PM&R最新文献

Objective: To compare the pooled estimates and variability in pain and function outcomes for spinal manipulative therapy (SMT) versus sham SMT in randomized clinical trials (RCTs), which informs the potential for heterogeneity of treatment effect.

Design: Meta-epidemiological study.

Literature search: We used results from the previous Cochrane review and meta-analysis and performed updated electronic searches from May 2018 to June 2025.

Study selection criteria: RCTs comparing SMT to sham SMT for chronic low back pain.

Data synthesis: For the meta-epidemiological analysis, we estimated the variance ratios of pain and function outcomes for both pooled results and individual trials. Variance ratio statistically different than 0 indicate greater variability in one group, providing evidence that heterogeneity of treatment effect may be present.

Results: Fifteen trials (n = 1141) were included in the analysis. No statistically significant or meaningful variance ratios were found in 1-, 3-, 6-, and 12-month pooled results for pain and function. Among individual RCTs, greater variability was found in two trials for the SMT group and four trials in the sham SMT for pain or function at the 1-month analysis.

Conclusion: There were no significant differences in the variability of pain and function outcomes for SMT groups compared to sham SMT groups for chronic low back pain. This suggests there is no evidence the distribution around the mean estimate is different between interventions at all time points and does not support the potential for heterogeneity of treatment effect in this population. Nevertheless, we cannot conclusively rule out heterogeneity of treatment effect using variance ratios alone. This study provides an example of how using variance ratios in meta-analyses and RCTs can add other statistically and clinically meaningful findings.

Background: Spine pathologies are associated with an inflammatory microenvironment, with previous studies demonstrating systemic inflammation based on analysis of serum from patients with low back pain (LBP). This pilot study used gene expression profiling to identify candidate cellular mechanisms mediating systemic inflammation in patients with LBP, with and without radicular pain, compared to asymptomatic controls.

Objective: To identify differences in expression of inflammation- and immune-related genes in whole blood from patients with LBP and spine pathology compared to control participants. Also, identify relationships between differentially expressed (DE) genes and patient-reported outcomes (PROs) for pain (Visual Analog Scale [VAS]) and disability (Oswestry Disability Index [ODI]).

Design: Case control, observational study.

Setting: Outpatient clinic at academic institution.

Patients: Nine participants with LBP who were 18 years or older and diagnosed with lumbar disc herniation, spinal stenosis, or disc degeneration. Eight control participants who were 18 years or older and had no history of LBP or spinal treatment.

Interventions: N/A.

Main outcome measure: Expression levels of inflammation- and immune-related genes in patients with LBP compared to control participants measured using Nanostring nCounter analysis.

Results: Analysis of patients with LBP versus controls resulted in 11 DE genes (p-adj < .05) and 9 trending genes (p-adj < .1) falling into three clusters: "Interferon α/β Signaling," "Immunoglobulin Binding," and "Toll-like Receptor (TLR) Binding." VAS scores were also associated with expression level of FCER1G, FCGR3A/B, and KLRK1. Further analysis showed significantly lower expression of FCER1G in patients with high versus low VAS (p < .05). No relationships between DE gene expression and ODI was identified; however, a significant correlation between VAS and ODI scores was observed (p < .05).

Conclusions: Clustering of DE and trending genes suggested increased interferon α/β signaling and TLR signaling may contribute to systemic inflammation related to LBP. Immunoglobulin binding was also implicated and varied with pain severity in patients with LBP.

Background: Participation in American-style football (ASF) results in trauma-related concerns including joint injuries. Limited work has described arthritis and knee and hip total joint arthroplasty (TJA) in this population. The association of these conditions to pain interference and physical and mental function has not been well described.

Objectives: 1. To characterize demographic, football, and health-related factors in former ASF players associated with arthritis and knee or hip TJA. 2. To investigate the association of arthritis and knee or hip TJA with pain interference and physical and mental function.

Study design: Cross-sectional cohort study.

Setting: Academic medical multisite hospital system.

Participants: Former ASF players who played professionally from 1960 to 2019.

Assessment of risk factors: Self-completed standardized questionnaires.

Main outcome measures: Surveys included self-reported arthritis and knee and hip TJA, Patient-Reported Outcome Measure Instrument Scale (PROMIS), physical function and mental function, and pain interference scales. Multivariable logistic regression models assessed the association between demographic, football-related, and health characteristics with arthritis and knee and hip TJA. Multivariable linear regression models evaluated the association between arthritis and knee and hip TJA with pain interference and physical and mental function.

Results: In 4189 former ASF players (average and SD: 51.8 ± 14.4 years old) over half (n = 2237, 53.4%) had arthritis (n = 1547) or knee or hip TJA (n = 690). Both arthritis and knee and hip TJA were more common in those who were older, with higher body mass index, and prior surgery during playing years and were linemen (p < .05). Additionally, arthritis was more common in players who were never married (p = .01) and with higher concussion symptoms score (p < .001). Knee and hip TJA were more common in players who self-identified as White (p < .001). Both arthritis and knee and hip TJA were associated with greater pain interference and reduced physical function (all p < .001) but not with mental function.

Conclusion: More than half of former ASF players reported arthritis or knee or hip TJA. Higher pain interference and reduced physical function in former ASF players with arthritis and knee or hip TJA highlight the importance of advancing strategies to prevent and treat joint conditions.

Background: Spinal cerebrospinal fluid (CSF) leaks, a rare but debilitating condition, have been described following spinal manipulative therapy (SMT) in case reports. However, the nature of the potential association between SMT and CSF leak is uncertain, and symptoms such as neck pain or headache may reflect preexisting leaks rather than effects of SMT.

Objective: To test the hypothesis of no significant association between SMT and spinal CSF leak, comparing chiropractic SMT recipients to matched controls undergoing physical therapist-supervised therapeutic exercises (PTE).

Methods: We searched a health-records-based U.S. dataset (TriNetX, LLC) for adults with spinal disorders receiving an index event of (1) SMT or (2) PTE without SMT from 2005 to 2024, excluding those with preexisting CSF leaks and related conditions, using propensity matching to minimize confounding. Our primary outcome was the risk ratio (RR) of spinal CSF leak occurring within 2-month follow-up. A secondary composite outcome included the diagnosis of spontaneous intracranial hypotension in addition to the primary outcome.

Results: After matching, 89,042 patients remained per cohort. There was no significant association between SMT and spinal CSF leak incidence or risk compared to PTE (both cohorts: 0.03% [95% confidence interval: 0.02%-0.04%]; RR = 0.85 [0.49-1.49]; p = .572). Adding spontaneous intracranial hypotension to the primary outcome yielded similar results.

Conclusions: The present findings suggest chiropractor-administered SMT does not increase the risk of spinal CSF leak in adults with spinal disorders relative to PTE. Although our analysis focused on chiropractor-delivered SMT, the findings could plausibly apply to SMT delivered by other clinician types, warranting further research. Given the overlapping symptoms of CSF leak and musculoskeletal neck pain or headache, clinicians who manage spinal disorders should be aware of this condition.

Background: Individuals with spinal cord injury (SCI) are known to have high rates of cardiovascular disease that have traditionally been attributed to inability to engage in adequate intensity exercise. However, individuals with SCI also commonly experience instability in blood pressure. Blood pressure fluctuations are known to contribute to cardiovascular disease in other conditions, though this relationship in SCI is unknown.

Objective: To evaluate correlations between a clinical history of symptomatic blood pressure instability and objective evidence of vascular endothelial dysfunction in individuals with SCI.

Design: Case control.

Setting: Academic medical center.

Participants: Twenty-four individuals with SCI, 14 uninjured controls of matched age, gender, and body mass index.

Interventions: Not applicable.

Main outcome measures: Symptomatic blood pressure instability was measured by the Autonomic Dysfunction Following SCI (ADFSCI) survey. Vascular endothelial dysfunction was quantified by ultrasound recordings of brachial flow mediated dilation following 5 minutes of forearm arterial occlusion.

Results: Total ADFSCI scores were significantly higher in individuals with SCI compared to controls (41.0 vs. 9.0, p = .002). Both percentage of brachial flow mediated dilation and consensus recommended allometrically scaled percentage of flow mediated dilation were significantly less in individuals with SCI (p < .001 for both), demonstrating greater vascular dysfunction. More symptoms of blood pressure instability on the ADFSCI survey were correlated with more objective evidence of vascular dysfunction (R² = 0.24, p = .03) for individuals with SCI. This relationship was not seen in uninjured controls.

Conclusions: In individuals with SCI, more severe symptoms of blood pressure instability are significantly correlated with more severe vascular endothelial dysfunction, making management of orthostatic hypotension and autonomic dysreflexia both high potential, modifiable risk factors for individuals with SCI to mitigate cardiovascular disease.

This scoping review aims to better characterize finger growth plate injuries in adolescent sport climbers and to create a diagnostic and management algorithm for adolescent climbers after a finger growth plate injury. PubMed, EMBASE, and ScienceDirect databases were queried to identify articles from database inception to July 2024 for inclusion. The following search terms were used: (epiphys* OR physis OR physeal OR metaphys* OR "growth plate*") AND (climb*). Studies that examined adolescent sport climbers with a diagnosis of finger growth plate injury were included. Demographic and clinical information, injury characteristics, imaging and treatment modalities, and outcome data were extracted and pooled from all included studies. Eleven studies were included. In total, 149 physeal stress injuries occurred in 98 adolescent climbers with a mean age of 14 years and range of 10 to 18 years. A total of 146 injuries (98%) occurred at the proximal interphalangeal joint. Of these injuries, 74% were fractures, of which 97% occurred at the epiphysis. Baseline radiograph was the most used imaging modality for initial diagnosis of fracture. Treatment ranged from complete rest (21%) to surgical intervention (8%). Overall, return to sport time ranged from 2 weeks to 6 months, and 91% were able to return to climbing. Epiphyseal fractures are the most common growth plate injury reported in adolescent climbers. Identification of these injuries with clinical history and timely diagnostic imaging is critical to return to sport.

Objective: To evaluate the reliability of physical examination tests used for assessing hip flexor flexibility, including the Modified Thomas Test (MTT), Thomas Test, Reactive Hip Flexor Test, Swing Test, and Falcon Test.

Literature survey: A systematic search was conducted across multiple databases (PubMed, CINAHL, SPORTDiscus, Scopus, Web of Science, and Rehabilitation & Sports Medicine Source) up to March 2024.

Methodology: Studies were included if they reported intra- or interrater reliability outcomes for clinical tests assessing hip flexor flexibility, using recognized statistical measures such as the intraclass correlation coefficient (ICC), SEM, minimal detectable change, or Bland-Altman plots. The methodological quality of included studies was assessed using the Quality Appraisal of Reliability Studies checklist. Meta-analyses were performed using random-effects models to calculate pooled ICC values for intra- and interrater reliability, with subgroup analyses based on the type of flexibility test.

Synthesis: The meta-analysis included 27 studies, comprising 1056 participants. The overall pooled intrarater ICC was 0.90 (95% CI, 0.85-0.95) in 888 participants, indicating excellent reliability, and the interrater ICC was 0.80 (95% CI, 0.71-0.88) in 665 participants, reflecting good reliability. However, substantial heterogeneity was observed for both intrarater (I² = 99%) and inte-rater (I² = 98.3%) analyses, particularly for the MTT and Thomas Test. In contrast, the Thomas Test demonstrated the lowest interrater reliability (ICC, 0.62 [95% CI, 0.46-0.78]) with significant between-study variability.

Conclusions: Physical examination tests for hip flexor flexibility demonstrate generally high intra- and interrater reliability. However, considerable methodological variability was identified, particularly for the MTT and Thomas Test, suggesting a need for standardized protocols. Newer tests, such as the Falcon and Swing Tests, showed excellent reliability but require further validation.