Presentation on theme: "RETURN TO ACTIVITY TIME FOR ATHLETES UNDERGOING TREATMENT FOR CHRONIC EXERTIONAL COMPARTMENT SYNDROME OF THE LEG Hancock S, Mizuta I, Moore J, Neilsen."— Presentation transcript:
RETURN TO ACTIVITY TIME FOR ATHLETES UNDERGOING TREATMENT FOR CHRONIC EXERTIONAL COMPARTMENT SYNDROME OF THE LEG Hancock S, Mizuta I, Moore J, Neilsen P, Whiting F
OUTLINE INTRODUCTIONINTRODUCTION Systematic Review Question Outcome Measures Operational Definitions BACKGROUNDBACKGROUND METHODSMETHODS Search Strategy Screening Strategy Quality Assessment Strategy Data Extraction Strategy RESULTSRESULTS Study Characteristics Quality Assessment Return to Activity Time Complications DISCUSSIONDISCUSSION CONCLUSIONCONCLUSION DISSEMINATIONDISSEMINATION ACKNOWLEDGEMENTSACKNOWLEDGEMENTS
INTRODUCTION Systematic Review Question “What is the effectiveness of treatment options for athletes diagnosed with Chronic Exertional Compartment Syndrome (CECS) in regards to return to activity (RTA) time and post-treatment complications?”
Outcome Measures Primary: RTA time Length of time required for the patient to return to their previous level of physical activity Secondary: ComplicationsSecondary: Complications Unplanned consequences of treatment
Operational Definitions Athletes: People involved in any sporting activity from recreational to professional levels of participation Physical Activity: Activity requiring energy expenditure above resting level
BACKGROUND 2 types of compartment syndromes: acute and chronic Acute commonly due to trauma and requires emergency fasciotomy CECS is a common cause of leg pain in competitive and recreational athletes, particularly runners
Patient History No pain at rest; pain gradually builds with exertion Type: dull ache, sensation of muscle tightness, cramping Specific onset variable between athletes, usually 10-15 mins into exercise, forces athlete to stop activity, shorten the duration or decrease intensity Ache may remain up to 30 min after exercise X-rays negative, Bone scans negative Intracompartmental Pressure Measurement (ICPM) diagnostic
Muscles expand Restricted by stiff, non-compliant layer of fascia Intramuscular pressures↑ Impairment of the arterial/venous gradient Pain CrampingMm tightness Distal paresthesia ↓Mm function Relieved by: rest Aggravated by: repetitive loading Pathophysiology
Chronic Exertional Leg Pain Correct diagnosis is essential but often misdiagnosed Differential diagnosis: Umbrella term “shin splints” Medial Tibial Stress Syndrome (MTSS) Stress fractures CECS Nerve compression Fascial hernias Popliteal artery entrapment syndromePopliteal artery entrapment syndrome
Diagnosis Gold Standard: ICPM Diagnostic criteria:Diagnostic criteria: Resting ~15 mmHg 1-min. post-exs >30 mmHg 5-min. post-exs >20 mmHg Non-invasive diagnostic measures: Infra-red Spectroscopy MRI Currently being researched to establish validity and reliability compared with ICPM
Incidence of CECS Bilaterally (~50-70% of patients) Gender distribution debated 95% occurs in leg Anterior > Deep Posterior/Lateral > Superficial Posterior compartment
Rationale CECS causes athletes to reconsider their athletic pursuitsCECS causes athletes to reconsider their athletic pursuits Successful treatment determines level of sport or activity they will be able to resumeSuccessful treatment determines level of sport or activity they will be able to resume Goal: Provide an evidence-based resource for clinicians to help educate athletes and physically active people diagnosed with CECS on the best available treatment options and treatment prognosis.Goal: Provide an evidence-based resource for clinicians to help educate athletes and physically active people diagnosed with CECS on the best available treatment options and treatment prognosis.
METHODS Search Strategy Searches performed: Oct ’08, Jan & June ’09Searches performed: Oct ’08, Jan & June ’09 Online Database SearchOnline Database Search CINAHL (from 1982), EMBASE (from 1980), MEDLINE (from 1950), PubMed (from 1949), SportDiscus (from 1837)CINAHL (from 1982), EMBASE (from 1980), MEDLINE (from 1950), PubMed (from 1949), SportDiscus (from 1837) Grey Literature SearchGrey Literature Search Google Scholar, Reference lists of included studiesGoogle Scholar, Reference lists of included studies
MEDLINE Search Strategy 1. exp Compartment Syndromes/ 2. compartment syndrome*.ti,ab. 3. (tibial stress or shin splint*).ti,ab. 4. (nerve adj2 (entrap* or compress*)).ti,ab. 5. (exertion* adj2 leg pain).ti,ab. 6. effort related compartment syndrome*.ti,ab. 7. chronic leg pain.ti,ab. 8. 1 or 2 or 3 or 4 or 5 or 6 or 7 9. Leg/ 10. leg.ti,ab. 11. 9 or 10 12. 8 and 11 13. exp Therapeutics/ 14. treat*.ti,ab. 15. Surgery/ 16. surgery.ti,ab. 17. fasciotomy.ti,ab. 18. manag*.ti,ab. 19. taping.ti,ab. 20. diuretic*.ti,ab. 21. Acupuncture Therapy/ 22. acupuncture.mp. 23. exp Physical Therapy Modalities/ 24. Ultrasonic Therapy/ 25. ultrasound.ti,ab. 26. (physical therap* or physiotherap*).ti,ab. 27. exp Massage/ 28. massage.ti,ab. 29. myofascial release.ti,ab. 30. exp Orthotic Devices/ 31. (orthoses or orthotic*).ti,ab. 32. Muscle Stretching Exercises/ 33. stretch*.ti,ab. 34. strength*.ti,ab. 35. Weight Lifting/ 36. Exercise Therapy/ 37. Exercise/ 38. (resist* exercise or resist* training).ti,ab. 39. Rest/ 40. or/13-38 41. 12 and 40 42. Prognosis/ 43. Treatment Outcome/ 44. Disease-free Survival/ 45. Medical Futility/ 46. Treatment Failure/ 47. Pain/ 48. "Recovery of Function"/ 49. exp Athletic Performance/ 50. activity.mp. 51. intracompartmental pressure.mp. 52. performance.mp. 53. or/42-52 54. 12 and 53 55. 41 or 54 56. limit 55 to "humans"
Article Search Results Databasen Title Screen Abstract Screen Full Text Screen Met Eligibility Excluded EMBASE78769800787 MEDLINE831901522829 PubMed779751233776 CINAHL541611811540 SPORT DISCUS 48586511484 Google Scholar 830008 Reference List 3636160036 TOTAL (N) 346773460
Screening Strategy InclusionExclusion - English - RCTs, CCTs, prospective cohort studies, retrospective case series, case studies - Athletic population (recreational to professional) - Physically active people - All ages - Any compartment of the leg - Diagnosed by ICPM - Conservative or surgical treatment - Outcome measure: RTA time - Review articles - Acute compartment syndrome
Data Extraction Strategy Information recorded:Information recorded: MethodologyMethodology InterventionIntervention Participant characteristicsParticipant characteristics Primary and secondary outcomesPrimary and secondary outcomes Statistical meta-analysis not conducted:Statistical meta-analysis not conducted: Differences in population characteristicsDifferences in population characteristics Methodological variations between studiesMethodological variations between studies No RCTsNo RCTs
RESULTS Study Characteristics 7 studies met inclusion criteria7 studies met inclusion criteria 4 Retrospective Studies, 3 Case Studies4 Retrospective Studies, 3 Case Studies No conservative treatmentsNo conservative treatments Subjects aged 12-50Subjects aged 12-50 Mean age: 21.1Mean age: 21.1 48.6% male; 51.4% female48.6% male; 51.4% female Compartments reported as limbs operated on or # of subjects affectedCompartments reported as limbs operated on or # of subjects affected Limbs: Anterior and Lateral compartments most affectedLimbs: Anterior and Lateral compartments most affected 40.4% 40.4% Subjects: Anterior compartment most affectedSubjects: Anterior compartment most affected 70% 70%
Study Characteristics Athletic Level n% Recreational4738.5 Amateur3629.5 High Performance 129.8 Non-Sport119 Professional43.3 Collegiate43.3 Competitive43.3 High-School21.6 Work-Related21.6 Total Reported 122 Physical Activity n%Running9658.2 In-line Skating 1710.3 Physical Activity Unspecified 169.7 Soccer63.6 Skiing63.6 Athletics53 Golf42.4 Rowing31.8 Gymnastics21.2 Boxing21.2 Basketball21.2 Field Hockey 21.2 Football10.6 Dancing10.6 Figure Skating 10.6 Badminton10.6 Total Total165
Quality Assessment van Tulder Methodological Quality Assessment Toolvan Tulder Methodological Quality Assessment Tool No RCTs low quality assessment scoresNo RCTs low quality assessment scores Retrospective studies scored between 6/19 – 9/19Retrospective studies scored between 6/19 – 9/19 Case studies scored between 4/19 – 5/19Case studies scored between 4/19 – 5/19 First Author Score Detmer (1985) 7 Farr (2008) 5 Garcia (2001) 7 Kitajima (2001) 4 Ota (1999) 4 Raikin (2005) 9 Schepsis (1999) 6
Return to Activity Time Return to Activity Time Cane ambulation: 24 - 36hrsCane ambulation: 24 - 36hrs Walking: 1, 2 or 3 daysWalking: 1, 2 or 3 days Running: 14, 21, 28 or 42 daysRunning: 14, 21, 28 or 42 days Full RTAFull RTA Simultaneous bilateral or unilateral: 3 - 12.2 wksSimultaneous bilateral or unilateral: 3 - 12.2 wks Mean RTA: 7.82 ± 3.36 wksMean RTA: 7.82 ± 3.36 wks Bilateral staged: 22.7 wksBilateral staged: 22.7 wks First AuthorWeeks Detmer3 Farr8 Garcia-Mata6 Kitajima8 Ota3 Raikin10.7 Schepsis - A8.1 Schepsis - A&L11.4 Schepsis - bilateral12.2 Mean7.82 Standard Deviation3.36 Coefficient of Variance42.93 A: Anterior; L: Lateral
DISCUSSION What is known? Surgical treatment via fasciotomy considered best treatment for resolution of symptoms of CECSSurgical treatment via fasciotomy considered best treatment for resolution of symptoms of CECS Conservative treatment poorly supported by evidenceConservative treatment poorly supported by evidence Anterior compartment most commonly affectedAnterior compartment most commonly affected Gender predominance unclearGender predominance unclear Complications of fasciotomies: 11-13%Complications of fasciotomies: 11-13%
What does this study add? No reviews have looked at recovery time post- fasciotomyNo reviews have looked at recovery time post- fasciotomy Mean RTA time post-fasciotomyMean RTA time post-fasciotomy 7.82 ± 3.36 wks7.82 ± 3.36 wks ComplicationsComplications 13% of included subjects13% of included subjects Bilateral simultaneous fasciotomies result in faster recovery timesBilateral simultaneous fasciotomies result in faster recovery times
LIMITATIONS No RCTsNo RCTs RTA time:RTA time: Not primary outcome measure for any article includedNot primary outcome measure for any article included Lacked measures of variability (SD of RTA scores)Lacked measures of variability (SD of RTA scores) Unknown if reported based on surgeon’s protocol or individual athlete’s recoveriesUnknown if reported based on surgeon’s protocol or individual athlete’s recoveries Low methodological quality scores of included articlesLow methodological quality scores of included articles Only one study identified differences in RTA time based upon the compartment affectedOnly one study identified differences in RTA time based upon the compartment affected No studies reported RTA times with respect to duration of symptoms prior to treatment, age or genderNo studies reported RTA times with respect to duration of symptoms prior to treatment, age or gender Limited number of included articlesLimited number of included articles Strict inclusion criteriaStrict inclusion criteria
CONCLUSION No studies indicating RTA times post-conservative treatmentNo studies indicating RTA times post-conservative treatment Results indicate:Results indicate: RTA time: 7.82 ± 3.36 wks post-fasciotomyRTA time: 7.82 ± 3.36 wks post-fasciotomy Complication rate: 13% (excluding swelling)Complication rate: 13% (excluding swelling) Evidence-based resource for health care practitioners including sports medicine physicians, physiotherapists, coaches and athletic trainersEvidence-based resource for health care practitioners including sports medicine physicians, physiotherapists, coaches and athletic trainers Educate clients on expected recovery times and complicationsEducate clients on expected recovery times and complications
CONCLUSION Direction of researchDirection of research Improvement of research methodology regarding existing treatmentsImprovement of research methodology regarding existing treatments Shift toward research of alternate diagnostic tests (infrared spectroscopy)Shift toward research of alternate diagnostic tests (infrared spectroscopy)
DISSEMINATION Manuscript will be sent to the British Journal of Sports Medicine for reviewManuscript will be sent to the British Journal of Sports Medicine for review
ACKNOWLEDGEMENTS Dr. Babak ShadganDr. Babak Shadgan Dr. Darlene ReidDr. Darlene Reid Dr. Elizabeth DeanDr. Elizabeth Dean Charlotte BeckCharlotte Beck Thank you for all of your support, direction, and constructive feedback!
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