n = 133, p < 0.001), as well as overall (r = 0.977, n = 241, p < 0.001). However, the i-Stat analyser consistently reported higher values (1.43 ± 1.3 mM, n = 241, p < 0.001), especially when lactate exceeded 4 mM (2.2 ± 1.0 mM, n = 133, p < 0.001). This was reflected in the Bland–Altman plots which revealed a marked disparity between the analysers with increasing lactate levels. Discussion: While there was a strong correlation between the Lactate Pro 2 and i-Stat analysers the level of agreement deteriorated once lactate levels exceeded 4 mM, with the i-Stat analyser consistently providing a higher reading compared to the Lactate Pro 2. These data further highlight the need for caution when interpreting or comparing lactate data obtained using different analysers. http://dx.doi.org/10.1016/j.jsams.2014.11.352