Treatment

Hyperbaric oxygen therapy for delayed onset muscle soreness and closed soft tissue injury

Soft tissue injuries are very common. Hyperbaric oxygen therapy (HBOT) involves people breathing pure oxygen in a specially designed chamber. It is sometimes used to increase the supply of oxygen to the injured area in an attempt to speed recovery. Our review included nine small trials, involving a total of 219 participants. Two trials compared HBOT versus sham therapy on ankle sprain and knee sprain respectively. Neither trial provided sufficient evidence to determine if HBOT helped people with these injuries. The other seven trials examined the effect of HBOT on muscle injury following unaccustomed exercise. There was no evidence that HBOT helped people with muscle injury following unaccustomed exercise, but some evidence that people given HBOT had slightly more pain. Further research on HBOT is not a high priority given the variety of other treatment interventions available.

Authors' conclusions: 

There was insufficient evidence from comparisons tested within randomised controlled trials to establish the effects of HBOT on ankle sprain or acute knee ligament injury, or on experimentally induced DOMS. There was some evidence that HBOT may increase interim pain in DOMS. Any future use of HBOT for these injuries would need to have been preceded by carefully conducted randomised controlled trials which have demonstrated effectiveness.

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Background: 

Soft tissue injuries (including muscle damage after unaccustomed exercise) are common and are often associated with athletic activity. Hyperbaric oxygen therapy (HBOT) is the therapeutic administration of 100% oxygen at environmental pressures greater than one atmosphere.

Objectives: 

To assess the benefits and harms of HBOT for treating soft tissue injury, including delayed onset muscle soreness (DOMS).

Search strategy: 

We searched The Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to February 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library (2010, Issue 1), MEDLINE (1950 to February 2010), EMBASE (1980 to 2010 Week 07), CINAHL (1982 to October 2008), an additional database developed in our hyperbaric facility and reference lists of articles. Relevant journals were handsearched and researchers in the field contacted.

Selection criteria: 

Randomised trials comparing the effect on closed soft tissue injury (including DOMS) of therapeutic regimens which include HBOT with those that exclude HBOT (with or without sham therapy).

Data collection and analysis: 

Four authors independently evaluated study quality and extracted data. Most of the data presented in the review were extracted from graphs in the trial reports.

Main results: 

Nine small trials involving 219 participants were included. Two trials compared HBOT versus sham therapy on acute closed soft tissue injuries (ankle sprain and medial collateral knee ligament injury respectively). The other seven trials examined the effect of HBOT on DOMS following eccentric exercise in unconditioned volunteers.

All 32 participants of the ankle sprain trial returned to their normal activities. There were no significant differences between the two groups in time to recovery, functional outcomes, pain, or swelling. There was no difference between the two groups in knee function scores in the second acute injury trial; however, intention-to-treat analysis was not possible for this trial.

Pooling of data from the seven DOMS trials showed significantly and consistently higher pain at 48 and 72 hours in the HBOT group (mean difference in pain score at 48 hours [0 to 10 worst pain] 0.88, 95% CI 0.09 to 1.67, P = 0.03) in trials where HBOT was started immediately. There were no differences between the two groups in longer-term pain scores or in any measures of swelling or muscle strength.

No trial reported complications of HBOT but careful selection of participants was evident in most trials.

Double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults

Anterior cruciate ligament injury is a common soft-tissue knee injury. Patients with anterior cruciate ligament deficiency, especially young physically active males, usually do not return to pre-injury level of activities due to knee instability. Surgical treatment of ACL rupture involves reconstruction of the anterior cruciate ligament by use of a graft (a piece of tendon usually obtained from the patient) that is passed through tunnels drilled into the tibia and femur at the insertion points of the ligament and then fixed. Repair may use a single-bundle or double-bundle technique. The ACL mainly consists of two distinct portions or 'bundles'. In single-bundle reconstruction, one of these bundles is restored whereas in double-bundle reconstruction, both are restored. Double-bundle reconstruction may give greater knee stability but is more technically demanding and invasive than single-bundle reconstruction. This review aimed to find out if double-bundle reconstruction gives a better result than single-bundle reconstruction.

Seventeen trials were included. These involved 1433 patients, who were mostly young physically active adults. All included trials had methodological weaknesses that are likely to undermine the reliability of their results. Data for pooling individual outcomes were available for a maximum of nine trials.

There was not enough evidence of differences between two groups in terms of functional knee scores, adverse effects and complications (infection, hardware problem such as pain from fixation device, graft failure), range of motion (flexion and extension deficit). At long term follow-up, some clinician-assessed measures of knee stability and repeated rupture rate or occurrence of new meniscal injuries were better after double-bundle reconstruction.

We concluded that there was not enough evidence to say whether double-bundle reconstruction gives better results than single-bundle reconstruction for anterior cruciate ligament rupture in adults. However, there is limited evidence that double-bundle ACL reconstruction has some superior results for knee stability and protection against repeat ACL rupture or newly occurring meniscal injury.

Authors' conclusions: 

There is insufficient evidence to determine the relative effectiveness of double-bundle and single-bundle reconstruction for anterior cruciate ligament rupture in adults, although there is limited evidence that double-bundle ACL reconstruction has some superior results in objective measurements of knee stability and protection against repeat ACL rupture or a new meniscal injury. High quality, large and appropriately reported randomised controlled trials of double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults appear justified.

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Background: 

Arthroscopic reconstruction for anterior cruciate ligament rupture is a common orthopaedic procedure. One area of controversy is whether the method of double-bundle reconstruction, which represents the 'more anatomical' approach, gives improved outcomes compared with the more traditional single-bundle reconstruction.

Objectives: 

To assess the effects of double-bundle versus single-bundle for anterior cruciate ligament reconstruction in adults with anterior cruciate ligament deficiency.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to February 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 2), MEDLINE (1966 to February week 3 2012) and EMBASE (1980 to 2012 Week 8). We also searched trial registers, conference proceedings, and contacted authors where necessary.

Selection criteria: 

Randomised and quasi-randomised controlled clinical trials comparing double-bundle versus single-bundle reconstruction for anterior cruciate ligament (ACL) rupture in adults.

Data collection and analysis: 

Two review authors independently selected articles, assessed risk of bias and extracted data. We contacted investigators to obtain missing information. Where appropriate, results of comparable studies were pooled.

Main results: 

Seventeen trials were included. These involved 1433 people, mostly young physically active adults. All included trials had methodological weaknesses and were at risk of bias, notably selection bias from inadequate or lack of allocation concealment. Data for pooling individual outcomes were available for a maximum of nine trials and 54% of participants.

There were no statistically or clinically significant differences between double-bundle and single-bundle reconstruction in the subjective functional knee scores (subjective IKDC score, Tegner activity score, Lysholm score) in the intermediate (six months up to two years since surgery) or long term (two to five years from surgery). For example, the long term results for the Lysholm score (0 to 100: best score) were: mean difference (MD) 0.12, 95% confidence interval (CI) -1.50 to 1.75; 5 trials, 263 participants). The only trial reporting on long term knee pain found no statistically significant differences between the two groups. There were no significant differences between the two groups in adverse effects and complications (e.g. infection reported by nine trials (7/285 versus 7/393; risk ratio (RR) 1.14, 95% CI 0.46 to 2.81); graft failure reported by six trials (1/169 versus 4/185; RR 0.45; 95% CI 0.07 to 2.90).

Limited data from five trials found a better return to pre-injury level of activity after double-bundle reconstruction (147/162 versus 208/255; RR 1.15, 95% CI 1.07 to 1.25). At long term follow-up, there were statistically significant differences in favour of double-bundle reconstruction for IKDC knee examination (normal or nearly normal categories: 325/344 versus 386/429; RR 1.05, 95% CI 1.01 to 1.08; 9 trials), knee stability measured with KT-1000 arthrometer (MD -0.74 mm, 95% CI -1.10 to -0.37; 5 trials, 363 participants) and rotational knee stability tested by the pivot-shift test (normal or nearly normal categories: 293/298 versus 382/415; RR 1.06, 95% CI 1.02 to 1.09; 9 trials). There were also statistically significant differences in favour of double-bundle reconstruction for newly occurring meniscal injury (9/240 versus 24/358; RR 0.46, 95% CI 0.23 to 0.92; 6 trials) and traumatic ACL rupture (1/120 versus 8/149; RR 0.17, 95% CI 0.03 to 0.96; 3 trials). There were no statistically significant differences found between the two groups in range of motion (flexion and extension) deficits.

Splints and other non-surgical methods for treating common injuries of the middle joints of the fingers

Injury to the ligaments of the middle joint (proximal interphalangeal joint) of a finger may occur as a result of the finger being forced backwards. This is known as a hyperextension injury. Characteristically, this occurs in sporting accidents, such as where a football strikes an outstretched hand. These injuries are common and typically affect people of working age. Usually, these patients are treated without surgery using a combination of support (splinting/strapping to the adjacent finger) and exercise advice. Use of the hand is commonly encouraged but restricted to some degree by the severity of the injury. By examining the evidence from randomised controlled trials, this review aimed to assess which treatment for hyperextension injuries of the proximal interphalangeal joints of the fingers results in the best outcome for patients. The outcomes examined included function (including return to work), pain and joint movement.

Three small studies including a total of 366 patients met the inclusion criteria for the review. The studies, which were all over 15 years old, were prone to bias. None of the studies reported any self assessment of function by participants. One study compared unrestricted mobility with immobilisation. One trial compared protected mobilisation (using a removable support in combination with exercise) with immobilisation. The remaining study compared immobilisation for one week versus three weeks. None of these trials found important differences between their intervention groups in various measures of poor outcome, pain and range of movement at six months follow-up.

We concluded that there was a lack of robust evidence to inform on the need for, and the extent and duration of, immobilisation for these injuries.

Authors' conclusions: 

There is insufficient evidence from trials testing the need for, and the extent and duration of, immobilisation to inform on the key conservative management decisions for treating hyperextension injuries of the proximal interphalangeal joints.

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Background: 

Immobilisation and early motion (protected or unrestricted) are both used following hyperextension injuries to the proximal interphalangeal (PIP) joint of the finger.

Objectives: 

To assess the effects of conservative interventions (non-surgical management) for treating hyperextension injuries of the proximal interphalangeal joints of the fingers.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2012), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2012, Issue 1), MEDLINE (1946 to January Week 2 2012), EMBASE (1980 to 2012 Week 03), CINAHL (1950 to 24 January 2012), PEDro (1929 to March 2012), trial registers and reference lists of articles.

Selection criteria: 

Randomised and quasi-randomised studies comparing immobilisation/protected mobilisation/unrestricted mobilisation in participants with PIP joint hyperextension injuries managed non-surgically.

Data collection and analysis: 

Two review authors independently assessed risk of bias and extracted data. There was no pooling of data.

Main results: 

Three trials involving 366 people were identified. All three trials, which were over 15 years old, were methodologically flawed with unclear or high risk of bias. None of the studies reported on self assessment of function. One trial compared unrestricted mobility with immobilisation; one trial compared protected mobilisation with immobilisation; and the remaining trial compared immobilisation for one week versus three weeks. None of these trials found statistically significant differences between their intervention groups in various measures of poor outcome, pain and range of movement at six months follow-up. This lack of difference applied at three years for the comparison between unrestricted mobility with immobilisation.

Cold-water immersion for preventing and treating muscle soreness after exercise

Delayed onset muscle soreness commonly results after sports and exercise activity. Cold-water immersion (CWI), which involves people immersing themselves in water at temperatures of less than 15°C, is sometimes used to manage muscle soreness after exercise and to speed up recovery time.

Our review included 17 small trials, involving a total of 366 participants. Study quality was low. Fourteen trials compared cold-water immersion applied after exercise with 'passive' treatment involving rest or no treatment. The temperature, duration and frequency of cold-water immersion varied between the different trials as did the exercises and settings. There was some evidence that cold-water immersion reduces muscle soreness at 24, 48, 72 and even at 96 hours after exercise compared with 'passive' treatment. Limited evidence from four trials indicated that participants considered that cold-water immersion improved recovery/reduced fatigue immediately afterwards. Most of the trials did not consider complications relating to cold-water immersion and so we cannot say whether these are a problem. There were only limited data available for other comparisons of cold-water immersion versus warm or contrasting (alternative warm/cold) water immersion, light jogging, and compression stockings. None of these showed important differences between the interventions being compared.

While the evidence shows that cold-water immersion reduces delayed onset muscle soreness after exercise, the optimum method of cold-water immersion and its safety are not clear.

Authors' conclusions: 

There was some evidence that cold-water immersion reduces delayed onset muscle soreness after exercise compared with passive interventions involving rest or no intervention. There was insufficient evidence to conclude on other outcomes or for other comparisons. The majority of trials did not undertake active surveillance of pre-defined adverse events. High quality, well reported research in this area is required.

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Background: 

Many strategies are in use with the intention of preventing or minimising delayed onset muscle soreness and fatigue after exercise. Cold-water immersion, in water temperatures of less than 15°C, is currently one of the most popular interventional strategies used after exercise.

Objectives: 

To determine the effects of cold-water immersion in the management of muscle soreness after exercise.

Search strategy: 

In February 2010, we searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library (2010, Issue 1), MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health (CINAHL), British Nursing Index and archive (BNI), and the Physiotherapy Evidence Database (PEDro). We also searched the reference lists of articles, handsearched journals and conference proceedings and contacted experts.

In November 2011, we updated the searches of CENTRAL (2011, Issue 4), MEDLINE (up to November Week 3 2011), EMBASE (to 2011 Week 46) and CINAHL (to 28 November 2011) to check for more recent publications.

Selection criteria: 

Randomised and quasi-randomised trials comparing the effect of using cold-water immersion after exercise with: passive intervention (rest/no intervention), contrast immersion, warm-water immersion, active recovery, compression, or a different duration/dosage of cold-water immersion. Primary outcomes were pain (muscle soreness) or tenderness (pain on palpation), and subjective recovery (return to previous activities without signs or symptoms).

Data collection and analysis: 

Three authors independently evaluated study quality and extracted data. Some of the data were obtained following author correspondence or extracted from graphs in the trial reports. Where possible, data were pooled using the fixed-effect model.

Main results: 

Seventeen small trials were included, involving a total of 366 participants. Study quality was low. The temperature, duration and frequency of cold-water immersion varied between the different trials as did the exercises and settings. The majority of studies failed to report active surveillance of pre-defined adverse events.

Fourteen studies compared cold-water immersion with passive intervention. Pooled results for muscle soreness showed statistically significant effects in favour of cold-water immersion after exercise at 24 hour (standardised mean difference (SMD) -0.55, 95% CI -0.84 to -0.27; 10 trials), 48 hour (SMD -0.66, 95% CI -0.97 to -0.35; 8 trials), 72 hour (SMD -0.93; 95% CI -1.36 to -0.51; 4 trials) and 96 hour (SMD -0.58; 95% CI -1.00 to -0.16; 5 trials) follow-ups. These results were heterogeneous. Exploratory subgroup analyses showed that studies using cross-over designs or running based exercises showed significantly larger effects in favour of cold-water immersion. Pooled results from two studies found cold-water immersion groups had significantly lower ratings of fatigue (MD -1.70; 95% CI -2.49 to -0.90; 10 units scale, best to worst), and potentially improved ratings of physical recovery (MD 0.97; 95% CI -0.10 to 2.05; 10 units scale, worst to best) immediately after the end of cold-water immersion.

Five studies compared cold-water with contrast immersion. Pooled data for pain showed no evidence of differences between the two groups at four follow-up times (immediately, 24, 48 and 72 hours after treatment). Similar findings for pooled analyses at 24, 48 and 72 hour follow-ups applied to the four studies comparing cold-water with warm-water immersion. Single trials only compared cold-water immersion with respectively active recovery, compression and a second dose of cold-water immersion at 24 hours.

Autologous chondrocyte implantation for full thickness articular cartilage defects of the knee

A layer of cartilage covering the knee joint surfaces acts to protect the joint and reduce friction. Damage to the cartilage (articular surface) can decrease mobility of the joint and cause pain on movement. Continuing deterioration of the surface may lead to osteoarthritis. Treatments for damaged cartilage include relieving symptoms, surgically cleaning up the joint, or surgically re-establishing the cartilage layer. The latter is done using marrow stimulation techniques (such as microfracture), mosaicplasty (also known as osteochondral cylinder transplantation), and more recently with implantation of healthy cartilage cells (chondrocytes). In the technique of autologous chondrocyte implantation (ACI), a small piece of cartilage is retrieved from the knee joint. This piece is brought to a laboratory where it is digested to free the chondrocyte cells; these cells are subsequently cultured in a culture media in order to expand the numbers of cells. Then, with a second surgery, the cells are placed into the joint defect in an effort to produce a tissue that substitutes the normal cartilage.

This review includes six small randomised controlled trials that compared ACI with either mosaicplasty or microfracture. Although there are some promising results for ACI compared with microfracture from one trial, the evidence from two other trials testing the same comparison did not confirm these. None of the other three trials testing different comparisons provided conclusive evidence in favour of ACI, although the longer-term results suggest that the results for some types of ACI may improve over time. The review identified several ongoing trials that should help to provide evidence to inform on the use of ACI in the future. Meanwhile, there is insufficient evidence to draw conclusions on the use of ACI.

Authors' conclusions: 

There is insufficient evidence to draw conclusions on the use of ACI for treating full thickness articular cartilage defects in the knee. Further good quality randomised controlled trials with long-term functional outcomes are required.

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Background: 

Treatments for managing articular cartilage defects of the knee, including drilling and abrasion arthroplasty, are not always effective. When they are, long-term benefits may not be maintained and osteoarthritis may develop. An alternative is autologous chondrocyte implantation (ACI), the surgical implantation of healthy cartilage cells into the damaged areas.

Objectives: 

To determine the efficacy and safety of ACI in people with full thickness articular cartilage defects of the knee.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (14 January 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 4), MEDLINE (1948 to January Week 1 2011), EMBASE (1980 to Week 1 2011), SPORTDiscus (1985 to 14 January 2011), the WHO International Clinical Trials Registry Platform (26 January 2011), and Current Controlled Trials (26 January 2011).

Selection criteria: 

Randomised and quasi-randomised trials comparing ACI with any other type of treatment (including no treatment or placebo) for symptomatic cartilage defects of the medial or lateral femoral condyle, femoral trochlea or patella.

Data collection and analysis: 

Review authors selected studies for inclusion independently. We assessed risk of bias based on adequacy of the randomisation and allocation concealment process, potential for selection bias after allocation and level of masking. We did not pool data due to clinical and methodological heterogeneity.

Main results: 

Six heterogeneous trials were identified with 442 participants. Methodological flaws of the included trials included incomplete follow-up and inadequate reporting of outcomes. Three trials compared ACI versus mosaicplasty. One reported statistically significant results in favour of ACI at one year in the numbers of people with 'good' or 'excellent' functional results. Conversely, another trial found significant improvement for the mosaicplasty group when assessed using one functional scoring system at two years, but no statistically significant differences based on two other scoring systems. A third trial found no difference between ACI and mosaicplasty, 10 months on average after the surgery.

There was no statistically significant difference in functional outcomes at two years in a single trial comparing ACI with microfracture nor in the functional results at 18 months of a single trial comparing characterised chondrocyte implantation versus microfracture. However, the results at 36 months for this trial seemed to indicate better functional results for characterised chondrocyte implantation compared with those for microfracture. The sixth trial comparing matrix-guided ACI versus microfracture found significantly better results for functional outcomes at two year follow-up in the MACI group.

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