What’s New in Orthopaedic Rehabilitation

Orthopaedic surgery and rehabilitation medicine continue to remain synergistic fields of medicine. Here we review articles published from March 2021 through February 2022. We considered articles from the American Journal of Physical Medicine & Rehabilitation, The American Journal of Sports Medicine, Clinical Journal of Sports Medicine, Archives of Physical Medicine and Rehabilitation, The BMJ, The Journal of Bone & Joint Surgery, JAMA, Journal of Rehabilitation Medicine, Journal of Shoulder and Elbow Surgery, The New England Journal of Medicine, Pain Medicine, PM&R, Regional Anesthesia & Pain Medicine, Spine, and The Spine Journal. Shoulder Gamification is an advancement in rehabilitation that has become increasingly popular. Marley et al. compared standard physical therapy with exergames using the principles of gamification with physical therapy support in patients following arthroscopic shoulder surgery for subacromial impingement syndrome, calcific tendinopathy, and/or rotator cuff tear1. They found no significant differences in range of motion, Oxford Shoulder Scores, Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire scores, or EuroQol Visual Analog Scale (EQ-VAS) scores, thus concluding that exergames can be an effective alternative in routine postoperative care, relieving some of the burden placed on physical therapy departments. Little is known about the effects of blood flow restriction combined with low-intensity exercise on muscles proximal to the site of occlusion. In a controlled laboratory study, Lambert et al. looked at blood flow restriction in 32 healthy adults and found that those who utilized blood flow restriction along with a low-intensity exercise using common rotator cuff muscle exercises had increases in lean mass, strength, and muscular endurance in the shoulder and arm compared with low-intensity exercise alone2. As musculoskeletal ultrasound gains popularity, the value of its use for injection guidance remains under question. Deng et al. performed a systematic review and meta-analysis examining the effectiveness of ultrasound-guided compared with anatomic landmark-guided subacromial bursa corticosteroid injections for the treatment of subacromial impingement syndrome3. Twelve randomized controlled trials (RCTs) were included and pooled. The results included 454 ultrasound-guided injections and 437 anatomic landmark-guided injections. Ultrasound-guided injections were shown to be more beneficial for pain relief and functional improvement, but there was no significant difference in shoulder range of motion. Cho et al. examined ultrasound-guided compared with anatomic landmark-guided intra-articular glenohumeral corticosteroid injections for adhesive capsulitis and found that those undergoing ultrasound-guided injections had an increased likelihood of successful injection (100% compared with 71%), but there was no significant difference in clinical outcomes at 12 weeks between groups4. Balazs pointed out that this should be interpreted with caution5; although 13 of the 45 anatomic landmark-guided injections failed by the authors’ criteria, 10 of the 13 had at least a portion of the injectate enter the glenohumeral joint, raising the question of exactly how failed these injections were. A more accurate takeaway may be that ultrasound guidance guarantees injection accuracy, but injections may still provide patients benefit even if the chosen technique is inaccurate. Elbow There is a paucity of strong evidence for a best second-line treatment of recalcitrant lateral elbow tendinopathy. Ang et al. studied ultrasound-guided percutaneous tenotomy of the brevis and common extensor tendons in 20 patients with lateral elbow tendinopathy6. At the median 90-month follow-up, satisfaction scores remained 100%, with no recurrences or secondary interventions. The Kruskal-Wallis test on median visual analog scale (VAS) for pain and DASH scores showed significant improvements. Ultrasound reevaluation demonstrated sustained tissue healing in all patients and reduced hypervascularity in 79% of cases. Hand First carpometacarpal (CMC) joint osteoarthritis is a common disease that can result in pain and functional limitations. In a cohort study consisting of 308 patients who underwent nonoperative treatment with exercise therapy, an orthosis, or both, Hoogendam et al. investigated how satisfaction with treatment outcome is associated with patient mindset and Michigan Hand Outcome Questionnaire (MHQ) scores at baseline and 3 months7. The authors found that more positive pre-treatment outcome expectations were associated with a higher probability of being satisfied with treatment outcomes at 3 months. They concluded that, although satisfaction after nonoperative treatment of first CMC osteoarthritis is not yet optimal, positive expectations of treatment outcomes are associated with higher satisfaction. Therefore, optimizing patient expectations may further improve treatment expectations and outcomes. Carpal tunnel syndrome is the most common compression neuropathy affecting the upper limb. In a double-blinded, placebo-controlled trial, Hofer et al. randomized 111 patients into 3 groups receiving an injection of 80-mg methylprednisolone, 40-mg methylprednisolone, or saline solution8. Participants were followed over 5 years with co-primary outcomes of the symptom severity score and rate of subsequent carpal tunnel release surgery on the study hand at 5 years. From baseline to the 5-year follow-up, there was no significant difference in the mean change in the symptom severity score for the 80-mg methylprednisolone group or the 40-mg methylprednisolone group when compared with placebo. However, local methylprednisolone injection (both 80 mg and 40 mg) resulted in a significant reduction in surgery rates and delay in the need for a surgical procedure when compared with placebo. Hip Image-guided intra-articular hip injections play an important role in both the diagnosis and the treatment of hip pathologies. In an early study, Wang et al. raised concern about injections increasing the risk of infection after hip arthroscopy9; however, in a follow-up study, Byrd et al. found no infections among 500 patients undergoing ultrasound-guided hip injections in the 3 months before hip arthroscopy10. In 2021, Varady et al. published a retrospective cohort study of 17,987 patients further evaluating the infection risk of ultrasound and fluoroscopy-guided injections prior to hip arthroscopy11. A total of 12.7% of patients received an image-guided hip injection within the year preceding the surgical procedure. The infection rate was 0.47% for patients who received injections and 0.46% for patients who did not receive injections. This trend persisted in sensitivity analyses, and there was no evidence of differential risk between the groups. Knee Patellofemoral pain is common in adolescents. In recent studies, authors have pointed toward an important psychological component contributing to patellofemoral pain. In an RCT by Selhorst et al., adolescents with patellofemoral pain watched either a psychologically informed video addressing pain-related fear and catastrophizing (n = 34) or a video discussing basic anatomy and biomechanical factors implicated in patellofemoral pain (n = 32) prior to completing a course of physical therapy12. Adolescents who viewed the psychologically informed video experienced a significant reduction in maladaptive psychological beliefs. Pain improved in both groups, with no significant between-group differences. There continues to be debate over appropriate activity levels with regard to both prevention and progression of knee osteoarthritis. In a prospective, multicenter, observational study, Master et al. enrolled 516 adults with or at high risk for knee osteoarthritis13. In these subjects, higher daily walking volume and intensity did not increase the incidence of knee replacement over 5 years and demonstrated some protective effects. Extracorporeal shockwave therapy (ESWT) is being explored for the treatment of musculoskeletal conditions, including knee osteoarthritis. In an RCT by Ho et al., 36 subjects with knee osteoarthritis were randomized to 3 weeks of ESWT or sham ESWT14. The ESWT group demonstrated significant improvements in WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain, physical function, and total scores, as well as VAS scores, compared with the control group at 1 week following the last treatment. There was also evidence for improved physical performance in this time frame. When conservative treatments fail, not all patients with knee osteoarthritis are ready and able to proceed with a knee replacement. Image-guided genicular nerve radiofrequency ablation (RFA) is a treatment option with the potential to improve both pain and function. In a prospective observational study by Chang et al., 13 patients underwent ultrasound-guided genicular nerve RFA and demonstrated significant improvements in the numeric rating scale score (worst pain and mean pain), 36-item Short Form Health Survey (SF-36) physical health domain score, and the WOMAC pain and stiffness scores at 3 months after treatment15. The step test time significantly improved, and there were no significant changes in the other physical performance tests, including quadriceps strength and proprioception measures. Blood flow restriction (BFR) training may be an effective means for strengthening muscle with low loads. A meta-analysis conducted by Li et al. consisted of 179 subjects who underwent low-load resistance training with BFR (L-BFR), 96 who underwent high-load resistance training, and 94 who underwent low-load resistance training16. Muscle strength increased in both the L-BFR and high-load resistance training groups, and pain scores significantly decreased only in the L-BFR group. Foot and Ankle Running-related injuries are prevalent in runners. In their study, Suda et al. sought to evaluate the protective effect of a therapeutic foot-core training intervention easily done at home. In a 12-month RCT, healthy recreational runners underwent an 8-week foot-core training program (n = 57) or a static stretching program (n = 61)17. The foot-core program was demonstrated to be a protective factor for running-related injuries. Eccentric strengthening exercise is commonly utilized to treat insertional Achilles tendinopathy, with mixed results. ESWT use is rising as a modality for the treatment of tendinopathy; however, in an RCT, Mansur et al. did not show a difference in the treatment of Achilles insertional tendinopathy when comparing eccentric exercises alone with eccentric exercises combined with ESWT18. Botulinum toxin is being explored in the treatment of some musculoskeletal conditions such as plantar fasciitis. In a meta-analysis of RCTs, Acosta-Olivo et al. showed that botulinum toxin treatment of plantar fasciitis provides significant improvements in pain and functional outcomes19. Spine Growing literature has identified the vertebral end plate as a likely source of chronic axial low back pain. Vertebral end-plate degeneration is correlated with Modic changes on imaging, and the vertebral end plates are innervated by the basivertebral nerve. In a prospective, open-label, multicenter RCT (n = 140), Smuck et al. compared basivertebral nerve ablation with standard care at up to 12 months20. The primary end point was the between-arm comparison of the mean Oswestry Disability Index change from baseline; the secondary end points were VAS scores, SF-36 scores, EuroQol 5-Dimension 5-Level (EQ-5D-5L) Quality-of-Life scores, responder rates, and the rates of continued opioid use. The authors concluded that basivertebral nerve ablation demonstrates significant improvements in pain and function over standard care, with treatment results sustained through 12 months in patients with chronic axial low back pain of vertebrogenic origin. Conger et al. further performed a systematic review to determine the effectiveness of intraosseous basivertebral nerve ablation for the treatment of chronic axial low back pain associated with Modic changes21. Findings indicated moderate-quality evidence suggesting that this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected on the basis of Modic changes (type 1 or 2). Arthroplasty The optimal approach to rehabilitation after reverse total shoulder arthroplasty (TSA) is unclear. Lee et al. compared accelerated rehabilitation with immediate activity following reverse TSA (no immobilization at all) with more conservative rehabilitation with immobilization for 3 and 6 weeks after reverse TSA22. There were 357 reverse TSAs, split evenly between the 3 groups. At the 1-year follow-up, there were no significant differences in the outcome measures between the groups, but there were significantly fewer postoperative complications in the accelerated rehabilitation group. These findings support an accelerated rehabilitation construct as safe, sound, and noninferior to conservative protocols. Additionally, a psychological benefit is implied as a secondary outcome of earlier mobilization. In January 2021, shoulder arthroplasty was removed from the Medicare inpatient-only list, despite a lack of clarity on whether more medically complex Medicare populations may experience higher complication rates relative to privately insured patients. Goltz et al. examined unplanned 90-day readmission rates in patients discharged on postoperative day 1 and those who were not and compared the readmission rates between the 2 insurance cohorts; 4,723 shoulder arthroplasties (2,459 anatomic and 2,264 reverse) were reviewed23. The data showed that Medicare patients who were stable for discharge on day 1 were not more likely to experience readmission than privately insured patients, advocating for the safety of outpatient or short-stay shoulder arthroplasty. Notably, in comparison with TSA, across both insurance cohorts, reverse TSA had a significantly higher rate of unplanned readmission. In a retrospective cohort study, Neoh et al. investigated 467 total knee arthroplasties (TKAs) postoperatively to determine the short-term outcomes at discharge of patients who were taught postoperative rehabilitative exercises by peer volunteers, in addition to standard physical therapy (combination education), and of patients who underwent only physical therapy24. There were 309 patients who received the combination education and 167 patients who received the control treatment (physical therapy only). 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