December 23, 2015 at 9:54 pm #3306Nick LawParticipant
I recently evaluated a patient s/p MVA who has a history of concussion symptoms and reported experiencing persistent concussion-type symptoms following her most recent MVA as well. She perceived that some of her symptoms (e.g., memory loss) were worsening. This was certainly of concern to me, leading me to inform her MD. I also felt fairly unacquainted with post-concussion symptoms, prognosis, treatment strategies altogether and therefore thought this article and the search strategies indicated might be useful.
My PICO was broad and simple: what are the classic symptoms, prognosis, and interventions (especially therapy related) for patients experiencing a concussion-injury?
I used the “narrow” search string listed in the article, and with the additional key word “concussion.” 23 articles were found; surprisingly, many were written by/published in chiropractic journals. The attached article seemed the most relevant.
The article itself proved fairly helpful in meeting portions of each of my objectives. A few key points:
– Imaging with concussion (or minor traumatic brain injury, MTBI) is typically normal. No sense in referring back to the MD if all you suspect is MTBI.
– The majority of patients with MTBI recover within the first year, though a significant minority do continue to report symptoms.
– There is little research regarding effectiveness of interventions, however current guidelines recommend patient education regarding the injury itself, coping strategies, encouragement regarding positive prognosis and return to premorbid ADLs.
– The difficulties in differentiating MTBI and whiplash, and the overlap of the two conditions are discussed. Significant to this, the authors mention how addressing patients beliefs following MTBI should be addressed, as patients who expected to get better following a whiplash injury improved 3 TIMES AS FAST as those who did not expect to improve. That was very revealing to me.
Overall, my take on the use of the search strings was that it seems helpful when searching broadly regarding therapy and any particular condition (e.g., concussion or AC pain). However, it seems to me that its advantage in breadth limits its specificity. Thus, if your condition of interest is simply “neck pain,” the narrow search string will give you 1318 results. In a case like this, it seems more prudent to simply use a more limited number of MeSH terms to achieve your result.
What did you guys think? Again, my take home is that I certainly have a new way to search broadly for conditions that I am not very familiar with/are not very common, and am looking for essentially any information that will probably be helpful and pertinent to therapy.
– Also, not sure why but having difficulty attaching my article…
December 26, 2015 at 9:07 pm #3309Laura HalleyModerator
For my article search, I decided to explore the current research on early passive range of motion for rotator cuff repairs. I just evaluated several this past week and each patient has slightly different surgical procedure as well as home environment/spousal support in terms of assisting with exercises at home.
PICO: In patients who have undergone rotator cuff repair within the past 7 days, what is the optimal frequency, duration, and type of passive manual therapy techniques for the first 6 weeks to maximize long term functional outcome?
I copy-and-pasted the search string and then under “name of disease”, I placed “rotator cuff repair.”
Narrow search strategy: 30
Expanded search strategy: 841
Right off the bat with the narrow search strategy, I found 5 appropriate articles on the first page looking at early rehabilitation protocols (slow vs. accelerated), including randomized controlled trials. The expanded search strategy included a lot more of surgical procedures and I needed to go through 3 pages to find as many appropriate articles. The narrow search strategy was already a headache saver from the start.
Most articles compare daily passive range of motion vs. delayed range of motion until 6 weeks. A meta-analysis of randomized controlled trials was published this past May in AJSM on early vs. delayed passive range of motion exercises. They found that there was no long-term difference in functional outcome with adding early range of motion in the first 6 weeks of rehabilitation, however short term improvements were made with flexion range of motion and therefore recovery of deficits from ROM limitations could be facilitated. The frequency of visits varied from 3-7 days a weekThere was an elevated rate of recurrent tears with massive to full tears with the early passive range of motion exercises. The authors conclude that early ROM exercises is preferable in cases without the risk of improper healing but with the risk of shoulders stiffness. Gradual and cautious passive range of motion is encouraged.
The narrow search strategy was extremely helpful in this case. Rotator cuff repair is a common procedure and well-researched, therefore a narrower search was optimal to save time and effort in finding appropriate articles. It was worth initially to search with the narrow string and based on how successful this strategy was, I wouldn’t have needed to do the broad string at all if I was limited on time.
- This reply was modified 4 years, 2 months ago by Laura Halley.
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December 28, 2015 at 8:34 am #3312Michael McMurrayKeymaster
Great job Laura and Nick – still waiting for others to post.
The more familiar you are with “tips and tricks” for the main database (PubMed usually) that you search, the more efficient you will continue to be.
Let’s continue this string throughout the year with additional successes/failures in literature searching to help each other become efficient and critical consumers of the evidence.
Happy New Year
December 28, 2015 at 5:39 pm #3313Nick LawParticipant
Agreed with Eric
I am still learning all that PubMed has to offer in terms of searching (which is way more than I previously understood), however I have really benefitted from what I have learned so far.
I have found that the “saved searches” feature, which repeatedly sends you current publications that make it in to PubMed on any given subject or any particular authors, to be very helpful. If you haven’t played with this yet, I think it is certainly worth the time doing so.
January 3, 2016 at 5:18 pm #3353ABengtssonParticipant
For the article I decided to look at shin splints/ medial tibial stress syndrome for one of my pts (14y/o female runner).
I kept the PICO very general – In patients with MTSS, what are risk factors/causes/etiology and what what are supported treatment approaches/methods?
Narrow search strategy using
“shin splints” = 4 articles
“medial tibial stress syndrome” = 2
Expanded search strategy using
“shin splints” = 65
“medial tibial stress syndrome” = 50
The article I looked at was included in the expanded results using both terms.
I read a lot of the abstracts and quite a few of the articles and just based on what I found with these searches there doesn’t seem to be a whole lot of research for causes/treatment etc of shin splints and certainly not a lot of consensus. That probably explains why I had to use the expanded search strategy to find more relevant articles.
A lot of the literature I found was looking at military recruits/service members and/or medical/radiologic dx tests. This article stood out bc it was more relevant to my pt.
– hip IR/ER ROM at 90 deg
– DF ROM at knee EXT and 90 deg FLX
– Intercondylar interval (knee valgus/varus)
– Intermalleolar interval (ankle inversion/eversion)
– Navicular drop test (NDT)
– hip ABD strength
Results – sign increased rist
MTSS in females
– >hip IR ROM
Stress fx in males
– <SLR ROM
All other measurements did not yield significant results.
I thought it was interesting to see how the different strategies work depending on the topic. I’ve used these with a couple of other topics and the narrow search strategy has definitely been a great help!
January 3, 2016 at 9:12 pm #3354omikutinParticipant
I recently evaluated a patient with a diagnosis RTC tendonopathy secondary to subacromial impingement. I remember in school we talked about prescribing “eccentrics” for tendonopathies and I’m curious to see if there are any articles that compare eccentrics. However, I kept my PICO question broad in hopes of looking at optimal innerventions.
My PICO question was: What is the optimal innervation for patients with rotator cuff tendonopathy?
I copied and pasted “rotator cuff tendinopathy” under name-of-disease.
I copied and pasted “rotator cuff tendinopathy eccentrics” under name-of disease
Narrow search: first 8 articles were published within the past 5 years and included articles such as Manual Therapy, Physiotherapy, JOPST, American journal of Physical Medicine and Rehabilitation. The first article was a systematic review showing the efficacy of manual therapy for RTC tendinopathy which found that manual therapy was found to decreased pain but more studies are needed to see if there is a functional improvement. None of these studies had eccentrics.
Expanded search: first 20 articles were all published within 2015, including RTC surgical procedures, multiple RTC diagnoses, modalities, taping, diagnostic images, ther ex, medications and other diagnosis. I noticed many of the articles that I used for my narrowed search appeared in the expanded search. I found myself getting lost in reading most of the articles that come up during the search.
There was one 2015 RTC “COMPARISON OF ECCENTRIC AND CONCENTRIC EXERCISE INTERVENTIONS IN ADULTS WITH SUBACROMIAL IMPINGEMENT SYNDROME.” It was found that there was no difference between concentric and eccentric program, both had improvements in function, AROM and strength.
There was another 2014 article” Eccentric training as a new approach for rotator cuff tendinopathy: Review and perspectives. That mentioned how eccentric training shoulder be used to improve tendon degeneration and more research is needed to help find optimal dose and long-term follow-up effect. I didn’t find this very useful, but under “similar articles” I found a 2015 article: “Eccentric strength training for the rotator cuff tendinopathies with subacromial impingement. Current evidence”. Only one study was a RCT that compared eccentric exercises to conservative treatment for impingement. It was found that the experiment group had an improvement in strength but no difference in functional gain.
Both narrow and expanded searches were very helpful. Narrow: I was able to find articles that were more centered around rotator cuff tendonopathies. Expanded: I was able to see multiple RTC diagnosis and it gave me more opportunities to search for eccentric exercise programs.
January 4, 2016 at 9:58 pm #3358sewhittaParticipant
I have a 31 year old, very fit guy with mild symptoms of FAI bilaterally and very limited hip IR bilaterally, surprisingly greater on the uninvolved side. X-ray confirmed mild CAM deformities bilaterally. He appears incredibly stiff in the posterior capsule of both hips. I’ve been trying to mobilize his hips manually and with power bands as part of the HEP, but I feel like there’s no significant benefit thus far. I’m also not sure how much to expect to improve with someone with an anatomical variation such as a CAM deformity, whether it be a mild deformity or otherwise.
My PICO question for him is: Will a patient with femoroacetabular impingement benefit from manual joint mobilizations compared to a home exercise program.
The narrow search string with with the addition of “femoroacetabular impingement” came back with a surprising 12 results.
The expanded search showed 337 results.
The narrow search results ranged from 2015 back to 2005, with 3 good hits discussing conservative management for a long distance runner, a case report for a HEP, and another discussing hip weakness in a patient with FAI. All I felt were applicable to my question. The remaining 9 addressed rehabilitation after surgery, still helpful.
The expanded search showed the first 20 results were from 2015 & 2016. A few results on the first page may be informative, discussing biomechanics during gait, strength, and hip kinematics with patients with FAI; however, most discussed objective findings rather than treatment.
I felt the two results were very different. Narrow was definitely more applicable to my question, but I think it may be worthwhile to do a quick scan with the expanded search stream if you want to find more “nice-to-know” information.
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