CPG - Treatment Recommendations

Question 1

What are best level treatments for Achilles tendinopathy:

Answer 1

• A: Exercise with mechanical loading
• B: Ionto with dexamethasone – acute
• C: Exercise with stretching – do not recommend night splints

Question 2

What are best level treatments for lateral ankle sprains:

Answer 2

• A: Progressive weight bearing with external supports, gait assistance
• A: Ice – improve WB, reduce pain, medications
• A: ultrasound – against use period
• A: therapeutic exercise esp in acute severe ankle sprains
• B: manual therapy – STM, Posterior glide in progressive loading
• C: shortwave diathermy
• C: neuro re-ed, balance, unstable surface in postacute period – balance & sport related activity training for reducing risk
• D: evidence for & against electrotherapy, low level laser

Question 3

What are best level treatments for carpal tunnel syndrome:

Answer 3

• B: NOT use low level laser or magnets, iontophoresis
• B: Neutral position wrist orthosis at night – short term
• C: Assistive technologies – alternating mouse hand, touch screen
• C: day & full time orthosis with poor outcomes only at night time use – orthosis for pregnant women
• C: manual therapy for cervical spine, UE
• C: therapeutic exercise - mild to moderate without thenar atrophy, normal 2 pt discrimination
• C: superficial heat – microwave or shortwave diathermy – IFC – phonophoresis – NOT USING ultrasound

Question 4

What are best level treatment for heel pain:

Answer 4

• A: manual therapy for flexibility, joint mobility
• A: stretching for plantar fascia specific & gastroc/soleus stretching for short term – heel pads
• A: foot orthoses – prefab/custom for short & long germ results
• A: night splints for 1-3 months
• C: low level laser, phonopohoresis with ketoprofen – NOT to use ultrasound
• C: rocker bottom shoes with foot orthoses – shoe rotation
• D: may or may not use ionto with dex or acetic acid

Question 5

What are best level treatments or arthric hip pain:

Answer 5

• A: Manual therapy – mild to moderate cases 1-3x/week, 6-12 weeks
• A: exercise with flexibility, strengthening, endurance exercise
• B: ultrasound 1 Mhz; 1W/cm for 5 minutes to A/L/P hip for 10 tx over two weeks
• B: patient education – activity modification, exercise, weight reduction, unloading joint
• C: weight loss with collaboration from other healthcare professionals
• C: assistive device use

Question 6

What are best level treatments for knee ligament sprains:

Answer 6

• A: Therex – within 4-6 weeks, 2-3x per week for 6-10 months (open & closed, concentric & eccentric)
• A: neuromuscular stim: 6-8 weeks to enhance outcomes
• A: neuromuscular re-ed: incorporated with strengthening
• B: immediate mobilization – within 1 week; avoid extension loss
• B: cryotherapy to reduce pain
• B: supervised rehab – augmented with HEP
• C: bracing – those with ACL deficiency
• C: CPM
• C: early WB within one week

Question 7

What are best level treatments for knee pain with mobility deficits (meniscus/cartilage):

Answer 7

• B: early progressive A/PROM after surgery – stepwise progression of WB to full WB by 6-8 weeks after ACI – supervised rehab - neuromuscular stim to inc quad – supervised, progressive strength training for knee & hip
• C: early progressive WB in meniscal repairs – earl progressive return to play/activity after meniscal repair surgery

Question 8

What are best level treatments for low back pain:

Answer 8

• A: manual therapy, SMT, thrust/nonthrust – trunk coordination, strengthening & endurance exercise – centralization & directional preference exercise
• A: progressive endurance exercise & fitness activities (mod to high intensity with CLBP, progressive, low intensity submaximal fitness/endurance)
• B: pt education & counseling on prognosis, pain science, bed rest, active coping strategies, return to work, focus on function
• C: flexion exercises with multi-modal approach – nerve glides for subacute/CLBP with radiating pain
• D: traction – subgroup with nerve root compression, peripheral sxs – should not use in acute/subacute nonradicular low back pain or chronic low back pain

Question 9

What are best level treatments for neck pain with mobility deficits:

Answer 9

• Mobility deficits:
  
  • B: acute – thoracic manip, neck ROM
  • C: acute – cervical manip
  • B: subacute – neck/shoulder girdle strengthening
  • C: subacute – cervical & thoracic manip
  • B: chronic – multimodal approach
  • C: chronic – active lifestyle, address cognitive/affective factors

Question 10

What are best level treatments for neck pain with movement coordination deficits (WAD):

Answer 10

• Pain with movement coordination (WAD)
  
  • Acute WAD:
    
    • B: reassurance – return to ADLs/non provocative – minimize collar – postural & mobility exercise
    • C: single session of advice, exercise, education – TENs
  • Chronic:
    
    • C: multimodal approach – TENs, behavioral therapy, cervicothoracic strengthening etc

Question 11

What are best level treatments for neck pain with headaches:

Answer 11

• Neck pain with headaches:
  
  • B: acute – active mobility exercise
  • C: acute - C1-2 snag exercise
  • B: subacute – cervical manip/mobilization
  • C: subacute – C1-2 snag exercise
  • B: chronic – cervical, cervicothoracic SMT/mobilization + shoulder girdle & neck stretching, strengthening

Question 12

What are best level treatments for neck pain with radicular pain:

Answer 12

• Neck pain with radicular pain:
  
  • C: acute – mobilizing/stabilizing exercise, laser, short term use collar
  • B: chronic – mechanical intermittent traction in multimodal approach – pt education on occupational and exercise activities

Question 13

What are best level treatments for nonarthritic hip pain:

Answer 13

• F: all professional opinion – pt education & counseling (activity modification), manual therapy, exercise and activities, neuro re-ed

Question 14

What are best level treatments for patellofemoral pain:

Answer 14

• A: combined hip & knee targeted exercise – posterolateral hip musculature, resisted squats/leg extension
• A: prefab foot orthoses for pronated foot for short term
• A: against dry needling – against manual therapy in isolation
• B: patellar taping in combination with exercise for short term
• B: recommendation against orthoses, braces/sleeves, strap
• B: recommendation against biofeedback to target vastus medialis & visual biofeedback on LE alignment during hip/knee exercise
• B: recommendation against biophysical agents: ultrasound, cryotherapy, phono/ionto, estim, laser
• C: acupuncture – cautiously
• C: gait retraining – forefoot strike program, inc cadence, reduce peak hip adduction while running

Question 15

What are best level treatments for adhesive capsulitis:

Answer 15

• A: corticosteroid injections – short term relief
• B: pt education – course of disease, activity modification, matches intensity of level of irritability
• B: stretching exercise – match irritability
• C: modalities – diathermy, ultrasound, electrical stim in combo with stretching
• C: joint mobs – GH joint
• C: translational manip under anesthesia