Journal of Physiotherapy 60 (2014) 174–175 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Correspondence Prophylactic stretching is unlikely to prevent nocturnal leg cramps In order to reduce the frequency of nocturnal leg cramps, leg not stretch leg muscles). This trial didn’t find a trend to benefit. stretching before sleep is commonly recommended. A little over a This lack of benefit is consistent with a recent survey in which year ago in this journal, Hallegraeff et al1 authored the first cramp sufferers were asked to rate the effectiveness of any randomised controlled trial to support this practice – demonstrat- therapies they had tried.5 Of the 21 patients who tried prophylactic ing 1.2 fewer cramps per night and less-severe cramp pain in the stretching, the vast majority (n = 18) found it to be ‘useless’ or ‘a stretching group, compared to those receiving no treatment. little help’ and only three found it to be ‘quite helpful’ or ‘very Missing from the analysis of this trial, however, was an explanation helpful’. This compares to the 18 users of quinine, the vast majority of why (despite similar recruitment methods and similar inclu- of whom (n = 16) found it to be ‘quite helpful’, ‘very helpful’ or sion/exclusion criteria) the cramp rate in the control group differed ‘100% effective’, with only two subjects reporting it to be ‘useless’ so dramatically from what had been observed in other randomised or ‘a little help’. While it was reported that the stretching technique trials. Cochrane systematic reviews of both quinine (13 trials with of some patients was clearly inappropriate (eg, plantarflexing the 952 subjects) and magnesium (4 trials with 213 subjects) for the foot), there were still very few people who rated prophylactic prophylaxis of rest cramps show mean cramp rates in placebo stretching as an effective therapy. controls of 4.4 and 4.35 cramps/week.2,3 In contrast, the control group cramp rate in the trial by Hallegraeff et al was 16.8 cramps/ The only randomised trial to compare prophylactic stretching week (2.4 cramps/night) – a cramp rate that is nearly fourfold with a sham intervention in a typical population of crampers higher. Is the population from which these subjects were derived remains with Coppin.4 Given that Coppin found no trend to benefit, unique? Were there extreme outliers skewing the distribution? and given the vast majority of surveyed crampers who have tried Can we be confident of the diagnosis? prophylactic stretching report it to be ineffective, I believe that the current body of evidence does not support bedtime stretching for An additional problem in interpreting the results of the trial by the prophylaxis of nocturnal leg cramps. Hallegraeff et al1 is the comparison of an intervention group to unblinded controls who were offered no treatment. This is Scott R Garrison problematic because there is potential subjectivity in the reporting Department of Family Medicine, University of Alberta, Canada of cramps. For example, is a brief cramp worth reporting? Was a long cramp episode really one single cramp, or multiple individual References cramps occurring in close succession? Given that the subjects in this trial were unblinded and can be assumed to have had different 1. Hallegraeff JM, et al. J Physiother. 2012;58:17–22. expectations of potential benefit (an intervention versus no 2. El-Tawil S, et al. Cochrane Database Syst Rev. 2010;12:CD005044. treatment), might those expectations have influenced the reporting 3. Garrison SR, et al. Cochrane Database Syst Rev. 2012;9:CD009402. of cramps? 4. Coppin RJ, et al. Br J Gen Pract. 2005;55:186–191. 5. Blyton F, et al. J Foot Ankle Res. 2012;5:7. The only other randomised controlled trial that has evaluated prophylactic stretch is by Coppin et al,4 in which 191 quinine users http://dx.doi.org/10.1016/j.jphys.2014.05.004 used either bedtime stretch or control (ie, leg movements that did A clear definition of nocturnal leg cramps is essential for comparability of research In 2012, our randomised trial demonstrated that stretching assist sleep, or who had orthopaedic problems, severe medical before sleep reduces the frequency and severity of nocturnal leg conditions, or comorbidities known to cause muscular spasms or cramps in older adults.1 These episodic cramp attacks are cramps. The homogeneity of our study cohort is important, characteristic: painful, sustained, involuntary muscle contractions because, for example, nocturnal leg cramps are more prevalent in of the calf muscles, hamstrings or feet. The sharp and intense pain older adults6,8 and medications can affect the frequency of may last from seconds to several minutes, accompanied by firm cramps.6 The two Cochrane reviews,6,7 however, include data and tender muscles, and in some cases, with plantar flexion of feet from participants of any age with ‘idiopathic’, ‘rest’ or ‘pregnancy- and toes.2–5 In his letter, Garrison argues that prophylactic associated’ cramps, with no clear eligibility criteria being applied stretching is unlikely to prevent nocturnal leg cramps. that are diagnostic of nocturnal leg cramps. This permits a heterogeneous population with different types of muscular Garrison’s first point is that the frequency of nocturnal leg cramps, affecting any body part, from any cause, in any setting cramps in our trial was higher than would be anticipated from the and at any time of day. Also, these cramps were measured at data from the study populations in two recent Cochrane reviews of weekly intervals and cramp diaries were not commonly used, so medications for cramps.6,7 The participants in our study were a recall bias may have caused underestimation of the true frequency. homogeneous group of adults aged over 55 years with regular Finally, quinine users were excluded from our study and most episodes of nocturnal leg cramps occurring at least once per week. participants in our study had tried quinine without success, We excluded people who were using quinine or medication to 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Appraisal Correspondence 175 suggesting intractable cramps; so a high cramp frequency might be by doing the opposite of what is needed; they contract their expected. In summary, although baseline cramp frequency differs muscles rather than stretch them. In addition, we want to reinforce between our trial and the two Cochrane reviews, this is reasonable that hamstrings, and often the whole leg, are involved in nocturnal due to the non-comparability of the participants and the ways in leg cramps, so we still recommend stretching both calf and which cramp was measured. hamstring muscles.1,10 Garrison’s second point is that the lack of blinding may have led Finally, we emphasise the application of the Classification of to biased reporting, especially because subjectivity may have Diseases (ICD-9), code 327.52 and the development of a diagnostic allowed a run of cramps to have been reported as either multiple instrument for diagnosing nocturnal leg cramps for use by general individual cramps or a single cramp episode. Unfortunately, practioners and physiotherapists.5 Besides, treatment of nocturnal neither blinding of the stretch intervention, nor objective leg cramps should not be restricted to the calf muscles alone measurement of cramps was feasible. However, all other criteria because the whole leg must be assessed, in particular the for methodological rigour were achieved (eg, concealed allocation, hamstrings. no loss to follow-up). To minimise the potential for knowledge of group assignment to influence the participants’ expectations, Joannes M Hallegraeffa, Mathieu H de Greefa,b and participants were instructed individually to avoid contact with Cees P van der Schansa,b each other so as not to contaminate information. aHanze University of Applied Sciences Garrison also compares our results to those of the trial by bUniversity Medical Center Groningen, The Netherlands Coppin et al,9 which did not find even a trend to benefit from stretching for nocturnal leg cramps. We note, however, several References important differences in the stretch intervention. In the Coppin trial, nurses provided the stretch technique, the time of day at 1. Hallegraeff JM, et al. J Physiother. 2012;58(1):17–22. which the stretch was performed is not described, and the actual 2. Monderer RS, et al. Curr Neurol Neurosci Rep. 2010;10(1):53–59. stretch technique is not defined well enough to know whether only 3. Sontag SJ, et al. Med Hypotheses. 1988;25(1):35–41. the calf was stretched or whether other muscle groups were also 4. Riley JD, et al. Am Fam Physician. 1995;52(6):1794–1798. stretched. Furthermore, it remains unclear how the stretching 5. Hallegraeff JM, et al. J Physiother. 2013;59(4):279. technique was monitored during the study. In this context, 6. Garrison SR, et al. Cochrane Database Syst Rev. 2012;9:CD009402. Garrison discusses the qualitative data analysis of Blyton et al,10 7. El-Tawil S, et al. Cochrane Database Syst Rev. 2010;12:CD005044. describing a heterogeneous group of cramp sufferers with no 8. Naylor JR, et al. Age Ageing. 1994;23(5):418–420. benefit from any current treatment option including stretching. In 9. Coppin RJ, et al. Br J Gen Pract. 2005;55(512):186–191. our opinion this arises by absence of a clear definition. We agree 10. Blyton F, et al. J Foot Ankle Res. 2012;5:7. with the Blyton study that cramp sufferers attempt to relieve pain http://dx.doi.org/10.1016/j.jphys.2014.06.017
Journal of Physiotherapy 60 (2014) 151–156 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research Adherence to exercise programs for older people is influenced by program characteristics and personal factors: a systematic review Alexandra Miranda Assumpc¸a˜o Picorelli a, Leani Souza Ma´ ximo Pereira a, Daniele Sirineu Pereira a, Diogo Felı´cio a, Catherine Sherrington b a Physiotherapy Department, Federal University of Minas Gerais, Belo Horizonte, Brazil; b The George Institute for Global Health, The University of Sydney, Australia KEYWORDS ABSTRACT Adherence Question: How has adherence been measured in recent prospective studies focusing on adherence to Older people exercise programs among older people? What is the range of adherence rates? Which factors are Physical activity associated with better adherence? Design: Systematic review of prospective studies that had a primary Exercise aim of assessing adherence to exercise programs. Participants: Older people undertaking exercise Physiotherapy programs. Intervention: Exercise programs. Outcome measures: Measures of adherence, adherence rates and factors associated with adherence. Results: Nine eligible papers were identified. The most common adherence measures were the proportion of participants completing exercise programs (ie, did not cease participation, four studies, range 65 to 86%), proportion of available sessions attended (five studies, range 58 to 77%) and average number of home exercise sessions completed per week (two studies, range 1.5 to 3 times per week). Adherence rates were generally higher in supervised programs. The person-level factors associated with better adherence included: demographic factors (higher socioeconomic status, living alone); health status (fewer health conditions, better self-rated health, taking fewer medications); physical factors (better physical abilities); and psychological factors (better cognitive ability, fewer depressive symptoms). Conclusion: Older people’s adherence to exercise programs is most commonly measured with dropout and attendance rates and is associated with a range of program and personal factors. [Picorelli AMA, Pereira LSM, Pereira DS, Felicio D, Sherrington C (2014) Adherence to exercise programs for older people is influenced by program characteristics and personal factors: a systematic review. Journal of Physiotherapy 60: 151–156] ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Introduction The aims of this study were to systematically review prospec- tive studies of older people’s adherence to exercise programs, in Physical activity has a range of physical and psychological order to answer the following research questions: health benefits for people of all ages.1 Structured exercise programs are a type of physical activity and have been found to 1. In prospective studies focusing on adherence to exercise be beneficial in older people. Carefully designed, structured programs among older people, how was adherence measured? exercise programs can prevent falls,2 increase muscle strength3 and enhance balance in older people.4 2. What adherence rates were found in these studies? 3. Which factors were associated with better adherence in these The benefits of exercise depend on continued participation; however, a change in lifestyle to include regular exercise is difficult studies? for many people of all ages. Older adults have more co-morbidity, less social support, and more disability and depression than the Method general population; these factors have all been associated with lower exercise adherence in people with particular health Identification and selection of studies conditions.5,6 Studies of exercise interventions in older people have demonstrated declining levels of adherence over time.7 An electronic search using the strategies outlined in Appendix 1 (see eAddenda) was conducted for five databases: Medical In order to develop effective strategies for increasing participa- Literature Analysis and Retrieval System Online (MEDLINE), tion in structured exercise programs by older adults it is important Excerpta Medica Database (EMBASE), Scientific Electronic Library to understand the individual, social, community and demographic (SciELO), Latin American Literature in Health Sciences (LILACS) and factors associated with adherence to this health-promoting Physiotherapy Evidence Database (PEDro). behaviour.6,8 Studies have measured adherence to exercise pro- grams in a range of ways, which makes comparison between studies The inclusion criteria for studies are presented in Box 1. Eligible difficult. Previous reviews have not systematically documented studies involved male and/or female participants with a mean age measurement methods and factors associated with adherence. of over 65, were prospective in design and evaluated factors http://dx.doi.org/10.1016/j.jphys.2014.06.012 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
_FIDGT)1]er[(ui$g152 Picorelli et al: Exercise program adherence among older people Box 1. Inclusion criteria. Titles and abstracts screened Papers excluded after screening (n = 1231) titles/abstracts and removal of Design duplicates (n = 1209) Randomised trials Papers retrieved for evaluation of full Cohort studies text (n = 22) Papers excluded after evaluation of Participants full text (n = 13) Adults Papers included in review (n = 9) Average age > 65 yr • ineligible participants (n = 10) Intervention • not enough information (n = 1) Exercise programs • specific disease (n = 1) Outcome measures • cross-sectional design (n = 1) Participant adherence to the exercise program Associations between program characteristics and Figure 1. Flow of studies through the review. adherence proportion of participants completing exercise programs (ie, did not cease participation, four studies, range 65 to 86%), proportion of associated with adherence as a primary aim. Studies were available sessions attended (five studies, range 58 to 77%) and excluded in which all participants had specific diseases or the average number of home exercise sessions completed per week (two sample did not consist only of older people. Studies published studies, range 1.5 to 3 times per week). Other measures were: class more than 10 years ago were also excluded, because the context attendance expressed as a proportion of participants reaching was judged to be outdated. certain cut offs (two studies); total number of classes attended (one study); number of weeks in which home exercise was undertaken Assessment of study characteristics (one study); proportion of days on which home exercise was undertaken (one study); number of minutes walked (one study); For each included study, descriptive data regarding partici- proportion of participants meeting physical activity guidelines (one pants, interventions, measures of adherence, rate of adherence and study); and proportion of participants exercising regularly (one factors associated with adherence were extracted, along with study). There was some inconsistency in the denominator used to statistics indicating the strength of association. calculate proportions, with some studies using the total participant number and some using the number of program completers, which Data analysis gave a higher number. As adherence was measured in so many different ways, it was not possible to compare adherence rates For each included study, two reviewers independently across the studies included in this review. extracted the relevant data. If different data were extracted by the two reviewers, data were rechecked by both reviewers. If Factors associated with adherence disagreement continued, a third author arbitrated. The character- istics of the studies were summarised with descriptive statistics. The factors that were significantly associated with adherence in The range of approaches for measuring adherence was noted and each study and the strength of the associations are presented in the number of studies measuring adherence with each approach Table 1. Generally, adherence rates were higher in the supervised was tallied. Comparable measures of adherence were summarised phases of exercise programs but there were no clear patterns of as ranges. The factors associated with adherence in each study greater adherence for different types of group exercise. were tabulated, including the strength of the association. The person-level factors associated with better adherence can Results be classified as demographic, health-related, physical and psycho- logical. Better program retention was evident in people with higher Flow of studies through the review socioeconomic status and better education. Living alone was associated with better program attendance. In general, program The MEDLINE and EMBASE database searches via Ovid attendance was better in people with better health (measured by identified 838 articles, of which 17 papers were retrieved in full fewer health conditions, better self-rated health, taking fewer text. The SciELO search did not identify any studies. The LILACS medications) and lower body mass index. One study found better search identified six studies, but none met the eligibility criteria. adherence in people with a pacemaker, which may reflect a greater The PEDro search identified 13 articles, of which five were eligible. motivation to exercise after the diagnosis of a heart condition.9 Therefore, a total of nine publications met the inclusion criteria. Better physical function, as measured by gait speed or endurance Reasons for exclusion are presented in Figure 1. (6-minute walk test), was associated with better adherence. Psychological factors were associated with poorer adherence in a Characteristics of studies number of the included studies. These factors included depression, loneliness, lower scores on the Mini-Mental Status Examination, The information contained in the included studies was psychoactive medication use and a higher perceived risk of falling. summarised independently by the authors of this review. The characteristics of the included studies are summarised in Table 1. Discussion Sample sizes ranged from 52 to 293. In all studies, the participants were judged to be representative of those undertaking exercise This systematic review found that recent studies focusing on programs and the assessment methods used were judged to be exercise program adherence in older adults have used a variety of valid and appropriate for the older population. methods to measure adherence. There is no agreed method of assessing adherence to exercise among older people, so various Measurement of adherence approaches are used, making the comparison of adherence rates The method of measuring adherence in each of the nine included studies and the adherence rates reported in each study are presented in Table 1. Most studies used more than one method for measuring adherence. The most common measures were the
Research 153 Table 1 Factors associated with adherence Characteristics and findings of the studies included in the review (n = 9). Retention rate was higher in the Trial Participants Intervention Adherence peer mentor group Dorgo14 Community volunteers aged Group 1: >60 (yr) participating in one Exercise sessions targeted 90% 14-wk retention rate Participation rates were Findorff7 of two intervention groups in cardiovascular fitness, strength, 25 (SD 5) of 35 sessions significantly higher in the a randomised trial muscle mass, power, agility and student mentor group (p = 0.008) n = 60 flexibility. attended by completers (72%) 75-min group sessions, 3/wk x Group 2: Walking: Sedentary women 14 wk 77% 14-wk retention rate Clinical variables accounted for participating as the Group 1: peer mentors 29 (SD 4) of 35 sessions intervention group in a Group 2: student mentors attended by completers (82%) 17% and cognitive variables for randomised trial At 12 wk (self-reported): 12% of the variance in walking n = 137 Home exercise program with Mean 95 min (SD 69) walked/ adherence (frequency) nurse home visits (6) and wk A multivariate analysis explained telephone counselling (6) with a 17% walked > 150 min 19% of the variance in walking goal of walking, 30 min x 5/wk Mean 1.5 sessions (SD 1.6) of adherence, with significant and 12 reps of 11 balance balance exercises/wk predictors: absence of probable exercises, 2/wk, for 12 wk. Then At 2 yr (self-reported among depression (p = 0.05); fewer 16 wk tapered computerised 127 completers): chronic conditions (p = 0.019); use telephone follow up. 66% walked 20 min x 3/wk or of behavioural process of change more (p = 0.027) Flegal13 ‘Generally healthy’ seniors Group 1: yoga, 90-min class/wk 40% did balance exercises 2/wk Balance: participating in one of two and home practice daily or more Health-related quality of life intervention groups in a Group 2: outdoor aerobic 29% did neither regularly variables accounted for 14% and randomised trial walking class, 60 min/wk and at 71% did one or both regularly cognitive variables for 12% of the n = 91 home 5/wk variance in completing balance Group 1: exercises >1/wk Jancey12 Insufficiently active adults Walking, strength and flexibility 86% completed study A multivariate model explained aged 65 to 74 yr recruited from exercise sessions conducted in 30 24% of the variance in adherence to the Australian federal local neighbourhoods using social- Among Group 1 completers: the balance program, with electoral roll cognitive theory incorporating 77% classes attended significant predictors: MMSE < 27 participating as the self-efficacy factors. home exercise on 64% of days (OR 0.08, 95% CI 0.01 to 0.73), self- intervention group in a 2 sessions/wk x 6 mth efficacy (OR 1.04, 95% CI 1.002 to randomised trial Group 2: 1.08), self-rated health (OR 0.03, n = 248 81% completed study 95% CI 0.002 to 0.50) McAuley18 Sedentary adults aged 60 to Group 1: Walking group Among Group 2 completers: The adherence differences 75 yr participating in one of Group 2: Stretching and toning 69% classes attended between the yoga and the exercise two intervention groups in a program home exercise on 64% of days group did not reach statistical randomised trial 3 sessions/wk x 6 mth significance (for percent n = 174 (76% of the prescribed 5 d/wk) attendance (p = 0.056) and for percent days practiced out of all 65% completed the program days possible, t = –1.822, p = 0.073) 77% of those who didn’t Home practice sessions lasted an complete the program ceased average of 38 min for the yoga participation in the first 3 mth group and 56 min for the exercise group (t = 3.8, p = 0.0003) 88% completed the programs Group 1: Class attendance was significantly 56 d (SD 15) average (p < 0.05) correlated with baseline measures of depression, fatigue attendance and physical components of Group 2: health-related quality of life 58 d (SD 13) average attendance A multivariate model found that non-completion was significantly associated with lower socioeconomic status (OR 0.4, 95% CI 0.19 to 0.83), overweight (OR 2.29, 95% CI 1.01 to 5.19), insufficient physical activity at baseline (OR 2.40, 95% CI 1.30 to 4.43), lower walking self-efficacy scores (OR 0.77, 95% CI 0.66 to 0.89) and higher loneliness scores (OR 1.03, 95% CI 1.01 to 1.07) Attendance rates did not differ significantly between treatment groups (p = 0.30) 18 mth follow up physical activity score did not differ significantly between groups Structural equation modelling indicated significant paths from social support, affect and exercise frequency to efficacy at 6 mth. Efficacy, in turn, was related to physical activity at 6-mth and 18- mth follow-up. The model accounted for 40% of the variance in 18-mth activity levels
154 Picorelli et al: Exercise program adherence among older people Table 1 (Continued ) Trial Participants Intervention Adherence Factors associated with adherence Rejeski9 People aged 70–89 yr who Walking aiming for 150 min/wk, 71% of sessions attended in mth were at elevated risk of and ‘limited’ training for balance Month 1 to 2: a multivariate Sjosten15 disability participating as the and strength. 1 to 2 model explained 10% of Stineman10 intervention group in a Mth 1 to 2: group exercise, 40- 61% of sessions attended in mth variability in adherence with randomised trial 60 min sessions, 3/wk, plus significant predictors: lung Sullivan-Marx17 n = 213 weekly group behaviour 3 to 6 disease (est –10.9, SE 4.5, counselling sessions, monthly Average of 3.7 sessions/wk in p = 0.017) and low barriers to Community-dwelling people telephone contact and home efficacy score (est 2.1, SE 0.8, aged >65 yr who had fallen in exercise sessions. mth 7 to 12 p = 0.010) the past yr participating as Mth 3 to 6: group exercise, 2/wk, the intervention group in a behaviour counselling sessions, Average of 58% (SD 30) of group Month 3 to 6: a multivariate randomised trial monthly phone call. exercise sessions attended model explained 10% of n = 293 Mth 7 to 12: optional centre- variability in adherence, with based sessions, 1/wk, monthly 47% of participants were highly significant predictors: Older people who had fallen phone contact. adherent (> 66% adherence pacemaker (est 23.75, SE 11.91, and visited an emergency rates) with group sessions p = 0.047), slower 400 m walk department participating as Group and home exercise, times (est –2.30, SE 1.00, the intervention group in a psychosocial group activities and Mean 3 (SD 2.1) home exercise p = 0.020), less than high school randomised trial lectures. sessions completed/wk education (est –9.4, SE 4.2, n = 102 Exercise targeted balance, p = 0.027). 21% of variability strength and respiratory 87% attended 4+ of 7 classes explained when prior African American women function. 73% attended all 7 classes attendance added needing assistance in ADL 45-min sessions, 2/mth, plus 78% exercised at home for 7 of participating in an home exercise, 3/wk. Month 7 to 12: a multivariate observational study the 12 wk (via diary) model explained 13% of n = 52 Exercise targeted fitness, 1% exercised 3 times/wk at variability in adherence, with balance, strength and flexibility. significant predictors: Mth 1: on-site group classes, home for all twelve weeks (via pacemaker (est 1.8, SE 0.8, 1/wk. diary) p = 0.029) and tiredness (est 0.3, Mth 2–4: exercises at home, SE 0.1, p = 0.014), 48% of 3 session/wk, plus 1 on-site 71% completed program variability was explained when class/mth, plus 1 home visit from Among completers: prior attendance added a trained community worker/ mth. 48% attended 3+ x/week Univariate analyses: lower age, 71% attended 2+ x/week low self-perceived risk of falling Warm-up, walking intervals, at home and better functional lower extremity exercises, cool ability were strongest predictors down and deep breathing. of exercise group adherence. 30 to 50-min group sessions, Using less than four prescription 3/wk x 16 wk. medicines was significantly associated with home-exercise adherence Multivariate analysis: Low self- perceived probability of falling at home (OR 1.6, 95% CI 1.0 to 2.6) and good physical functional abilities (OR 2.7, 95% CI 1.5 to 4.8) were significant predictors of exercise group adherence On-site exercise adherence was better than home Univariate predictors of full adherence to on-site exercise: advanced age, non-African Americans, males, high school or higher education, living alone, SF-36 score, lower BMI, fewer comorbidities, fewer medications, physical function, physical role function, perceived general health, 6 MWD, less depression, fewer psychometric medications and MMSE scores Multivariate analysis: Living alone associated with full adherence to on-site exercise (adjusted OR = 3.0, 95% CI 1.1 to 8.1). Depressed mood was associated with decreased adherence to on-site exercise (adjusted OR = 0.85, 95% CI 0.72 to 1.0) Analysis of factors associated with adherence to home program not undertaken due to low adherence rates Completers had lower scores on the depression scale than non- completers (p = 0.004) ADL = activities of daily living, est = estimate, MMSE = Mini Mental Status Exam, SF-36 = short form 36, 6 MWD = six-minute walk distance.
Research 155 between studies difficult. This hampers progress toward under- contexts, to raise commitment to exercise among the largely standing exercise adherence in older people, as well as how to sedentary population of older people with their multiple illnesses enhance it. Adherence to centre-based exercise programs is and functional deficits.10,17 relatively easy to document but adherence to home-based exercise currently relies on self-report, which may overestimate or A limitation of this review is that the results of the individual underestimate actual exercise frequency and duration. In the observational studies may have been confounded by the presence future, technology may enable more accurate measurement of of other variables that were associated with both participant adherence in home-based physical activity studies. characteristics and exercise adherence rates. Social and psycho- logical variables, such as motivation and social support, were not Given the variability in measurement of adherence it was not measured in all studies and may explain larger amounts of possible to meaningfully compare adherence rates across studies. variance in exercise adherence than the measured variables. However, it was noted that retention and adherence rates in most Furthermore, the pragmatic decision to limit this review to the last of the included studies were suboptimal. ten years of research may have impacted on the results. The apparently higher rate of adherence to centre-based Understanding the variables that influence adherence to programs provides challenges for the widespread implementation exercise among older people is very important for clinical of exercise programs. Some programs combine group and home- physiotherapists because low rates of adherence are likely to based aspects. This may be a feasible and cost-effective solution. limit the benefits obtained from exercise. Exercise adherence in Given the limitations of this review, this issue requires further older people is multifactorial, involving demographic, health- investigation. related, physical and psychological factors. The range of predictors of exercise adherence underscores the need for health profes- A number of person-level factors were found to be associated sionals to consider these findings in designing strategies to with greater adherence rates. Interestingly, reduced mental enhance exercise adherence in this vulnerable population. wellbeing appeared to present a greater barrier to exercise adherence than reduced physical wellbeing.10 People at risk of What is already known on this topic: Physical activity has a depression were less likely to adhere to prescribed programs. range of benefits for older people. In particular, structured Physical activity is potentially beneficial for fatigue and depres- exercise programs can prevent falls and increase strength. sion, so future intervention could specifically target adherence in However, older people’s adherence to exercise interventions this group of people. The concept of loneliness also requires more declines over time. investigation. This group of people might require more encour- What this study adds: In studies of exercise interventions for agement, affirmation and feedback.11,12 older people, few studies measure adherence the same way. Few studies report very high adherence, but adherence is Adherence is promoted by the belief that an intervention will be generally higher in supervised programs. Factors associated effective (the outcome expectancy), as well as the belief that the with greater adherence include: higher socioeconomic status, individual is capable of following the requirements of the living alone, better health status, better physical ability, better intervention (the efficacy expectancy).13 It has been postulated cognitive ability and fewer depressive symptoms. that people with greater adherence may engage in other health- promoting behaviours. Thus, adherence may be a marker for a eAddenda: Appendix 1 can be found online at doi:10.1016/ personality type, or related to motivation or goal-directed j.jphys.2014.06.012 behaviours. Self-efficacy, which may relate to motivation, is the perceived confidence in one’s ability to accomplish a specific Ethics approval: Not applicable. task.13 Self-efficacy has been shown to affect exercise adoption and Competing interests: Nil. maintenance.11 Therefore, intervention programs should develop Source(s) of support: Nil. and nurture this characteristic to enable individuals to continue Acknowledgements: Nil. with the program. Correspondence: Catherine Sherrington, The George Institute for Global Health, The University of Sydney, Australia. Email: Several of the studies included in this review used a range of [email protected] strategies in an effort to enhance adherence. Strategies to promote adherence included: making instructions to subjects simpler and References less demanding; addressing cognitive-motivational factors such as self-efficacy and health beliefs; offering social support and 1. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. reinforcement; and providing reminders.13 Dorgo and colleagues14 American College of Sports Medicine position stand. Quantity and quality of showed that the peer-mentoring model has the potential to be a exercise for developing and maintaining cardiorespiratory, musculoskeletal, and cost-effective method of reaching out to older adults, engaging neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. them in physical exercise programs for extended periods and Med Sci Sports Exerc. 2011;43:1334–1359. improving their health and fitness. The assistance of professional trainers with extensive experience would be costly, especially in 2. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. long-term programs with high numbers of participants, while Interventions for preventing falls in older people living in the community. Cochrane older adult peer mentors assisting on a volunteer basis would Database Syst Rev. 2012;9:CD007146. significantly reduce program costs. Appropriate activities should be carefully planned before program implementation to best suit 3. Liu C-J, Latham NK. Progressive resistance strength training for improving physical the specific needs of aged individuals. Good reachability and function in older adults. Cochrane Database Syst Rev. 2009;3:CD002759. continuous motivation might also increase participation.15 Thus, a major responsibility of physiotherapists and other exercise 4. Howe TE, Rochester L, Jackson A, Banks PM, Blair VA. Exercise for improving prescribers is to educate people on the importance and value of balance in older people. Cochrane Database Syst Rev. 2011;11:CD004963. exercise, as it relates to optimal physical function, wellness and quality of life.16 This review has focused on factors associated with 5. Macchi C, Polcaro P, Cecchi F, Zipoli R, Sofi F, Romanelli A, et al. One-Year Adherence adherence rather than interventions designed to enhance adher- to Exercise in Elderly Patients Adherence to Exercise in Elderly Patients Receiving ence. Therefore, these suggestions about enhancing exercise Post acute Inpatient Rehabilitation After Cardiac Surgery. Am J Phys Med Rehabil. adherence need further investigation in clinical trials. 2009;88(9):727–734. Future research targeted at older people should be designed to 6. Dolansky MA, Stepanczuk B, Charvat JM, Moore SM. Women’s and Men’s Exercise incorporate specific strategies that will enhance the recruitment, Adherence after a Cardiac Event: Does Age Make a Difference? Res Gerontol Nurs. adherence and retention of people from diverse cultures and ethnic 2010;3(1):30–38. backgrounds. Future work in this area should also address behavioural motivation, as well as social and environmental 7. Findorff MJ, Wyman JF, Gross CR. Predictors of Long-Term Exercise Adherence in a Community Sample of Older Women. J Women’s Health. 2009;18(11):1769–1776. 8. Seguin RA, Economos CD, Palombo R, Hyatt R, Kuder J, Nelson ME. Strength training and older women: a cross-sectional study examining factors related to exercise adherence. J Aging Phys Activ. 2010;18:201–218. 9. Rejeski WJ, Miller ME, King AC, Studenski SA, Katula JA, Fielding RA, et al. Predictors of adherence to physical activity in the Lifestyle Interventions and Independence for Elders pilot study (LIFE-P). Clin Interventions Aging. 2007;2(3):485–494. 10. Stineman MG, Strumpf N, Kurichi JE, Charles J, Grisso JA, Jayadevappa R. Attempts to reach the oldest and frailest: recruitment, adherence, and retention of urban
156 Picorelli et al: Exercise program adherence among older people elderly persons to a falls reduction exercise program. The Gerontologist. 15. Sjosten NM, Salanoja M, Piirtola M, Vahlberg TJ, Isoaho R, Hyttinem HK, et al. A 2011;51(1):59–72. multifactorial fall prevention programme in the community-dwelling aged: pre- 11. Fielding RA, Katula J, Miller ME, Abbot-Pillola K, Jordan A, Glynn NW, et al. Activity dictors of adherence. Eur J Public Health. 2007;17(5):464–470. adherence and physical function in older adults with functional limitations. Med Sci Sports Exerc. 2007;39(11):1997–2004. 16. Forkan R, Pumper B, Smyth N, Wirkkala H, Ciol MA, Shumway-Cook A. Exercise 12. Jancey J, Lee A, Howat P, Clarke A, Wang K, Shilton T. Reducing attrition in physical adherence following physical therapy intervention in older adults with impaired activity programs for older adults. J Aging Phys Activ. 2007;15:152–165. balance. Physical Therapy. 2006;86(3):401–410. 13. Flegal KE, Kishiyama S, Zajdel D, Haas M, Oken BS. Adherence to yoga and exercise interventions in a 6-month clinical trial. BMC Complement Altern Med. 17. Sullivan-Marx EM, Mangione KK, Ackerson T, Sidorov I, Maislin G, Volpe ST, et al. 2007;7(37):1–7. Recruitment and retention strategies among older African American women 14. Dorgo S, King GA, Brickey GD. The application of peer mentoring to improve fitness enrolled in an exercise study at a PACE program. The Gerontologist. 2011;51(1): in older adults. J Aging Phys Activ. 2009;17:344–361. 73–81. 18. McAuley E, Jerome GJ, Elavsky S, Ma´ rquez DX, Ramsey SN. Predicting long-term maintenance of physical activity in older adults. Preventive Med. 2003;37:110–118.
Journal of Physiotherapy 60 (2014) 119 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Call for applications for membership of the Editorial Board The Editorial Board currently consists of 10 members: eight local and two international. To increase the standing of Journal of Physiotherapy on the international stage and further increase the number of high-quality submissions, the Editorial Board is seeking to expand the number of international members from two to six. Applications are invited to fill the following Editorial Board vacancies beginning in 2015: • one local • six international. All incumbents are entitled to re-apply. Four of the six international positions are new positions that cannot be filled by the incumbents. The initial term of office commences on 1 January 2015 and expires on 31 December 2017. Editorial Board members are entitled to renominate for a further two successive terms. Knowledge and skills required: • broad understanding of research methods • extensive experience in publication of research • excellent written communication skills • good working knowledge of the physiotherapy profession and an interest in its future. Australian applicants must: • hold a PhD • be a physiotherapist registered in Australia • be a financial member of the Australian Physiotherapy Association (APA). International applicants must: • hold a PhD • have authority to practise in their own country • be a financial member of a WCPT member association. Responsibilities: • contribute to the establishment of policies which guide the publication of the journal • participate in the activities of the Editorial Board as a voting member • attend regular Editorial Board teleconferences and a two-day face-to-face meeting (international members to participate electronically where feasible) • meet and liaise with other members of the Editorial Board and the journal Editor as required • undertake specific tasks from time to time to promote the standing of the journal • ensure that the journal meets the needs of the APA membership and the physiotherapy profession. On appointment, successful applicants will be required to complete the ICMJE-endorsed conflict of interest statement. See icmje.org/coi_disclosure.pdf Physiotherapists wishing to apply for positions should address these criteria and include a brief CV for consideration by the APA Board of Directors. Applications should be directed to Marko Stechiwskyj at [email protected] Applications close 5.00 pm AEST, Tuesday 30 September 2014. http://dx.doi.org/10.1016/j.jphys.2014.07.004 1836-9553
Journal of Physiotherapy 60 (2014) 169 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinical Practice Guidelines Chronic pain Management of chronic pain pain assessment, early management and care planning in non- specialist settings (contained within Annex 2). This is followed by Date of latest update: December 2013. Date of next update: Will evidence for a variety of management approaches, including: be considered for review in three years. Patient group: Adults with supported self-management; pharmacological therapies (eg, chronic, non-malignant pain. Intended audience: Health care opioids, non-opioid analgesics); psychological-based intervention professionals involved in the assessment and management of (eg, multidisciplinary pain management programs, cognitive adults with chronic pain. Additional versions: The main guideline behavioural therapy); physical therapies (eg, manual therapy, is accompanied by a patient version and three treatment pathways. exercise, traction, electrotherapy); complementary therapies (eg, Expert working group: The expert working groups was comprised acupuncture, herbal medicine); and dietary therapies. Evidence for of a 24-member committee of medical professionals (consultants, manual therapy is presented for low back pain and neck pain. pharmacologist, psychologist, physiotherapist) and patient repre- Exercise approaches covered include: aerobic, strengthening, sentatives from Scotland and Australia. Funded by: Not stated. movement facilitation, stabilisation exercises, walking, T’ai Chi, Consultation with: Targeted consultation occurred with expert yoga, Pilates, aquatic and general exercise therapy. Care pathways reviewers invited to comment on draft versions. In addition, draft are also provided for people with neuropathic pain, and for people guidelines were presented at a national open meeting and with chronic pain using strong opioids. The guidelines concluded available on the SIGN website. Approved by: The Scottish with recommendations for future research. Intercollegiate Guidelines Network (SIGN), Healthcare Improve- ment Scotland. Location: The guidelines and associated docu- Sandra Brauer ments are available at: http://www.sign.ac.uk. The University of Queensland, Australia Description: These guidelines are published in a 71-page document beginning with a one-page summary of key recom- http://dx.doi.org/10.1016/j.jphys.2014.06.006 mendations and the associated supporting levels of evidence. Evidence for the assessment and planning of care for people with chronic pain is presented first; this includes a pathway for chronic Urinary incontinence Urinary incontinence: the management of urinary incontinence in women Date of latest update: September 2013. Date of next update: Not incontinence in women. They replace a previous guideline published stated. in 2006, so it is indicated whether recommendations in the current Patient group: Women aged over 18 years with any type of urinary version are an update, or are the same as in the previous guidelines. incontinence. Intended audience: Health care professionals The full guidelines include: recommendations, detailed discussion involved in the management of women with urinary incontinence. of the evidence underpinning the recommendations, care pathways Additional versions: The current guidelines are an update of the and all references. They outline the evidence for assessment and National Institute for Health and Care Excellence (NICE) clinical investigation, including history taking, physical examination and guideline 40 (2006): Urinary continence: the management of pelvic floor muscle assessment. Evidence for management of urinary urinary incontinence in women. Additional documents include incontinence is then presented. This begins with conservative appendices, a summary document and a version for the public. management, including: physical therapies, lifestyle interventions Expert working group: The expert working group was comprised and neurostimulation, and discusses evidence for preventative use of a 10-member committee of medical professionals (consultants, and the optimal sequence and timescale for conservative therapies. GPs, nurse, physiotherapist) and a consumer representative, all Other management options discussed include pharmacological from the UK. Funded by: Not stated. Consultation with: The therapies, invasive procedures and surgical interventions. The guidelines were developed in consultation with the National evidence is underpinned by over 1000 references. Collaborating Centre for Women’s and Children’s Health, which is based at the Royal College of Obstetricians and Gynaecologists, UK. Sandra Brauer Approved by: National Institute for Health and Care Excellence The University of Queensland, Australia (NICE). Location: The guidelines and additional documents are available at: http://guidance.nice.org.uk/CG171 http://dx.doi.org/10.1016/j.jphys.2014.06.001 Description: These guidelines are published in a 387-page document and provide evidence for the management of urinary 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association.
Journal of Physiotherapy 60 (2014) 165 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Exercise training decreases fasting insulin levels and improves insulin resistance in children and adolescents Summary Summary of: Fedewa MV, Gist NH, Evans EM, Dishman RK. comparison group with a mean effect size of 0.31 (95% CI 0.06 to Exercise and insulin resistance in youth: A meta-analysis. 0.56). The results were consistent across gender, age and ethnicity. Pediatrics 2013;133:e163-e174. Body mass index moderated the effect of exercise on fasting insulin, that is: a greater effect was observed in children and Objective: To review the evidence as to whether exercise adolescents with higher body mass index. Each of the exercise training improves fasting insulin and insulin resistance in children interventions varied in design and included aerobic, resistance, a and adolescents. Data Sources: PubMed, SPORTDiscus, Physical combination of training modes, games and play. When reported, Education Index, Web of Science, searched up to June, 2013. This exercise training consisted of 3 (SD 1) sessions per week, for 53 (SD search was supplemented by review of the reference lists from 20) minutes at a moderate to vigorous intensity of physical activity retrieved articles. Study Selection: Randomised controlled trials per session, for 16 (SD 11) weeks. Conclusion: Exercise is effective involving healthy children or adolescents in which exercise in decreasing fasting insulin and improving insulin resistance in training was compared to a non-exercise comparison. Outcome healthy children and adolescents. Regular physical activity and measures were fasting insulin and insulin resistance. Data exercise training should be included in programs for children and Extraction: Two reviewers extracted data, and discrepancies were adolescents at risk of developing type II diabetes. resolved by discussion. Methodological quality was not assessed. Data Synthesis: Of the 546 studies initially identified by the search, Nora Shields 24 studies, with a total of 1599 participants, met the selection Department of Physiotherapy, criteria and were included in the review. Based on the quantitative La Trobe University and Northern Health, Australia pooling of the available data from these trials, exercise training reduced fasting insulin levels in children and adolescents http://dx.doi.org/10.1016/j.jphys.2014.06.009 significantly more than the non-exercise comparison group with a mean effect size of 0.48 (95% CI 0.22 to 0.74). Exercise training was also more effective in reducing insulin resistance than the ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. Commentary Whilst the prevalence of obesity and type 2 diabetes mellitus is of exercise is ideal; what exercise intensity should be prescribed; increasing, the relationship between these two conditions varies and what frequency of exercise is needed? Data from mainly adult worldwide.1 Other factors, such as differences in sugar availability, studies show that both aerobic and resistance training exercise explain variations in diabetes rates that are not explained by reduce insulin resistance and that moderate-to-vigorous-intensity physical activity, being overweight or obese. Therefore, underlying exercise is associated with greater metabolic benefit compared to metabolic abnormalities and, in particular, insulin resistance are low-intensity exercise.2 However, the effect of exercise on insulin more closely associated with type 2 diabetes mellitus rather than resistance begins to wane 48 hours after a bout of exercise. Thus, to being indices of obesity. maximise metabolic effect, exercise needs to be regular and ideally performed on most days. The chosen mode of exercise may come Fedewa et al. show that regular exercise in youth reduces down to an individual’s preference and which type of exercise they insulin resistance, especially in those with greater insulin are more likely to adhere to. If exercise can be made satisfying and resistance (generally those who are more obese and older). enjoyable it will most likely lead to better compliance and health These data confirm the importance of physical activity and outcomes. exercise to health in younger populations. This is relevant to later life, as those with greater insulin resistance in childhood and Paul Hofman adolescence have greater insulin resistance in adulthood and are Liggins Institute, University of Auckland, New Zealand therefore predisposed to health problems, including: type 2 diabetes mellitus, hypertension, coronary artery disease, malig- References nancy and stroke. Thus, reducing insulin resistance during childhood and adolescence may result in long-term improvement 1. Basu S, et al. PLoS ONE. 2013;8:e57873. in health outcomes. 2. Roberts CK, et al. Med Sci Sport Exerc. 2013;45:1868–1877. This review generically describes exercise interventions and http://dx.doi.org/10.1016/j.jphys.2014.06.008 only provides broad guidelines on three critical issues: what type DOI of original article: http://dx.doi.org/10.1016/j.jphys.2014.06.009 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 60 (2014) 166 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Including upper extremity robotic therapy during early inpatient stroke rehabilitation may not lead to better outcomes than conventional treatment Synopsis Summary of: Masiero S, Armani M, Ferlini G, Rosati G, Rossi A. rehabilitation only. Outcome measures: Main outcomes were Randomized trial of a robotic assistive device for the upper Medical Research Council strength scale, Fugl-Meyer Assessment, extremity during early inpatient stroke rehabilitation. Neurorehabil Motor-Functional Independence Measure, Modified Ashworth Neural Repair 2014;28:377–386. Scale, Frenchay Arm test, and Box and Block Test of manual dexterity. Tolerability of treatment (as indicated by the number of Question: Does a robotic assistive device (NeReBot) lead to complications) and the degree of acceptance of robotic training better upper extremity outcomes than standard upper limb (visual analogue scale) were also evaluated. The outcomes were rehabilitation among post-acute stroke inpatients? Design: measured at baseline, at the end of the five-week treatment period, Randomised controlled trial and blinded outcome assessment. at three months, and seven months after the end of treatment. Setting: A rehabilitation unit in Italy. Participants: Key inclusion Results: A total of 30 participants completed the study. No criteria were: adults in the post-acute phase of stroke, Mini-Mental significant between-group difference was found in any of the State Examination score > 18, and inability to move the upper limb outcome measures at the four measurement time points. Conclu- against gravity or weak resistance. Key exclusion criteria were: sion: Incorporating NeReBot therapy into upper limb rehabilitation cardiovascular instability, early appearance of marked spasticity is not more efficacious than conventional upper limb rehabilitation (Ashworth Scale 3), use of functional electrical stimulation or in post-acute stroke inpatients. Botox in the affected upper extremity. Randomisation of 34 participants allocated 16 to the experimental group and 18 to the Marco YC Pang control group. Interventions: All participants received a total of Department of Rehabilitation Sciences, 120 minutes of upper limb therapy per day, 5 days a week for 5 The Hong Kong Polytechnic University, Hong Kong weeks. The experimental group received NeReBot therapy for 35% of the exercise time, and standard upper limb rehabilitation for 65% http://dx.doi.org/10.1016/j.jphys.2014.06.007 of the time. The control group received standard upper limb Commentary randomised controlled trial with the ARMin robotic system used people in the chronic phase post-stroke ( six months after To find more-effective methods of neurorehabilitation to regain stroke).2 Their results showed better motor function recovery with lost motor function is challenging. Effective motor functional the use of the robotic system.2 recovery depends on the intensive physical practice of the affected joints. With the advance in engineering-based technologies, robot- Whether the type of control system accounts for the effective- assisted rehabilitation has been applied in post-stroke training ness (or ineffectiveness) of robot-assisted therapy is a matter of with the advantages of high motion repeatability and training debate. Whilst a number of clinical studies have shown positive intensity. In a Cochrane meta-analysis, the efficacy of robotic- results with robotic training, it would be interesting to compare assisted arm training devices was compared with other therapeu- the effectiveness between different robotic systems in future tic interventions in stroke rehabilitation.1 This systematic review studies. Moreover, the time window for arm training with different of randomised controlled trials concluded that paretic arm robotic systems could be further investigated. function and activities of daily living can be improved, but arm muscle strength did not improve. However, only a few studies have Raymond Kai-yu Tong been conducted in the early post-stroke phase. Division of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong The randomised trial conducted by Masiero and colleagues contributes important clinical data in early stroke rehabilitation References (intervention started an average 8.4 days after stroke) with the NeReBot robotic system. The results did not show any better 1. Mehrholz J, et al. Cochrane Database Syst Rev. 2012;6:CD006876. outcomes in motor function and activity rating scales when 2. Klamroth-Marganska V, et al. Lancet Neurol. 2014;13(2):159–166. compared with conventional rehabilitation. However, other types of robotic systems have applied their own control methods and http://dx.doi.org/10.1016/j.jphys.2014.06.005 involved different arm movements. It is possible that these factors may contribute to the effectiveness of the training. Another DOI of original article: http://dx.doi.org/10.1016/j.jphys.2014.06.007 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 60 (2014) 163 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Light intensity physical activity is associated with lower disability in adults with or at risk of knee osteoarthritis Synopsis Summary of: Dunlop DD, Song J, Semanik PA, Sharma L, Bathon Physical activity was monitored with 7 days of accelerometry and JM, Eaton CB, et al. Relation of physical activity time to incident analysed as time spent doing light (100 to 2020 counts/minute) or disability in community dwelling adults with or at risk of knee moderate to vigorous (> 2020 counts/minute) activity. The osteoarthritis: prospective cohort study. BMJ 2014;348:g2472. potential covariates measured were: race, age, gender, education, income, comorbidities, knee-specific health factors and health Question: In adults with or at risk of knee osteoarthritis, is the behaviours. Results: Among the 1680 participants, 149 reported amount of time spent in light intensity physical activity related to the onset of disability during follow-up. When categorised as the onset or progression of disability? Design: Multi-centre, quartiles, increasing time doing light activity was significantly prospective cohort study with 2 years of follow-up. Setting: Four associated with lower risk of disability onset (Hazard Ratios 1.00, treatment centres in Northeastern USA. Participants: Community- 0.62, 0.47 and 0.58, p for trend = 0.007) and lower risk of disability dwelling adults aged 49 years or older with knee osteoarthritis (ie, progression (Hazard Ratios 1.00, 0.59, 0.50 and 0.53, p for at least one osteophyte with pain, aching or stiffness) or with risk trend = 0.003), with control for the covariates. Additional time factors for developing knee osteoarthritis (ie, recent knee spent doing higher intensity activity did not influence these symptoms, overweight, knee injury or surgery, family history, associations. Conclusion: Daily time spent doing light intensity Heberden’s nodes, repetitive knee bending, or aged 70 to 79 years). physical activity is associated with lower risk of onset and Outcomes: The primary outcome was the onset of disability, which progression of disability in adults with or at risk of knee was defined as difficulty completing instrumental activities (eg, osteoarthritis. cooking, shopping) or basic activities (eg, walking, dressing, bathing) independently, as reported on a questionnaire. The Mark Elkins secondary outcome was disability progression, based on a change Journal of Physiotherapy to a more severe level of disability over 2 years. Levels were none, mild (limitation in instrumental activities only), moderate http://dx.doi.org/10.1016/j.jphys.2014.06.019 (limitation in one or two basic activities) or severe (limitation in three or more basic activities). Potential predictor and covariates: ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved. Commentary physical activity will lead to reduced osteoarthritis-related disability. Second, even if further research does confirm the Lack of physical activity is a major health issue for people with benefits of prescribing light physical activity in reducing disability osteoarthritis of the knee, with only about one in ten people who in this population, it remains to be demonstrated whether light are affected meeting the current physical activity guidelines of physical activity provides a sufficient stimulus to lead to important 150 minutes of at least moderate intensity physical activity in at health benefits associated with physical activity, such as reduced least 10 minute bouts each week.1 Even after total knee risk of cardiovascular disease.3 This could be important because arthroplasty, only about one in two people report exercise levels cardiovascular disease is such a problem for older adults with consistent with the physical activity guidelines.2 People with osteoarthritis of the knee.4 mobility restrictions due to their pain, comorbidities and disabilities associated with knee osteoarthritis may find it very Jason Wallis difficult to achieve these recommended levels at moderate Department of Physiotherapy, Eastern Health, Melbourne, Australia intensity. References The key finding from this study was that for people with or at risk of developing osteoarthritis, completing 255 minutes of light 1. Wallis JA, et al. Osteoarthr Cartil. 2013;21:1648–1659. physical activity per day was associated with a 43% lower risk of 2. Groen J-W, et al. J Physiother. 2012;58:113–116. developing disability than people who averaged 192 minutes. 3. Nelson ME, et al. Circulation. 2007;116:1094–1105. These results are potentially significant, as people with osteoar- 4. Neusch E, et al. BMJ. 2011;342:d1165. thritis of the knee might more easily achieve completion of light physical activity than moderate or vigorous intensity exercise. http://dx.doi.org/10.1016/j.jphys.2014.06.018 However, before the results change practice, a number of factors have to be considered. First, the presence of an association does not imply causation, so it is not certain that prescribing light intensity DOI of original article: http://dx.doi.org/10.1016/j.jphys.2014.06.019 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association.
Journal of Physiotherapy 60 (2014) 164 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Pelvic floor muscle training can reduce prolapse symptoms in women with pelvic organ prolapse Synopsis Summary of: Hagen A, Stark D, Glazener C, Dickson S, Barry S, Outcome measures: The primary outcome was prolapse symptoms Elders A, et al. Individualised pelvic floor muscle training in women at 12 months. Prolapse symptoms were measured by the pelvic with pelvic organ prolapse (POPPY): a multicentre randomised organ prolapse symptom score (POP-SS), with scores ranging from 0 controlled trial. Lancet 2014;383:796-806. (no symptoms) to 28. Secondary outcome measures included: perceived change in prolapse, number of days with prolapse Question: Does individualised pelvic floor muscle training symptoms in the last 4 weeks, and prolapse type and stage. Results: improve self-report of prolapse symptoms in women with 295 (66%) of participants completed the study at 12 months, and 377 symptomatic pelvic organ prolapse? Design: Randomised, con- (84%) completed assessments at 6 months. At 12 months, prolapse trolled trial with concealed allocation and blinded outcome symptoms were significantly less in the intervention group, by 1.5 assessment. Setting: A total of 25 outpatient gynaecology clinics units (95% CI 0.5 to 2.6 units). Participants in the intervention group in the United Kingdom, New Zealand and Australia. Participants: were also more likely than the control group to perceive that their The key inclusion criterion was symptomatic prolapse (stages I – prolapse had improved and reported fewer days with symptoms in III) as the main presenting complaint. Key exclusion criteria the last 4 weeks. There was no difference between the groups in included: previous treatment for prolapse, including surgery, change in their prolapse stage. Conclusion: Individualised pelvic pregnancy, or being less than 6 months postnatal. Randomisation floor muscle training supervised by physiotherapists was effective in of 447 patients allocated 225 to the intervention group and 222 to reducing symptoms in women with pelvic organ prolapse. the control group. Interventions: Patients allocated to the intervention group were invited to receive five one-on-one Nicholas Taylor appointments for pelvic floor muscle training with a women’s Associate Editor, Journal of Physiotherapy health physiotherapist over 16 weeks. Intervention included the prescription of an individualised home exercise program. The http://dx.doi.org/10.1016/j.jphys.2014.06.013 control group received a prolapse lifestyle advice leaflet that did not include any advice about pelvic floor muscle training. ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved. Commentary Pelvic organ prolapse is a common condition found in 40% of Additionally, there appears to be little correlation between women over the age of 50 years.1 Until now, there has been limited prolapse symptoms and stage of prolapse. This assists in evidence to support the use of pelvic floor muscle training (PFMT) transferability to clinical practice, as physiotherapists can admin- as a treatment for women with prolapse.2 This is an important ister the POP-SS but would not commonly assess stage of prolapse study for women and women’s health physiotherapists alike, as it using the prolapse classification (POP-Q) system. provides the strongest evidence to date that an individualised PFMT program can improve prolapse symptoms. Future studies are needed to investigate the use of PFMT for women following failed surgical intervention, or early post As this rigorously designed study is the largest, multicentre trial childbirth, and for PFMT as an adjunct to surgery or pessary of PFMT for prolapse, with the longest follow-up, it is very applicable treatment. to clinical practice. In contrast to some previous work in this area,3 the pragmatic features of this study ensure its feasibility within Sally Sheppard clinical practice. With only five physiotherapy sessions across 16 Department of Physiotherapy, La Trobe University, weeks (initial 60 minutes, review 40 minutes), no equipment such as biofeedback or electrical stimulation, and an easily administered Melbourne, Australia primary outcome measure, the POP-SS, this is very translatable to current physiotherapy practice in women’s health. References The primary outcome measure in this study related to 1. Hendrix SL, et al. Am J Obstet Gynecol. 2002;186:1160–1166. symptoms rather than the impairment of body structure: prolapse 2. Hagen S, et al. Cochrane Database of Syst Rev. 2011;12:CD003882.pub4. stage. The authors justify this patient-centred approach, as 3. Braekken IH, et al. Am J Obstet Gynecol. 2010;203:170.e1–7. symptom reduction is the most important outcome for women, and symptoms are what typically prompt them to seek treatment. http://dx.doi.org/10.1016/j.jphys.2014.06.004 DOI of original article: http://dx.doi.org/10.1016/j.jphys.2014.06.013 1836-9553/Crown Copyright ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. All rights reserved.
Journal of Physiotherapy 60 (2014) 176–177 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Correspondence Review of Kinesio Taping ignored other models and techniques A systematic review of randomised trials of Kinesio Taping Elastic therapeutic tape can be used in many ways and the was recently published in Journal of Physiotherapy by Parreira results of other models (eg, skin model) have recently been and colleagues.1 The methods used were very thorough and I published. For example, elastic tape applied to the knee can have congratulate the authors for their great job and for having had the profound effects on neuromuscular control.6 Guimberteau7 has insight to look at all the available evidence in as many languages shown that skin always returns to its original shape and size after as possible. being manipulated, and Fukui8 has demonstrated that the skin moves in a specific physiological direction in the extremities and My main problem with the title and conclusion is that only two trunk. Taping the skin affects these skin properties. of the more than 10 taping possibilities were used in the appraised articles. One was the ‘muscle technique’, which involves taping Currently, numerous professionals persist in using this tape from origin to insertion or vice versa to stimulate or inhibit the because of the perceived positive effect in the daily clinic. On the underlying muscle. The other was the ‘star application’, which is other hand, researchers are telling us that it doesn’t work. We must intended to lift the skin. These taping methods are examples of the be missing something. Is it time for clinician and researchers to original model of taping developed by Kenzo Kase. However, the team up? authors used this evidence to mistakenly conclude that all Kinesio Taping techniques and models do not work. It seems that the Esther de Ru authors have not taken into account that there are many other GoPhysio, Zutphen, The Netherlands schools of thought as to how and why Kinesio Taping works. This tape is used and applied in many different ways around the world. References For at least a decade, allied health professionals have been using 1. Parreira PdCS, et al. J Physiother. 2014;60:31–39. tape in a number of ways: according to the original ideas of Kenzo 2. Lee Y-Y, et al. The effect of applied direction of kinesio taping in ankle strength and Kase (original model); using the concept that the fascia is involved through ‘biotensegrity’ to tape according to ‘fascia lines’ and ‘muscle flexibility. In: 30th Annual Conference of Biomechanics in Sports, Melbourne. 2012; trains’ (fascia model); using the concept that skin and brain are 140–143. involved through mechanical and sensory stimuli (skin model); 3. Luque Saurez A, et al. Man Ther. 2013;18:573–577. using alternative methods such as taping meridians, Chi and chakras 4. Ferna´ ndez Rodrı´guez JM, et al. Apunts Med Esport. 2010;45:61–67. (energy model); and combining Mulligan, Maitland and McConnell 5. Aguado Jodar X, et al. Mechanical behaviour of functional tape: implications for tape applications in various manners (combination model). functional taping preparation. In: 13th Annual Congress European College of Sports Science, Portugal. 2008. Recent studies of the hypotheses of the original model have 6. Konishi Y. J Sci Med Sport. 2013;16:45–48. found no significant differences in effect due to direction of tape.2,3 7. Guimberteau J-C. The skin excursion. Sept 2009. http://www.endovivo.com/en/ No evidence of a skin-lifting effect of the star application has been [accessed 17-05-2014] found. Two studies have shown that tape properties differ by brand 8. Fukui T. Skin movement of the trunk during trunk rotation. In: World Congress of and colour.4,5 Physical Therapy Conference. 2011; RR-PO-203-1-Thu. http://dx.doi.org/10.1016/j.jphys.2014.06.014 Different models and techniques of Kinesio Taping have never been tested We appreciate the opportunity to comment on de Ru’s opinions population was included. Our conclusions are based upon these and interpretations of our systematic review, which aimed to 12 eligible randomised controlled trials and our interpretation was evaluate the efficacy of Kinesio Taping in people with musculo- balanced using the GRADE recommendations. skeletal conditions,1 and to respond to the issues that she raised. These other Kinesio Taping models, to the best of our In her letter to the editor, de Ru claims that there are multiple knowledge, have never been tested in randomised controlled Kinesio Taping models and techniques that can be used, and that trials (therefore these models were not even mentioned in our the eligible articles included in our study just evaluated the review). The seven references provided by de Ru are conference ‘original Kinesio Taping developed by Kenzo Kase’ and we presentations (ie, not published in peer-reviewed journals), ‘mistakenly concluded that all Kinesio Taping techniques and studies of mechanisms, and a randomised trial conducted in models do not work’. She then presents references for supporting asymptomatic subjects (the results cannot be generalisable for these other models, claiming that they might work. people with musculoskeletal conditions). Therefore, the arguments that these other models might work are not based upon high- We do not support the idea that we ignored other Kinesio quality, clinical research. These models and techniques are only Taping models, as we selected all articles that used any model of theoretical and not evidence-based. As responsible researchers, we Kinesio Taping in people with musculoskeletal conditions. We would never recommend something that has never been tested. used comprehensive search strategies, following the recommen- dations from the Cochrane Collaboration, and we are confident that Finally, the statement ‘Currently, numerous professionals all available evidence on the use of Kinesio Taping for this persist in using this tape because of the perceived positive effect 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Appraisal Correspondence 177 in the daily clinic. On the other hand, researchers are telling us that should acknowledge that this intervention is not as good as it is it doesn’t work. We must be missing something’ ignores the basic claimed to be. principle that improvement in outcomes provided by patients is not always due to the effects of the intervention.2 Patients can Leonardo Oliveira Pena Costa, Luciola da Cunha Menezes Costa, improve due to confounders, such as placebo effects, natural Luiz Carlos Hespanhol Junior, Alexandre Dias Lopes and history, regression to the mean, polite patients and recall bias.3 Patrı´cia do Carmo Silva Parreira The only way of controlling for these confounders is by testing the Masters and Doctoral Programs in Physical Therapy, interventions against a comparison group in a randomised Universidade Cidade de Sa˜o Paulo, Brazil controlled trial design (not by observing patients at the clinic). Therefore, the interpretation from the researchers is not wrong. All References available evidence from five different systematic reviews of randomised controlled trials is very consistent: Kinesio Taping 1. Parreira PdCS, et al. J Physiother. 2014;60:31–39. just does not work.4–7 2. Herbert R, et al. Aust J Physiother. 2005;51:3–4. 3. Herbert R, et al. Practical Evidence-Based Physiotherapy. London: Elsevier’s Health As a final note, de Ru invited clinicians and researchers to team up. We totally agree with her. Our research team is composed Sciences; 2005. of professional researchers and extensively trained clinicians (all of 4. Morris D, et al. Physiother Theory Prac. 2013;29:259–270. them are certified by the Kinesio Taping Association International). 5. Mostafavifar M, et al. Physician Sportsmed. 2012;40:33–40. Our group believes that more studies are still needed, and we are 6. Williams S, et al. Sports Med. 2012;42:153–164. conducting two large randomised controlled trials in patients with 7. Kalron A, et al. Eur J Phys Rehabil Med. 2013;49:699–709. low back pain.8–10 On the other hand, clinicians and Kinesio Taping 8. Parreira PdCS, et al. J Physiother. 2013;59:52. instructors should be more open to the existing evidence and 9. Added MA, et al. BMC Musculoskel Disord. 2013;14:301. 10. Parreira PdCS, et al. J Physiother. 2014;60:90–96. http://dx.doi.org/10.1016/j.jphys.2014.06.015
Journal of Physiotherapy 60 (2014) 120–121 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Editorial Elevating the quality of disability and rehabilitation research: mandatory use of the reporting guidelines§ Leighton Chan a, Allen W Heinemann a, Jason Roberts b a Archives of Physical Medicine and Rehabilitation; b Origin Editorial With the remarkable growth of disability- and rehabilitation- the Quality and Transparency of Health Research (EQUATOR) related research in the last decade, it is imperative that we support network,4 an important organisation that promotes improvements the highest quality research possible. With cuts in research in the accuracy and comprehensiveness of reporting. Examples funding, rehabilitation research is now under a microscope like include the following: never before, and it is critical that we put our best foot forward. (1) CONSORT for randomised controlled trials (www.consort- To ensure the quality of the disability and rehabilitation statement.org); research that is published, the 28 rehabilitation journals simulta- neously publishing this editorial (see acknowledgments) have (2) Strengthening the Reporting of Observational studies in agreed to take a more aggressive stance on the use of reporting Epidemiology (STROBE) for observational studies guidelines. Physical Therapy, Journal of Orthopaedic & Sports Physical (www.strobe-statement.org); Therapy, Journal of Physiotherapy, and European Journal of Physical and Rehabilitation Medicine have already successfully required (3) Preferred Reporting Items for Systematic Reviews and Meta- reporting guidelines, for as many as 10 years. Analyses (PRISMA) for systematic reviews and meta-analyses (www.prisma-statement.org); Research reports must contain sufficient information to allow readers to understand how a study was designed and conducted, (4) Standards for the Reporting of Diagnostic accuracy studies including variable definitions, instruments and other measures, (STARD) for studies of diagnostic accuracy (www.stard- and analytical techniques.1 For review articles, systematic or statement.org); and narrative, readers should be informed of the rationale and details behind the literature search strategy. Too often articles fail to (5) Case Reports (CARE) for case reports (www.care-statement. include their standard for inclusion and their criteria for evaluating org). quality of the studies.2 As noted by Doug Altman, co-originator of the Consolidated Standards of Reporting Trials (CONSORT) There is accumulating evidence that the use of reporting statement and head of the Centre for Statistics in Medicine at guidelines improves the quality of research. Turner et al5 Oxford University: ‘‘Good reporting is not an optional extra: it is an established that the use of the CONSORT statement improved essential component of good research. . .we all share this obliga- the completeness of reporting in randomised controlled trials. tion and responsibility.’’3 Diagnostic accuracy studies appeared to show improvement in reporting standards when the STARD guidelines were applied.6 What are reporting guidelines? Early evidence also suggests that inclusion of reporting standards during peer review raises manuscript quality.7 The International Reporting guidelines are documents that assist authors in Committee of Medical Journal Editors now encourages all journals reporting research methods and findings. They are typically to monitor reporting standards and collect associated reporting presented as checklists or flow diagrams that lay out the core guideline checklists in the process.8 Furthermore, the National reporting criteria required to give a clear account of a study’s Library of Medicine also now actively promotes the use of methods and results. The intent is not just that authors complete a reporting guidelines.9 specific reporting checklist but that they ensure that their articles contain key elements. Reporting guidelines should not be seen as How will reporting guidelines be integrated into manuscript an administrative burden; rather, they are a template by which an flow? author can construct their articles more completely. By January 1, 2015, all of the journals publishing this editorial Reporting guidelines have been developed for almost every will have worked through implementation and the mandatory use study design. More information on the design, use, and array of of guidelines and checklists will be firmly in place. Because each reporting guidelines can be found on the website for the Enhancing journal has its unique system for managing submissions, there may be several ways that these reporting requirements will be DOI of original article: http://dx.doi.org/10.1016/j.apmr.2013.12.010 integrated into the manuscript flow. Some journals will make § This Editorial was originally published in Archives of Physical Medicine & adherence to reporting criteria and associated checklists manda- Rehabilitation, 2014, and is republished with the kind permission of the American tory for all submissions. Other journals may require them only Congress of Rehabilitation Medicine. For citation purposes, please use the original when the article is closer to acceptance for publication. In any case, publication details; Arch. Phy. Med. Rehab. 2014; 95:415-7. the onus will be on the author not only to ensure the inclusion of the appropriate reporting criteria but also to document evidence of http://dx.doi.org/10.1016/j.jphys.2014.07.003 1836-9553/ß 2014 The American Congress of Rehabilitation Medicine. Republished by Elsevier BV on behalf of Australian Physiotherapy Association under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/deed.en US), with the kind permission of The American Congress of Rehabilitation Medicine.
Editorial 121 inclusion through the use of the reporting guideline checklists. Mark Elkins, PhD, MHSc, BA, BPhty Authors should consult the Instructions for Authors of participat- Editor-in-Chief ing journals for more information. Journal of Physiotherapy Stacieann C. Yuhasz, PhD We hope that simultaneous implementation of this new Editor-in-Chief reporting requirement will send a strong message to all disability Journal of Rehabilitation Research and Development and rehabilitation researchers of the need to adhere to the highest Bengt H. Sjo¨ lund, MD, DMSc standards when performing and disseminating research. Although Editor-in-Chief we expect that there will be growing pains with this process, we Journal of Rehabilitation Medicine hope that within a short period, researchers will begin to use these Carl G. Mattacola, PhD, ATC guidelines during the design phases of their research, thereby Editor-in-Chief improving their methods. The potential benefits to authors are Journal of Sport Rehabilitation obvious: articles are improved through superior reporting of a Ann Moore, PhD and Gwendolen Jull, PhD study’s design and methods, and the usefulness of the article to Co-Editors-in-Chief readers is enhanced. Reporting guidelines also allow for greater Manual Therapy transparency in reporting how studies were conducted and can Randolph J. Nudo, PhD help, hopefully, during the peer review process to expose Editor-in-Chief misleading or selective reporting. Reporting guidelines are an Neurorehabilitation & Neural Repair important tool to assist authors in the structural development of a Kathleen Matuska, PhD, OTR/L manuscript, eventually allowing an article to realise its full Editor-in-Chief potential. Occupational Therapy Journal of Research: Occupation, Participation, and Health Acknowledgments Ann F Van Sant, PT, PhD Editor-in-Chief As this issue went to press, the following Editors agreed to Pediatric Physical Therapy participate in the initiative to mandate reporting guidelines and Greg Carter, MD publish this Position Statement in their respective journals. As a Consulting Editor collective group, we encourage others to adopt these guidelines Physical Medicine and Rehabilitation Clinics of North America and welcome them to share this editorial with their readerships. Rebecca L. Craik, PT, PhD Editor-in-Chief Sharon A. Gutman, PhD, OTR Physical Therapy Editor-in-Chief Dina Brooks, PhD American Journal of Occupational Therapy Scientific Editor Walter R. Frontera, MD, PhD Physiotherapy Canada Editor-in-Chief Stuart M. Weinstein, MD American Journal of Physical Medicine and Rehabilitation Editor-in-Chief Leighton Chan, MD, MPH, and Allen W. Heinemann, PhD PM&R Co-Editors-in-Chief Elaine L. Miller, PhD, RN Archives of Physical Medicine and Rehabilitation Editor-in-Chief Helene J. Polatajko, PhD, OT(C) Rehabilitation Nursing Editor-in-Chief Elliot J. Roth, MD Canadian Journal of Occupational Therapy Editor-in-Chief Derick T. Wade, MD Topics in Stroke Rehabilitation Editor-in-Chief Dils¸ ad Sindel, MD Clinical Rehabilitation Editor-in-Chief Suzanne McDermott, PhD, and Margaret A. Turk, MD Turkish Journal of Physical Medicine and Rehabilitation Co-Editors-in-Chief Disability and Health Journal References Stefano Negrini, MD Editor-in-Chief 1. Moher D, Simera I, Schulz KF, Hoey J, Altman DG. Helping editors, peer reviewers and European Journal of Physical and Rehabilitation Medicine authors improve the clarity, completeness and transparency of reporting health Steven Vogel, DO(Hon) research. BMC Med. 2008;6:13. Editor-in-Chief The International Journal of Osteopathic Medicine 2. Simera I, Altman DG, Moher D, Schulz KF, Hoey J. Guidelines for reporting health Cˇ rt Marincˇek, MD, PhD research: the EQUATOR network’s survey of guideline authors. PLoS Med. Editor-in-Chief 2008;5:e139. International Journal of Rehabilitation Research M. Solomonow, PhD, MD(hon) 3. Altman D. Why we need transparent reporting of health research. Excerpt from a Editor-in-Chief presentation delivered at the launch of the EQUATOR Network, June 2008. Available at: Journal of Electromyography & Kinesiology http://www.equator-network.org/2008/06/26/achieving- transparency-in-reporting- Paolo Bonato, PhD health-research/. Accessed January 9, 2013. Editor-in-Chief Journal of NeuroEngineering and Rehabilitation 4. EQUATOR network. Available at: www.equator-network.org. Accessed October 21, Edelle [Edee] Field-Fote, PT, PhD 2013. Editor-in-Chief Journal of Neurologic Physical Therapy 5. Turner L, Shamseer L, Altman DG, Schulz KF, Moher D. Does use of the CONSORT Guy G. Simoneau, PhD, PT Statement impact the completeness of reporting of randomised controlled trials Editor-in-Chief published in medical journals?. A Cochrane review Syst Rev. 2012;1:60. Journal of Orthopaedic & Sports Physical Therapy (JOSPT) 6. Smidt N, Rutjes AW, van der Windt DA, et al. The quality of diagnostic accuracy studies since the STARD statement: has it improved? Neurology. 2006;67:792–797. 7. Cobo E, Corte´ s J, Ribera JM, et al. Effect of using reporting guidelines during peer review on quality of final manuscripts submitted to a biomedical journal: masked randomised trial. BMJ. 2011;343:d6783. 8. International Committee of Medical Journal Editors. Preparing a manuscript for submission to a medical journal. Available at: http://www.icmje.org/manuscrip- t_a.html. Accessed October 21, 2013. 9. U.S. National Library of Medicine. Research reporting guidelines and initiatives: by organization. Available at: http://www.nlm.nih.gov/services/research_report_gui- de.html. Accessed October 21, 2013.
Journal of Physiotherapy 60 (2014) 130–135 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research Exercise and physical training improve physical function in older adults with visual impairments but their effect on falls is unclear: a systematic review Michael Gleeson, Catherine Sherrington, Lisa Keay Sydney Medical School, The George Institute for Global Health, The University of Sydney, Australia KEYWORDS ABSTRACT Visual impairment Question: Can exercise or physical training improve physical function and prevent falls in older adults Falls risk with visual impairments? Design: Systematic review of randomised controlled trials with meta- Falls analysis. Participants: Older adults (! 60 years) with visual impairments. Intervention: Individual or Ageing group exercise or physical training classes in any settings. Outcome measures: Mobility, balance, Exercise strength and proprioception measured with performance tests or questionnaires and/or falls with Mobility calendars or incident reports. Results: Four eligible trials with a total of 522 participants were identified. Multimodal group exercise (n = 50 and 41) and Tai Chi (n = 40) improved physical function among residents of care settings. Meta-analysis of data from two trials indicated a significant positive impact of multimodal exercise on the Berg Balance Score (weighted mean difference 3.9 points, 95% CI 1.8 to 6.0), but not on the Timed Up and Go test (weighted mean difference 1.5 seconds, 95% CI –1.7 to 4.6). One trial (n = 41) found that multimodal exercise reduced the time to first fall (p = 0.049). A factorial trial (n = 391) among community dwellers did not find a significant effect on falls from a home-based exercise intervention, although clinically relevant effects in either direction were not excluded by the study (incidence rate ratio = 1.15, 95% CI 0.82 to 1.61). Conclusion: Exercise interventions in residential care settings improve performance on some tests of physical function that are risk factors for falls but the impact on falls is not yet clear. The impact of exercise and training on physical function and falls in community-dwelling older adults with visual impairments also warrants further investigation. [Gleeson M, Sherrington C, Keay L (2014) Exercise and physical training improve physical function in older adults with visual impairments but their effect on falls is unclear: a systematic review. Journal of Physiotherapy 60: 130–135] ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Introduction scanning the environment ahead with sufficient time to recognise potential hazards and avoid them. Glare can interfere with Falls are a leading cause of morbidity and mortality. At least 30% environmental preview in people with visual impairment. High of people aged 65 and over fall each year.1–3 Older adults with levels of glare sensitivity are reported in individuals with visual impairment are 1.7 times more likely to fall than their glaucoma13 and recovery from glare exposure is slower in people sighted peers and 1.9 times more likely to have multiple falls.4 with age-related macular degeneration.14 Fluctuations in environ- Visual impairment has been found to be an independent risk factor mental light can divide attention and reduce the available reaction for falls, particularly with relation to impaired edge-contrast time to hazards for this population. When attention is divided, sensitivity and depth perception.5,6 older adults have a decreased ability to avoid obstacles in the environment, compared to younger adults.15 Individuals with People with visual impairment are at a particularly high risk of visual impairments may also rely on memorised aspects of the falls due to impaired balance7 and difficulty detecting environ- environment and often employ a mobility aid as they travel. If the mental hazards. With normal ageing, conduction speed and central individual is using a long cane as a mobility aid, the cane is nervous system processing slows down,8 forcing balance control detecting the next footfall, giving little warning before a hazard is mechanisms to rely more heavily on visual input to maintain encountered. Attention allocated to route memory and mobility- stability,9 particularly during single limb balance.10 This has aid use, in addition to postural stability and hazard avoidance, obvious implications for older adults with visual impairments. could thus overload attention resources and further increase the Deterioration in balance control in older people is primarily in the risk of falls in people with visual impairment. medio-lateral direction11 and reduced visual input has been shown to have a greater impact on lateral balance control,12 which A Cochrane review by Gillespie et al16 identified several amplifies the deterioration in the older population with visual effective approaches to fall prevention for the general population impairments on mobility tasks involving single-limb balance. of older adults living in the community, including exercise, home safety, medication management and interventions targeting Travel in the community presents additional hazards for older multiple risk factors. The latest update of that review included people with visual impairment. Environmental preview involves http://dx.doi.org/10.1016/j.jphys.2014.06.010 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
Research 131 no new trials that provided physical training for community- discussion. Data extracted included: the settings in which the trials dwelling older adults with untreatable visual impairments. A were conducted; the characteristics of the participants (age, Cochrane review by Cameron et al17 identified that Vitamin D gender and visual status); the programs provided to the interven- prescription reduces falls in residential care facilities and that tion and control groups; and outcome measures. interventions targeting multiple risk factors may also do so, but it included no trials that provided physical training for older adults Quality with visual impairments in care facilities and hospitals. It is The studies had already been assessed for quality using the believed that the present study is the first systematic review to address this question. PEDro scale,19 which includes items related to risk of bias and completeness of reporting, and reported on PEDro (http:// Older adults with visual impairments are affected by age- www.pedro.org.au). Studies were not excluded on the basis of related deterioration in balance to an even greater extent than the the rating. general population.18 Thus, exercise and physical training warrant particular investigation as fall prevention strategies for people Design with visual impairment living in the community, as well as in Only published, randomised trials were eligible. Language of residential care settings. Mobility, balance, strength and proprio- ception are aspects of physical function that have been identified publication was not an exclusion criterion. as risk factors for falls. Thus, the impact of exercise on these factors, as well as on falls themselves, was investigated. Therefore, the Participants research questions for this review were: This review focused on studies in older adults with untreatable 1. Does exercise or other physical training improve physical visual impairments, and so excluded studies of people with visual function in older adults with visual impairments? disturbance relating to cataract surgery, refractive correction and medication. The study populations were required to be primarily 2. Does exercise or other physical training prevent falls in older aged 60 or older. Trials that included younger participants were adults with visual impairments? considered eligible if the mean age of participants minus one standard deviation was over 60 years. Method Interventions Eligible interventions included strength and balance training, Identification and selection of studies and physical training such as dance, Tai Chi and other comple- A search of the literature was conducted in February 2013 of mentary therapies. Comparisons in eligible studies were between MEDLINE, Embase, CINAHL and the Cochrane Register of Con- the intervention group and either a usual care or control group, and trolled Trials (CENTRAL). The MEDLINE search strategy used is studies with factorial designs comparing more than one interven- shown in Appendix 1 (see eAddenda) and this was adapted for tion were also included. other databases. Supplementary searches of the Physiotherapy Evidence Database (PEDro), the WHO International Clinical Trials Outcome measures Registry and Literatura Latino-Americana e do Caribe em Cieˆncias Included studies measured physical function with performance da Sau´ de (LILACS) were also undertaken. The searches sought trials of exercise and training to improve physical function or reduce falls tests or questionnaires and/or falls with calendars or incident in older adults with untreatable visual impairments. The inclusion reports. Eligible aspects of physical function were mobility, criteria are summarised in Box 1. balance, strength and proprioception. Assessment of study characteristics Data analysis The researchers were not blinded to any aspects of the papers. Random-effects meta-analyses were conducted using commer- Study titles and abstracts were independently screened by two cial softwarea to compare the impact on the outcomes of interest of investigators (MG and LK) for inclusion in the review and any programs designed to enhance physical function or prevent falls discrepancies were resolved by discussion with a third investigator with control programs or usual care. The weighted mean difference (CS). Data were extracted by one investigator (MG) and checked by (WMD) was calculated using the pre-intervention and post- a second investigator (CS) and any discrepancies resolved by intervention means and standard deviations. Statistical heteroge- neity was quantified with the I2 and Q statistics. Results Box 1. Inclusion criteria. Flow of studies through the review Design The electronic database search identified 3451 records after Randomised controlled trials or trials with factorial design removal of duplicates. After screening by title and abstract, full articles were then obtained for 10 trials and their eligibility assessed Participants against the inclusion criteria. After more detailed investigation, Older adults ! 60 years of age three papers were excluded because they were not randomised Uncorrectable visual impairment controlled trials, one because the participants were not visually impaired, one because there was no physical intervention and one Intervention because it was another report of an included trial. Four trials were Exercise deemed to fit the inclusion criteria and results from two trials Physical training other than exercise, such as Tai Chi, were combined in a meta-analysis. Figure 1 shows the flow of search Yoga, dance results through to the selection for meta-analysis. Outcome measures Characteristics of studies Measures of physical function with performance tests or questionnaires The four studies included in the review were randomised Falls with calendars or incident reports controlled trials published in English. Their quality scores are Comparisons Exercise program designed to enhance physical function compared with control program or usual care
$FT)1_erugi([IG]D132 Gleeson et al: Exercise training in older adults with visual impairments Titles and abstracts screened absolute angle error of passive knee joint repositioning, measured (n = 3451) with a Cybex Norm dynamometer, in the intervention group (- 26 Æ 29%) compared to the control group (4 Æ 31%). There was an Papers excluded after screening overall significant difference in favour of the intervention group on titles/abstracts (n = 3441) the Sensory Organisation Test (p = 0.024), but there were also significant differences in the vestibular and visual ratios between Potentially relevant papers retrieved the two groups. The intervention group achieved a greater (p = 0.048) for evaluation of full text (n = 10) percentage improvement in the vestibular ratio (33 Æ 40%) compared to controls (–18 Æ 57%) and a greater (p = 0.006) percentage change of Papers excluded after evaluation of visual ratio (58 Æ 42%) compared to the control group (–2 Æ 29%). full text (n = 6) There was no significant difference between the two groups in muscle • research design not RCT (n = 3) strength in the dominant leg. • participants not visually impaired Kova´ cs and colleagues23 and Cheung and colleagues22 both (n = 1) reported outcomes using the Timed Up and Go test26 and the Berg • intervention not a physical Balance Score27 so these data were pooled for meta-analysis. Forest plots and weighted mean differences for the Berg Balance Scale are intervention (n = 1) presented in Figure 2 and for the Timed Up and Go test in Figure 3. • secondary paper describing the In both cases the pooled estimates showed a favorable effect of the intervention. The pooled estimate indicated statistically significant intervention in more detail (n = 1) differences between intervention and control groups for the Berg Balance Score (WMD 3.9 points, 95% CI 1.8 to 6.0). The pooled Papers included in review (n = 4) estimate of effect for the Timed Up and Go test indicated a between-group difference in favour of the intervention that did not Papers included in meta-analysis reach statistical significance (WMD 1.5 seconds, 95% CI –1.7 to 4.6). (n = 2) The Berg Balance Scale estimates showed a low level of heterogeneity (I2 = 0%, Q = 0.45), as did the Timed Up and Go test Figure 1. Flow of studies through the review. estimates (I2 = 0%, Q = 1.0). presented in Table 1, and their designs, participant characteristics, Cheung and colleagues22 also used a chair stand test and found interventions and outcome measures are summarised in Table 2. that the intervention group showed significant improvement The VIP trial by Campbell and colleagues20 was a 12-month, 2 x 2 compared with the control group (mean time difference 2.35 sec- factorial community-based trial involving men and women over 75 onds, 95% CI 0.03 to 4.67). Kova´ cs and colleagues23 used the Barthel years of age with visual impairment. The remaining three trials Activities of Daily Living Index28 but found no significant were undertaken in residential care settings. The trial by Chen and difference between intervention and control groups (p = 0.622). colleagues21 ran for 16 weeks and stratified the randomisation based on gender, age and level of visual impairment. Cheung and Falls outcomes colleagues22 assessed women over 70 years of age in a 12-week Only the VIP trial by Campbell and colleagues20 collected trial, and Kova´ cs and colleagues23 assessed women over 60 years of age in a 6-month trial. There were 522 participants in total in the prospective falls data. The VIP trial was a 2 x 2 factorial design with included studies, but data from only 91 participants could be prospective calendars and 12 months of follow-up. Community- pooled for meta-analysis. dwelling older adults were randomised into: a home safety assessment and modification program; an exercise program; both Effect of the intervention the home safety and exercise programs; or social visits. The study found that home safety assessment and modification reduced falls Physical function outcomes (41% fewer falls, incidence rate ratio = 0.59, 95% CI 0.42 to 0.83). Three trials21–23 measured physical function as the primary The study did not find a significant effect of the exercise intervention on falls, although clinically relevant effects in either outcome. One used Tai Chi as the intervention21 and the other two direction were not excluded by the study (incidence rate used group multimodal exercise, which incorporated both strength ratio = 1.15, 95% CI 0.82 to 1.61). The successful home safety and balance training.22,23 aspect of the study is described in a separate paper.29 The Tai Chi trial of Chen and colleagues21 used a passive knee Kova´ cs and colleagues23 used medical records and nursing joint repositioning test,24 the Sensory Organisation Test,25 and documentation during the 6-month study period to collect falls concentric isokinetic strength of the knee flexors and extensors of data and reported that the risk for falls was reduced by 46% in the the dominant leg as outcome measures. This trial showed a intervention group, but the difference did not reach statistical significant decrease (p = 0.032) in the percentage change of significance (relative risk = 0.54, 95% CI 0.29 to 1.01). This trial found a significant between-group difference in the mean length of time to first fall in favour of the intervention group (p = 0.049). The mean length of time to first fall was 18.5 weeks (95% CI 15.4 to 21.7) for the intervention group and 14.8 weeks (95% CI 11.1 to 18.4) for the control group. As acknowledged by the authors, these results need to be treated with caution due to the small sample size Table 1 PEDro scores of included studies. Study Random Concealed Groups similar Participant Therapist Assessor Adequate Intention-to- Between-group Point estimate Total allocation allocation at baseline blinding blinding blinding follow-up treat analysis difference and variability (0 to 10) Campbell20 reported Chen21 Y Y Y N N Y Y Y reported 8 Cheung22 Y N N N N N N Y Y 4 Kova´ cs23 Y Y Y N N Y Y N Y Y 7 Y Y Y N N Y Y Y Y Y 8 Y Y Y Y = yes, N = no
Research 133 Table 2 Summary of included studies. Study Design Participants Intervention Outcome measures Campbell20 2x2 n = 391 Exp = 2 x 2 factorial Otago exercise program (multimodal) and home falls measured with prospective factorial Age (yr) ! 75 safety. calendars over 12 mth RCT Gender = 124 M, 267 F 5 home visits by physiotherapist at 1,2,4,8 wk and 6 mth to progress and Community dwelling encourage independent practice of the Otago exercise program. follow-up = 12 mth Visual acuity 6/24 30 min x 3/wk and walk x 2/wk if safe to do so for 12 mth, plus Vitamin D supplementation. muscle strength = % change of Chen21 RCT n = 40 Con = 2 x 1 hr social visits in first 6 mth. knee muscle strength with Age (yr) ! 70 Cybex Norm dynamometer Gender = M & F Exp = Modified 8-form Yang-style Tai Chi in small group with verbal and but data unavailable manual support. proprioception = % change of Residential facility 90 min x 3/wk x 16 wk. absolute angle error with Cybex Visual acuity Con = Social music group - time and duration not stated. Norm dynamometer stratified ! 3/60, < 6/18 or < 3/60 Sensory Organisation Test = % change of sensory ratios using Cheung22 RCT n = 50 Exp = Multimodal exercise program with verbal and manual support sway referencing Age (yr) ! 65 delivered by physiotherapist. Kova´ cs23 RCT Gender = F only 45 min x 3/wk x 12 wk, plus standard residential exercise program given follow-up = 16 wk Residential facility to control group 45–60 min x 3/wk x 12 wk. Visual acuity 6/120 Con = Standard residential exercise program Berg Balance Score 45–60 min x 3/wk x 12 wk. Timed Up and Go test n = 41 Chair stand test Age (yr) ! 60 Exp = Otago exercise program (multimodal) with verbal and manual follow-up = 12 wk Gender = F only support in small group delivered by physiotherapists 30 min x 2/wk x 6 Residential facility mth, plus standard osteoporosis exercise program given to the control Berg Balance Score for visually impaired group below x 2/wk x 6 mth. Timed Up and Go test Excluded if totally blind Con = Standard osteoporosis program 30 min x 4/wk x 6 mth. Barthel Activity Index falls follow-up = 6 mth Con = control group, Exp = experimental group, RCT = randomised controlled trial, M = male, F = female. ]GIF$DT)2_erugi([ Study Time Experimental Control Mean difference Weight Association measure point n, Mean (SD) n, Mean (SD) (95% CI) (%) (95% CI) Cheung22 12 wk 27, 48.6 (4.4) 23, 44.3 (5.2) 72 4.3 (1.8 to 6.8) Kovacs23 6 mth 21, 45.1 (7.4) 20, 43.3 (6.8) 28 2.7 (–1.3 to 6.7) Pooled 3.9 (1.8 to 6.0) –15 –10 –5 0 5 10 15 Favours control Favours experimental Figure 2. Weighted mean differences (95% CI) of effect of multimodal exercise immediately after 12 weeks to 6 months of training on the Berg Balance Scale by pooling data from two studies (n = 91). GIF$DT)3_er]ugi([ Study Time Experimental Control Mean difference Weight Association measure point n, Mean (SD) n, Mean (SD) (95% CI) (%) (95% CI) Cheung22 12 wk 27, 23.6 (11.3) 23, 26.1 (15.0) 19 4.8 (–2.0 to 11.5) Kovacs23 6 mth 21, 17.9 (5.0) 20, 19.3 (4.2) 81 0.7 (–1.9 to 3.3) Pooled 1.5 (–1.7 to 4.6) –15 –10 –5 0 5 10 15 Favours control Favours experimental Figure 3. Weighted mean differences (95% CI) of effect of multimodal exercise immediately after 12 weeks to 6 months of training on the Timed Up and Go Test by pooling data from two studies (n = 91). (n = 41). Cheung and colleagues22 reported no falls in either group Discussion during the three-month study period (n = 50), but did not state how the data were collected. The Tai Chi trial by Chen and This systematic review found few studies of mixed quality in colleagues21 did not collect falls data. Due to the differences in this vulnerable population. There was only one community-based settings and follow-up periods a meta-analysis for the falls trial among older adults with visual impairments.20 It had falls as outcome was not undertaken. the primary outcome and it found a protective effect of home
134 Gleeson et al: Exercise training in older adults with visual impairments modification but not exercise. Data from three small trials in facility for the people with visual impairment and needs residential care settings,21–23 one of which specialised in people confirmation in a further study with a larger sample size. At with visual impairment,23 indicated that multimodal exercise present, no strong conclusions can be drawn regarding the impact programs and Tai Chi can improve balance and physical function, of improved physical function on fall rates within residential and thus may reduce fall risk. This provides a rationale for future settings for older adults with visual impairments. larger trials of physical interventions in this population that would measure actual fall rates, given the known effect of visual There are several limitations to this review. Only four trials impairment as an intrinsic risk factor for falls, and its subsequent qualified for inclusion, and three of these had small sample sizes. negative effect on physical function. Only data from two trials could be combined for meta-analysis, and in addition to this, the difference in setting between the In the meta-analyses, although both outcome measures were in community and residential care-facilities makes it difficult to a direction favouring the intervention, only the Berg Balance Scale generalise findings between them. The quality of the studies was reached significance. The Timed Up and Go Test is widely used, but generally high, but one study21 only scored 4 out of 10, so those it may not be the most appropriate measure for adults with a visual results should be interpreted with caution. impairment. It is possible that there is a limit to how much it can be expected that walking speed will increase, given the visual In conclusion, it has been shown that exercise programs that impairment, regardless of the level of physical improvement that include a balance component and Tai Chi can improve physical the intervention provides. A study of sighted and visually impaired function in older adults with visual impairments living in residential adults, matched for age and gender, found that sighted adults care, but any effect on fall rates requires larger trials before it can be responded faster than those with visual impairments on the Timed verified. Translating these results into community settings poses Up and Go test and concluded that adults with visual impairments some problems due to the differences in residential and community have difficulty with fast-paced movements.30 It should also be kept populations. Home modification and safety programs have been in mind that the only outcome data reported from these studies shown to have a protective effect on falls in the community- were immediately post-intervention, so there was no follow-up dwelling, visually impaired population. Apart from the VIP trial,20 period looking at effect duration over time. which investigated an exercise intervention with falls as the primary outcome, this review found no trials designed to improve strength Three of the trials were conducted in residential care settings, and balance in visually impaired older adults living in the one of which specialised in people with visual impairment; this community, and so appropriate interventions and their method of limits how much can be inferred about these results for a delivery have yet to be determined. community-dwelling population. Adherence to the study protocol may be easier in the controlled setting of a residential facility, plus, What is already known on this topic: Falls are a leading verbal guidance and manual assistance were provided,21–23 which cause of morbidity in older people; visual impairment in older may have improved the precision of the exercise performed people increases the risk of falls even more. In older people compared to a person exercising at home without feedback. without visual impairment, exercise training has a range of Adherence has already been shown to be an issue in home-based benefits, including improved physical function and reduced programs in this population group20 and group classes in the falls risk. community are difficult for some people with visual impairments What this study adds: In older people with visual im- to access. Improving physical ability may not always translate into pairment, multimodal exercise improves performance on a reduction in fall rates in the community, as those individuals are physical function tests that are associated with falls risk. likely to be more mobile and may be at a higher risk due to One study involving community-dwelling older people found environmental hazards. Providing the level of manual assistance that an exercise program reduced falls. However, the studies and verbal support available in a residential setting, or provision of involving institutionalised older people had variable results, transport to and from existing fall prevention programs in the making the overall effect on falls unclear. community are possible options, but their cost effectiveness has yet to be established. These results suggest that residential care Footnotes: a Comprehensive Meta-Analysis software, Version 2, facilities should include visually impaired residents in fall Biostsat, Englewood NJ, USA. prevention programs when it is possible to provide the additional support necessary to do so. eAddenda: Appendix 1 can be found online at doi:10.1016/ j.jphys.2014.06.010 This review found only one trial powered to detect a reduction in falls and this was undertaken in a community setting.20 This trial Ethics approval: Not applicable. found that home safety and home modification programs reduce Competing interests: Nil. falls in community-dwelling older adults with visual impairments Source(s) of support: Australian Federal Government Austra- when delivered by an occupational therapist.20,29 Home safety lian Postgraduate Award scholarship (MG); Australian Research interventions are designed to reduce the presence of extrinsic risk Council Postdoctoral Fellowship (LK) and Australian National factors in the home environment, along with general advice about Health and Medical Research Council Senior Research Fellowship fall prevention. To date, this is the only large-scale trial that has (CS). implemented non-vision-related interventions for older adults Acknowledgements: Nil. with visual impairments designed to reduce falls. The Otago Correspondence: Michael Gleeson, Injury Division, The George Exercise Programme, which was used in this trial, is effective in Institute for Global Health, The University of Sydney, Australia. preventing falls in the general community-dwelling population Email: [email protected] and is also a multimodal program incorporating elements of strength and balance training.31,32 In addition to the home-based References exercise program, there was a walking program33 and participants in the exercise groups in the trial were expected to walk at least 1. Lord SR, Ward JA, Williams P, Anstey KJ. An epidemiological study of falls in older twice a week for 30 minutes, if it was safe to do so. It is possible community-dwelling women: the Randwick falls and fractures study. Aust J Public that the walking program may have exposed some of the Health. 1993;17:240–245. participants in the exercise group to greater risk of falling, given their visual impairment. 2. Morris M, Lundgren-Lindquist B, Reid J, Browning C, Kendig H, Osborne D, et al. Predisposing factors for occasional and multiple falls in older Australians who live Falls were also recorded in two of the trials that delivered at home. Aust J Physiother. 2004;50:153–159. programs to improve physical function in residential settings.22,23 Data from one small trial (n = 41) suggested a fall prevention effect 3. Tinetti ME, Speechley M, Ginter SF. Risk Factors for Falls among Elderly Persons of multimodal exercise,23 but this was in a specialty residential Living in the Community. New Engl J Med. 1988;319:1701–1707. 4. Legood R, Scuffham P, Cryer C. Are we blind to injuries in the visually impaired? A review of the literature Injury Prevention. 2002;8:155–160. 5. Ivers RQ, Cumming RG, Mitchell P, Attebo K. Visual impairment and falls in older adults: the Blue Mountains Eye Study. J Am Geriatr Soc. 1998;46:58–64.
Research 135 6. Lord SR. Visual risk factors for falls in older people. Age and Ageing. 2006;35: 21. Chen EW, Fu ASN, Chan KM, Tsang WWN. The effects of Tai Chi on the balance ii42–ii45. control of elderly persons with visual impairment: a randomised clinical trial. Age Ageing. 2012;41:254–259. 7. Ray CT, Horvat M, Croce R, Mason RC, Wolf SL. The impact of vision loss on postural stability and balance strategies in individuals with profound vision loss. Gait 22. Cheung KKW, Au KY, Lam WWS, Jones AYM. Effects of a structured exercise Posture. 2008;28:58–61. programme on functional balance in visually impaired elderly living in a residen- tial setting. Hong Kong Physiother J. 2008;26:45–50. 8. Perrin PP, Jeandel C, Perrin CA, Be´ ne´ MC. Influence of visual control, conduction and central integration on static and dynamic balance in healthy older adults. Gerontol. 23. Kova´ cs E´ au, To´ th K, De´ nes L, Valasek T, Hazafi K, Molna´ r G, et al. Effects of exercise 1997;43:223–231. programs on balance in older women with age-related visual problems: A pilot study. Arch Gerontol Geriatr. 2012;55:446–452. 9. Bugnariu N, Fung J. Aging and selective sensorimotor strategies in the regulation of upright balance. J NeuroEng Rehabil. 2007;4:19. 24. Tsang WW, Hui-Chan CW. Effects of Tai Chi on joint proprioception and stability limits in elderly subjects. Med Sci Sports Exerc. 2003;35:1962–1971. 10. Hazime FA, Allard P, Ide MR, Siqueira CM, Amorim CF, Tanaka C. Postural control under visual and proprioceptive perturbations during double and single limb 25. Ford-Smith CD, Wyman JF, Elswick Jr RK, Fernandez T, Newton RA. Test-retest stances: Insights for balance training. J Bodyw Mov Ther. 2012;16:224–229. reliability of the sensory organization test in noninstitutionalized older adults. Arch Phys Med Rehabil. 1995;76:77–81. 11. Day BL, Steiger MJ, Thompson PD, Marsden CD. Effect of vision and stance width on human body motion when standing: implications for afferent control of lateral 26. Podsiadlo D, Richardson S. The timed ‘‘Up & Go’’: a test of basic functional mobility sway. J Physiol. 1993;469:479–499. for frail elderly persons. J Am Geriatr Soc. 1991;39:142–148. 12. Bauby CE, Kuo AD. Active control of lateral balance in human walking. Biomech. 27. Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the 2000;33:1433–1440. elderly: Validation of an instrument. Can J Pub Health. 1992;83:S7–S11. 13. McKean-Cowdin R, Wang Y, Wu J, Azen SP, Varma R. Impact of Visual Field Loss on 28. Wade DT, Collin C, The Barthel ADL. Index: a standard measure of physical Health-Related Quality of Life in Glaucoma: The Los Angeles Latino Eye Study. disability? Int Disabil Stud. 1988;10:64–67. Ophthalmol. 2008;115:941-948.e1. 29. La Grow SJ, Robertson MC, Campbell AJ, Clarke GA, Kerse NM. Reducing hazard 14. Sandberg MA, Gaudio AR. Slow photostress recovery and disease severity in age- related falls in people 75 years and older with significant visual impairment: how related macular degeneration. Retina. 1995;15:407–412. did a successful program work? Injury Prevention. 2006;12:296–301. 15. Chen H-C, Schultz AB, Ashton-Miller JA, Giordani B, Alexander NB, Guire KE. 30. Ray CT, Horvat M, Williams M, Blasch BB. Clinical assessment of functional Stepping Over Obstacles: Dividing Attention Impairs Performance of Old More movement in adults with visual impairments. J Vis Impair Blind. 2007;101: Than Young Adults. J Gerontol A: Biol Sci Med Sci. 1996;51A:M116–M122. 108–113. 16. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. 31. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. Interventions for preventing falls in older people living in the community. Randomised controlled trial of a general practice programme of home based Cochrane Database Syst Rev. 2012;9:CD007146. exercise to prevent falls in elderly women. BMJ. 1997;315:1065–1069. 17. Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, et al. 32. Robertson MC, Campbell AJ, Melinda MG, Nancy D. Preventing injuries in older Interventions for preventing falls in older people in care facilities and hospitals. people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr Cochrane Database Syst Rev. 2012;12:CD005465. Soc. 2002;50:905–911. 18. Kulmala J, Viljanen A, Sipila S, Pajala S, Parssinen O, Kauppinen M, et al. Poor vision 33. Gardner MM, Buchner DM, Robertson MC, Campbell AJ. Practical implementation accompanied with other sensory impairments as a predictor of falls in older of an exercise-based falls prevention programme. Age Ageing. 2001;30:77–83. women. Age Ageing. 2009;38:162–167. Websites 19. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83: www.pedro.org.au 713–721. 20. Campbell AJ, Robertson MC, La Grow SJ, Kerse NM, Sanderson GF, Jacobs RJ, et al. Randomised controlled trial of prevention of falls in people aged >=75 with severe visual impairment: the VIP trial. BMJ. 2005;331:817–825.
Journal of Physiotherapy 60 (2014) 165 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Exercise training decreases fasting insulin levels and improves insulin resistance in children and adolescents Summary Summary of: Fedewa MV, Gist NH, Evans EM, Dishman RK. comparison group with a mean effect size of 0.31 (95% CI 0.06 to Exercise and insulin resistance in youth: A meta-analysis. 0.56). The results were consistent across gender, age and ethnicity. Pediatrics 2013;133:e163-e174. Body mass index moderated the effect of exercise on fasting insulin, that is: a greater effect was observed in children and Objective: To review the evidence as to whether exercise adolescents with higher body mass index. Each of the exercise training improves fasting insulin and insulin resistance in children interventions varied in design and included aerobic, resistance, a and adolescents. Data Sources: PubMed, SPORTDiscus, Physical combination of training modes, games and play. When reported, Education Index, Web of Science, searched up to June, 2013. This exercise training consisted of 3 (SD 1) sessions per week, for 53 (SD search was supplemented by review of the reference lists from 20) minutes at a moderate to vigorous intensity of physical activity retrieved articles. Study Selection: Randomised controlled trials per session, for 16 (SD 11) weeks. Conclusion: Exercise is effective involving healthy children or adolescents in which exercise in decreasing fasting insulin and improving insulin resistance in training was compared to a non-exercise comparison. Outcome healthy children and adolescents. Regular physical activity and measures were fasting insulin and insulin resistance. Data exercise training should be included in programs for children and Extraction: Two reviewers extracted data, and discrepancies were adolescents at risk of developing type II diabetes. resolved by discussion. Methodological quality was not assessed. Data Synthesis: Of the 546 studies initially identified by the search, Nora Shields 24 studies, with a total of 1599 participants, met the selection Department of Physiotherapy, criteria and were included in the review. Based on the quantitative La Trobe University and Northern Health, Australia pooling of the available data from these trials, exercise training reduced fasting insulin levels in children and adolescents http://dx.doi.org/10.1016/j.jphys.2014.06.009 significantly more than the non-exercise comparison group with a mean effect size of 0.48 (95% CI 0.22 to 0.74). Exercise training was also more effective in reducing insulin resistance than the ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. Commentary Whilst the prevalence of obesity and type 2 diabetes mellitus is of exercise is ideal; what exercise intensity should be prescribed; increasing, the relationship between these two conditions varies and what frequency of exercise is needed? Data from mainly adult worldwide.1 Other factors, such as differences in sugar availability, studies show that both aerobic and resistance training exercise explain variations in diabetes rates that are not explained by reduce insulin resistance and that moderate-to-vigorous-intensity physical activity, being overweight or obese. Therefore, underlying exercise is associated with greater metabolic benefit compared to metabolic abnormalities and, in particular, insulin resistance are low-intensity exercise.2 However, the effect of exercise on insulin more closely associated with type 2 diabetes mellitus rather than resistance begins to wane 48 hours after a bout of exercise. Thus, to being indices of obesity. maximise metabolic effect, exercise needs to be regular and ideally performed on most days. The chosen mode of exercise may come Fedewa et al. show that regular exercise in youth reduces down to an individual’s preference and which type of exercise they insulin resistance, especially in those with greater insulin are more likely to adhere to. If exercise can be made satisfying and resistance (generally those who are more obese and older). enjoyable it will most likely lead to better compliance and health These data confirm the importance of physical activity and outcomes. exercise to health in younger populations. This is relevant to later life, as those with greater insulin resistance in childhood and Paul Hofman adolescence have greater insulin resistance in adulthood and are Liggins Institute, University of Auckland, New Zealand therefore predisposed to health problems, including: type 2 diabetes mellitus, hypertension, coronary artery disease, malig- References nancy and stroke. Thus, reducing insulin resistance during childhood and adolescence may result in long-term improvement 1. Basu S, et al. PLoS ONE. 2013;8:e57873. in health outcomes. 2. Roberts CK, et al. Med Sci Sport Exerc. 2013;45:1868–1877. This review generically describes exercise interventions and http://dx.doi.org/10.1016/j.jphys.2014.06.008 only provides broad guidelines on three critical issues: what type DOI of original article: http://dx.doi.org/10.1016/j.jphys.2014.06.009 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 60 (2014) 168 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinimetrics Five-repetition sit-to-stand Description The five-repetition sit-to-stand is commonly used to measure sits back fully in the chair after the fifth repetition with his/her mobility and function in older adults. Sit-to-stand is a mechani- back coming to rest against the back of the chair. cally demanding task performed frequently each day,1 yet many Reliability, validity and responsiveness: The five-repetition sit- older adults have difficulty performing this task, for example, people with neurological impairment.2 The five-repetition sit-to- to-stand is highly reliable (intraclass correlation coefficients stand may be used as an individual measure3 or as part of a standardised battery to assess physical function.4 [ICCs] 0.76–0.99 for test-retest reliability and ICCs 0.97–1.00 for inter-rater reliability) in older adults.3,5,6 This includes those with The five-repetition sit-to-stand requires the individual to stand musculoskeletal and neurological conditions such as osteoarthri- up and sit down five times as fast as possible without using their tis,7 Parkinson’s disease,8,9 stroke10 and spinal cord injury.11 The associated measurement error is also small (0.6–1.4 seconds).7,9 hands to push up from the chair. The time taken to perform the task is measured using a handheld stopwatch;5 increased time Validity of the five-repetition sit-to-stand has been reported reflects poorer performance. A standard armless chair is used, in these populations, although the correlations with gait (r = 0.4–0.7),4,8,11–13 balance (r = 0.3–0.7)3,4,8 and knee extensor usually 43–47 cm in height. The back of the chair should be strength (r = 0.3–0.5)3,8 are variable. Additionally, increased time stabilised against a wall to ensure safety and stability. The taken to perform this task discriminates between individuals with and without neurological impairment.10,12 A clinically relevant individual is instructed to fold his/her arms across his/her chest to change of 2.3 seconds and moderate responsiveness have been avoid using the hands. The test commences upon the assessor reported for people with vestibular disorders.13 instructing the individual to begin and ceases when the individual Commentary Serene S Paula,b and Colleen G Canningb aThe George Institute for Global Health, Sydney Medical School, The five-repetition sit-to-stand is a simple to use, reliable and bFaculty of Health Sciences, The University of Sydney, Australia valid measure of physical function in older people, including those with musculoskeletal or neurological conditions. Poor performance References on this test highlights mobility problems and is associated with subsequent disability.14 While successful performance of the 1. Dall PM, et al. Appl Ergon. 2010;41:58–61. five-repetition sit-to-stand requires lower limb muscle strength,15 2. Brod M, et al. J Gerontol B Psychol Sci Soc Sci. 1998;53:213–222. individuals who complete this task have met the minimum threshold 3. Lord SR, et al. J Gerontol A Biol Sci Med Sci. 2002;57:M539–M543. for strength; this may explain why strength accounts for only a 4. Guralink JM, et al. J Gerontol. 1994;49:M85–M94. small proportion of the variance in this timed measure.3 Completing 5. Tiedemann A, et al. Age Ageing. 2008;37:430–435. the five-repetition sit-to-stand requires considerable skill to 6. Wallmann HW, et al. Home Health Care Manage Pract. 2013;25:13–17. generate sufficient speed of movement16,17 and co-ordinate multiple 7. Lin YC, et al. Scand J Med Sci Sports. 2001;11:280–286. segments with correct timing16,18 in order to maintain balance. 8. Duncan RP, et al. Arch Phys Med Rehabil. 2011;92:1431–1436. Hence, the time taken to complete this task is likely determined by 9. Paul SS, et al. Gait Posture. 2012;36:639–642. factors such as co-ordination and disease-specific impairments.7 10. Mong Y, et al. Arch Phys Med Rehabil. 2010;91:407–413. 11. Poncumhak P, et al. Spinal Cord. 2013;51:214–217. Apart from being a quick and valid measure of mobility, another 12. Whitney SL, et al. Phys Ther. 2005;85:1034–1045. advantage of the five-repetition sit-to-stand is its ability to predict 13. Meretta BM, et al. J Vestib Res. 2006;16:233–243. fall risk.5,19 Cut-off scores of 12 to 16 seconds on the five-repetition 14. Guralink JM, et al. N Engl J Med. 1995;332:556–561. sit-to-stand are associated with an increased risk of falls in the 15. Wretenberg P, et al. Eur J Appl Physiol. 1994;68:413–417. general older population and in people with Parkinson’s disease, 16. Mak MK, et al. Phys Ther. 2011;91:381–391. respectively.5,8 Further research to determine clinically relevant 17. Pojednic RM, et al. Exp Gerontol. 2012;47:608–613. change and responsiveness of the five-repetition sit-to-stand in 18. Mak MKY, et al. Clin Biomech. 2003;18:197–206. different population groups will assist clinicians to determine 19. Paul SS, et al. Neurorehabil Neural Repair. 2014;28:282–290. meaningful change in mobility and fall risk for diverse patient groups. http://dx.doi.org/10.1016/j.jphys.2014.06.002 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Appraisal Journal of Physiotherapy 60 (2014) 170–173 Research Note Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Forest plots Introduction Forest plots of randomised trials A systematic literature review can provide a robust answer to a Continuous measures of treatment outcome clinical question by identifying individual studies that provide evidence relevant to the question and summarising their results. In The forest plot presented in Figure 1 was generated using data the field of physiotherapy, systematic reviews commonly summa- from a systematic review of randomised controlled trials of rise the results of randomised trials that test the effect of an rhythmic cueing to improve walking speed in people with intervention.1 However, systematic reviews can also summarise Parkinson’s disease.10 The first column (on the left) lists the studies studies of the accuracy of diagnostic tests,2 studies of the included in the meta-analysis. Next are three columns of data for the prevalence of a clinical condition,3 studies of prognostic factors,4 experimental group in each study: the mean walking speed (in cm/s), or other study types. If the included studies are sufficiently similar the standard deviation (to indicate how much walking speed varied and the results can be obtained in the same format, a meta-analysis among the participants) and the number of participants. The same may be performed.5,6 Meta-analysis is a statistical method used to three columns of data are then presented for the control group. These summarise numerical data from the individual studies into one data are then used to generate a mean difference in walking speed overall estimate. The results of the individual studies and the (still in cm/s) between the groups for each study. In the first study, for overall estimate from the meta-analysis are usually presented in a example, walking speed improved by a mean of 6 cm/s in the graph called a forest plot. experimental group and 1 cm/s in the control group. The mean difference is therefore 6 minus 1 = 5 cm/s. This is presented What is a forest plot? numerically and also graphically by plotting a blue square over the horizontal line. Blue squares to the right of the vertical line Although forest plots have been used since the 1970s,7 the indicate that the study favoured cueing, whilst those to left favour name ‘forest plot’ was first used in 2001.8 The name refers to the control. Note that a 95% CI is presented in both the numerical forest of lines produced when the results of multiple individual presentation (by two numbers in parentheses) and the graphical studies are plotted against the same axis. The Cochrane display (by a horizontal black line). Confidence intervals have been Collaboration’s official definition9 states: ‘A forest plot is a discussed previously in this journal.11,12 Briefly, each study provides graphical representation of the individual results of each study an estimate of the true effect of cueing on gait speed in people with included in a meta-analysis together with the combined meta- Parkinson’s disease. If any of the studies were repeated, a slightly analysis result. The plot also allows readers to see the heterogene- different result would be expected. Loosely speaking, the confidence ity among the results of the studies.’ The forest plot provides a interval indicates the range within which the true effect of cueing quick visual representation of overall effect estimates and study probably lies. The estimate from each study is plotted, with the heterogeneity and is therefore considered to be a very powerful vertical line presenting the line of no effect. The size of the squares tool in meta-analysis.5,6 denotes the weight given to the study, with larger squares reflecting [(Figure_)TD$IG]1 Cueing Control Study mean SD Total mean SD Total Weight Mean difference Mean difference IV, Random, 95% CI IV, Random, 95% CI Almeida 2012 6 19 28 1 27 14 4.7% 5.00 (−10.80, 20.80) de Bruin 2010 3 22 11 −2 17 11 4.3% 5.00 (−11.43, 21.43) Haase 201 −5 26 17 5 20 6 2.8% −10.00 (−30.22, 10.22) Mak 2008 5 6 19 0 6 14 67.8% 5.00 (0.86, 9.14) Nieuwboer 2007 8 16 76 2 23 77 17.3% 6.00 (−2.20, 14.20) Thaut 1996 16 22 15 −5 27 11 3.1% 21.00 (−2.20, 14.20) Total 166 133 100% 5.24 (1.83, 8.65) Heterogeneity: Tau2 = 0.00; Chi2 = 4.75, df = 5 (p = 0.45); I2 = 0% −50 −25 0 25 50 Test for overall effect: Z = 3.01 (p = 0.003) Favours control Favours cueing Figure 1. Meta-analysis of trials of the effect of cueing versus no cueing on gait speed (cm/s) in people with Parkinson’s disease, using a random-effect model. A negative mean gait speed means a slower overall gait speed, SD = standard deviation, total = number of participants. Test for heterogeneity: chi2 = 4.75, I2 = 0%, p = 0.45. Modified from the systematic review by Tomlinson and colleagues.10 http://dx.doi.org/10.1016/j.jphys.2014.06.021 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Appraisal Research Note 171 more weight. The weight given to each study is automatically Interpreting forest plots calculated based on the precision of the study’s estimate (precise estimates receive more weight). All the individual estimates are then Statistical significance statistically pooled using meta-analysis to produce an overall estimate. This is presented graphically as a black diamond, where When a confidence interval includes the vertical line of no the centre of the diamond is the overall estimate and the width of the effect, the result is statistically non-significant. This is evident diamond is the overall confidence interval. The pooled estimate is graphically when the horizontal black line (for an individual study) also presented numerically. or the black diamond (for the pooled estimate) crosses the vertical line of the forest plot. Therefore, the pooled estimate in Figure 1 is The format of the forest plot presented in Figure 1 would be statistically significant but several of the individual studies are not. suitable for other continuous outcomes, such as activities of daily This illustrates the ability of meta-analyses to harness the living or quality of life, where higher values are better. For statistical power of multiple studies to produce a more precise continuous outcomes where lower values are better (such as pain overall estimate, as shown by the narrower confidence interval of intensity), values to the left of the vertical line would favour the the pooled estimate than the individual studies. experimental group. Also, the studies in Figure 1 all reported gait speed in more or less the same way and reported the results in Analysis of subgroups cm/s, so these units can be retained throughout the analysis. If instead the group of studies had measured an outcome using a Individual studies in a forest plot can be arranged in groups variety of tests (such as different scales for depression), the data according to a characteristic of the patient population, interven- could still be pooled, but each result would be reported as a tion or follow-up. The estimate of the treatment effect in each standardised mean difference (SMD). To calculate the SMD, the subgroup can be compared to the overall effect estimate. Figure 3 data in the original units are divided by the standard deviation. presents a hypothetical subgroup analysis according to the age of This presents the size of the treatment effect independent of participants. Subgroup differences can occur by chance, so a test the scale used. Commonly, effect sizes below 0.3 are considered to for subgroup heterogeneity is presented. Subgroup differences be small, above 0.5 are considered to be moderate, and above 0.8 can occur even when the test for heterogeneity does not indicate are considered to be large. However, these thresholds can be heterogeneity. misleading if they are not interpreted in relation to the standard deviation of the study population. Another way that forest plots can reveal the relationship between the treatment effect and a characteristic of the Dichotomous measures of treatment outcome participants, interventions or assessment is to place the studies on a vertical axis that shows the range of that characteristic. Although forest plots for dichotomous outcomes are similar to A forest plot with an extra vertical axis locating each study by those for continuous outcomes, some differences in format are a characteristic on a continuous scale (eg, the gender ratio of the required. The forest plot presented in Figure 2 is from a systematic participants, the duration of the intervention, or the time of review of trials of surgical techniques in people with chronic neck assessment) is called a modified forest plot.14 pain.13 The outcome assessed in the studies is recovery, so the data columns now present the number of events (ie, people who had Clinical relevance recovered during the follow-up period) and the total number of participants. The contrast between groups is now calculated as a Sometimes, an additional vertical line is added to the forest plot, risk difference (ie, the difference in the chance or ‘risk’ of recovery indicating the threshold for clinical relevance; that is, the effect between the groups) and this is again presented numerically and that is large enough to justify the cost, risks and inconvenience of graphically. Although Figure 2 shows risk difference, other the intervention. A hypothetical example of this is shown by the statistics can be calculated and meta-analysed for dichotomous red dotted line in Figure 3. The location of the confidence interval outcomes. One is relative risk, which is the ratio of the probability in relation to this line and the line of no effect shows how it should of an event in the treated and control groups. Another is the odds be interpreted. The effect in children is statistically non-significant, ratio, which is the ratio of the odds of recovery in the treatment whereas the other subgroups all show a statistically significant group to the odds of recovery in the control group. effect because their confidence intervals are all to the right of the line of no effect. Among the subgroups with a statistically $FIGT)D2_erugi([] Prosthetic disc Fusion Study, Year Events Total Events Total Weight Risk Difference Risk Difference 32.3% M-H, Random, 95% CI M-H, Random, 95% CI Mummameni 2007 44 276 61 265 −0.07 (−0.14, −0.00) Murrey 2009 21 103 23 106 13.7% −0.01 (−0.12, 0.10) Heller 2009 40 242 53 221 27.8% −0.07 (−0.15, −0.00) Cheng 2009 6 31 10 34 4.2% −0.10 (−0.31, 0.11) Jawahar 2010 20 59 9 34 4.9% 0.07 (−0.12, 0.27) Coric 2011 20 136 39 133 17.1% −0.15 (−0.24, −0.05) Total (95% CI) 847 793 100.0% −0.07 (−0.11, −0.03) Total events 151 195 −0.5 −0.25 0 0.25 0.5 Heterogeneity: Tau2 = 0.00; Chi2 = 5.64, df = 5 (p = 0.34); I2 = 11% Favours prosthetic disc Favours fusion Test for overall effect: Z = 3.23 ( p = 0.001) Figure 2. Meta-analysis of trials of the effect of prosthetic disc versus cervical fusion on recovery in people with chronic disabling neck pain, using a random-effects model and the Mantel-Haenszel method. Test for heterogeneity: chi2 = 5.64, I2 = 11%, p = 0.34. Modified from the systematic review by Verhagen and colleagues.13
1]GIFDT)3_erugi([$ 72 Appraisal Mean difference re_4ugiF()TD$IG][ Research Note 95% CI Children Study Prevalence (95% CI) Study A Hanania 0.26 (0.24 to 0.28) Study B Manen 0.22 (0.16 to 0.29) Subtotal Ng 0.23 (0.17 to 0.29) Yohannes 0.46 (0.36 to 0.56) Adolescents Omachi 0.27 (0.25 to 0.30) Study C Engstrom 0.07 (0.03 to 0.16) Study D Aghanwa 0.17 (0.07 to 0.34) Subtotal Schneider 0.21 (0.21 to 0.22) 0.25 (0.21 to 0.29) Adults Pooled Study E Study F 0 0.2 0.4 0.6 0.8 1 Subtotal Prevalence (95% CI) Elderly Figure 4. Forest plot of eight studies of the prevalence of depression among people Study G with chronic obstructive pulmonary disease. Study H Modified from the systematic review by Zhang and colleagues.3 Subtotal has high reproducibility (intra-class correlation = 0.87) and has a significant association with the presence of heterogeneity, as assessed by a statistical test,7 suggesting this is a reasonable approach. Total Forest plots of other study types -2.5 0 2.5 5 7.5 Prevalence studies Favours control Favours treatment Estimates of the prevalence of a clinical condition from Figure 3. Hypothetical meta-analysis of trials, using a random-effects model, with multiple observational studies can also be summarised in a forest plot. The individual and pooled estimates of prevalence subgrouping by age categories. Dotted vertical line represents the threshold for and their confidence intervals are presented in a similar clinical relevance. Test for heterogeneity: I2 = 67%, p = 0.04. way to the forest plots discussed earlier. However, the estimates are plotted over the x-axis, which extends from 0 significant effect, the effect in adolescents is clearly not worth- (no members of the population have the condition) to 1 while because the confidence interval is below the threshold for (all members of the population have the condition). An example, clinical relevance. The effect in adults may or may not be clinically which is summarising studies of the prevalence of depression worthwhile because the confidence interval crosses the threshold. among people with chronic obstructive pulmonary disease,3 is The effect in the elderly is clearly worthwhile. presented in Figure 4. Note that the confidence intervals are symmetrical around prevalence estimates near 0.5, but they Heterogeneity become increasingly asymmetrical as the estimates approach 0 or 1. Heterogeneity refers to variability between studies and can affect the ability to combine the data of the individual studies. Reliability studies There are two types of heterogeneity: clinical heterogeneity and statistical heterogeneity. Clinical heterogeneity refers to the Multiple reliability studies can also be presented on a forest variability caused by differences in clinical variables, such as the patient population, interventions, outcome measures or setting of plot. The example shown in Figure 5 is derived from a systematic the included studies. Clinicians determine clinical heterogeneity, review of reliability studies of the Berg Balance Scale.2 which means that it will always be a rather subjective decision. Readers should also consider these differences and subjectively ]GIF$DT)5_erugi([The example summarises intra-rater reliability, with uniformly decide whether the clinical heterogeneity is small enough for meta-analysis to be appropriate. Statistical heterogeneity is the Study Relative reliability Relative reliability Weight variability in effect estimates between the studies and can be (random (95% CI) (random (95% CI) (%) quantified by various statistics. Forest plots only present the statistical heterogeneity. The simplest statistic is the I2, which Berg 0.97 (0.93 to 0.99) 9 quantifies the heterogeneity from 0 to 100%. There is no clear cut- point beyond which there is too much heterogeneity. Some use a Cattaneo 0.97 (0.91 to 0.98) 6 rule of thumb stating that around 25% is low heterogeneity, around 50% medium and around 75% high heterogeneity.15 Liaw 0.98 (0.97 to 0.99) 83 Although other statistics, such as the Tau2 or chi,2 are sometimes used, the I2 does not suffer from some of the drawbacks of these Pooled (I2 = 0%, p = 0.73) 0.98 (0.97 to 0.99) 100 other tests.15 0 0.5 1 Because forest plots provide a visual representation of study estimates, another approach is to simply view the variation Figure 5. Forest plot of three studies of the intra-rater reliability of the Berg Balance between studies and judge the presence of heterogeneity Scale. (‘eyeball’ analysis). This subjective assessment of heterogeneity Modified from the systematic review by Downs and colleagues.2
A[(Figure_6)TD$IG] ppraisal Research Note 173 Specificity Study TP FP FN TN Sensitivity Specificity Sensitivity 8 7 0.92 (0.86 to 0.97) 0.64 (0.31 to 0.89) Firooznia 1984 97 4 4 5 0.83 (0.63 to 0.95) 0.71 (0.29 to 0.96) 0.71 (0.62 to 0.79) 0.76 (0.67 to 0.84) Forristall 1988 20 2 36 81 0.59 (0.46 to 0.72) 0.87 (0.76 to 0.94) 24 53 0.72 (0.47 to 0.90) 0.45 (0.17 to 0.77) Jackson 1989 I 89 25 0.71 (0.64 to 0.77) 0.82 (0.66 to 0.92) 5 5 0.94 (0.73 to 1.00) 0.64 (0.35 to 0.87) Jackson 1989 II 35 8 57 31 Schaub 1989 13 6 1 9 Schipper 1987 140 7 Thornbury 1993 17 5 0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1 Figure 6. Forest plot of seven studies of the diagnostic accuracy of computer tomography (CT) scan compared to surgery as reference standard in people with low back pain. TP = true positive, FP = false positive, FN = false negative, TN = true negative. Modified from the systematic review by van Rijn and colleagues.16 excellent results across all of the studies. Again the x-axis extends Summary from 0 to 1 and the confidence intervals are asymmetrical. The same review uses exactly the same format for a forest plot of inter-rater Forest plots are frequently used in meta-analysis to present the reliability.2 results graphically. Without specific knowledge of statistics, a visual assessment of heterogeneity appears to be valid and Diagnostic accuracy studies reproducible. Possible causes of heterogeneity can be explored in modified forest plots. Forest plots in meta-analyses appear to be The forest plots of diagnostic accuracy studies differ from a valid and useful tool to quickly and efficiently scan and interpret forest plots of treatment effectiveness because they show a the evidence. The expression ‘a picture is worth a thousand words’ double plot. The sensitivity and specificity estimates are certainly expresses the value of forest plots. presented together in one graph, as shown in Figure 6. In diagnostic test accuracy meta-analyses, the data presented Arianne P Verhagena and Manuela L Ferreirab entail true positive, false positive, false negative and true aDepartment of General Practice, Erasmus Medical Centre University, negative data for each study. Forest plots of diagnostic accuracy can provide the same information of pooled summary estimates Rotterdam, The Netherlands and test heterogeneity. However, this is not recommended and bMusculoskeletal Division, The George Institute for Global Health, therefore the program Review Manager of the Cochrane Collaboration does not provide this information together with Sydney, Australia the forest plots, but shows that in a receiver operating characteristic (ROC) graph. References Other variations 1. Moseley A, et al. J Clin Epidemiol. 2009;62:1021–1030. 2. Downs S, et al. J Physiother. 2013;59:93–99. Forest plots may also report information about the statistical 3. Zhang MWB, et al. Gen Hosp Psychiatry. 2011;33:217–223. method used in the meta-analysis. For example, the meta-analysis 4. Fermont AJ, et al. J Orthop Sports Phys Ther. 2014;33:153–163. in Figure 2 used the Mantel-Haenszel method, but other methods 5. Israel H, Richter RR. J Orthop Sports Phys Ther. 2011;41:496–504. for dichotomous outcomes include the Inverse Variance method 6. Callcut RA, Branson RD. Respir Care. 2009;54:1379–1385. and the Peto method. Another possible variation in meta-analyses 7. Bax L, et al. Am J Epidemiol. 2009;169:249–255. is whether a fixed-effect model or a random-effects model is used. 8. Lewis D, Clarke M. BMJ. 2001;322:1479–1480. Further information about these methods is available in the 9. Cochrane glossary. <www.cochrane.org/glossary> [Accessed May 4 2014]. Cochrane handbook.17 10. Tomlinson CL, et al. Cochrane Database Syst Rev. 2013;9:CD002817. 11. Herbert RD. Aust J Physiother. 2000;46:229. 12. Herbert RD. Aust J Physiother. 2000;46:309. 13. Verhagen AP, et al. Pain. 2013;154:2388–2396. 14. Groenwold RHH, et al. BMC Med Res Methodol. 2010;65:253–261. 15. Higgins JP, et al. BMJ. 2003;327:557–560. 16. van Rijn RM, et al. Eur Spine J. 2012;21:228–239. 17. Cochrane handbook. <www.cochrane.org/handbook> [Accessed May 5 2014].
Journal of Physiotherapy 60 (2014) 166 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Including upper extremity robotic therapy during early inpatient stroke rehabilitation may not lead to better outcomes than conventional treatment Synopsis Summary of: Masiero S, Armani M, Ferlini G, Rosati G, Rossi A. rehabilitation only. Outcome measures: Main outcomes were Randomized trial of a robotic assistive device for the upper Medical Research Council strength scale, Fugl-Meyer Assessment, extremity during early inpatient stroke rehabilitation. Neurorehabil Motor-Functional Independence Measure, Modified Ashworth Neural Repair 2014;28:377–386. Scale, Frenchay Arm test, and Box and Block Test of manual dexterity. Tolerability of treatment (as indicated by the number of Question: Does a robotic assistive device (NeReBot) lead to complications) and the degree of acceptance of robotic training better upper extremity outcomes than standard upper limb (visual analogue scale) were also evaluated. The outcomes were rehabilitation among post-acute stroke inpatients? Design: measured at baseline, at the end of the five-week treatment period, Randomised controlled trial and blinded outcome assessment. at three months, and seven months after the end of treatment. Setting: A rehabilitation unit in Italy. Participants: Key inclusion Results: A total of 30 participants completed the study. No criteria were: adults in the post-acute phase of stroke, Mini-Mental significant between-group difference was found in any of the State Examination score > 18, and inability to move the upper limb outcome measures at the four measurement time points. Conclu- against gravity or weak resistance. Key exclusion criteria were: sion: Incorporating NeReBot therapy into upper limb rehabilitation cardiovascular instability, early appearance of marked spasticity is not more efficacious than conventional upper limb rehabilitation (Ashworth Scale 3), use of functional electrical stimulation or in post-acute stroke inpatients. Botox in the affected upper extremity. Randomisation of 34 participants allocated 16 to the experimental group and 18 to the Marco YC Pang control group. Interventions: All participants received a total of Department of Rehabilitation Sciences, 120 minutes of upper limb therapy per day, 5 days a week for 5 The Hong Kong Polytechnic University, Hong Kong weeks. The experimental group received NeReBot therapy for 35% of the exercise time, and standard upper limb rehabilitation for 65% http://dx.doi.org/10.1016/j.jphys.2014.06.007 of the time. The control group received standard upper limb Commentary randomised controlled trial with the ARMin robotic system used people in the chronic phase post-stroke ( six months after To find more-effective methods of neurorehabilitation to regain stroke).2 Their results showed better motor function recovery with lost motor function is challenging. Effective motor functional the use of the robotic system.2 recovery depends on the intensive physical practice of the affected joints. With the advance in engineering-based technologies, robot- Whether the type of control system accounts for the effective- assisted rehabilitation has been applied in post-stroke training ness (or ineffectiveness) of robot-assisted therapy is a matter of with the advantages of high motion repeatability and training debate. Whilst a number of clinical studies have shown positive intensity. In a Cochrane meta-analysis, the efficacy of robotic- results with robotic training, it would be interesting to compare assisted arm training devices was compared with other therapeu- the effectiveness between different robotic systems in future tic interventions in stroke rehabilitation.1 This systematic review studies. Moreover, the time window for arm training with different of randomised controlled trials concluded that paretic arm robotic systems could be further investigated. function and activities of daily living can be improved, but arm muscle strength did not improve. However, only a few studies have Raymond Kai-yu Tong been conducted in the early post-stroke phase. Division of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong The randomised trial conducted by Masiero and colleagues contributes important clinical data in early stroke rehabilitation References (intervention started an average 8.4 days after stroke) with the NeReBot robotic system. The results did not show any better 1. Mehrholz J, et al. Cochrane Database Syst Rev. 2012;6:CD006876. outcomes in motor function and activity rating scales when 2. Klamroth-Marganska V, et al. Lancet Neurol. 2014;13(2):159–166. compared with conventional rehabilitation. However, other types of robotic systems have applied their own control methods and http://dx.doi.org/10.1016/j.jphys.2014.06.005 involved different arm movements. It is possible that these factors may contribute to the effectiveness of the training. Another DOI of original article: http://dx.doi.org/10.1016/j.jphys.2014.06.007 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 60 (2014) 163 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Light intensity physical activity is associated with lower disability in adults with or at risk of knee osteoarthritis Synopsis Summary of: Dunlop DD, Song J, Semanik PA, Sharma L, Bathon Physical activity was monitored with 7 days of accelerometry and JM, Eaton CB, et al. Relation of physical activity time to incident analysed as time spent doing light (100 to 2020 counts/minute) or disability in community dwelling adults with or at risk of knee moderate to vigorous (> 2020 counts/minute) activity. The osteoarthritis: prospective cohort study. BMJ 2014;348:g2472. potential covariates measured were: race, age, gender, education, income, comorbidities, knee-specific health factors and health Question: In adults with or at risk of knee osteoarthritis, is the behaviours. Results: Among the 1680 participants, 149 reported amount of time spent in light intensity physical activity related to the onset of disability during follow-up. When categorised as the onset or progression of disability? Design: Multi-centre, quartiles, increasing time doing light activity was significantly prospective cohort study with 2 years of follow-up. Setting: Four associated with lower risk of disability onset (Hazard Ratios 1.00, treatment centres in Northeastern USA. Participants: Community- 0.62, 0.47 and 0.58, p for trend = 0.007) and lower risk of disability dwelling adults aged 49 years or older with knee osteoarthritis (ie, progression (Hazard Ratios 1.00, 0.59, 0.50 and 0.53, p for at least one osteophyte with pain, aching or stiffness) or with risk trend = 0.003), with control for the covariates. Additional time factors for developing knee osteoarthritis (ie, recent knee spent doing higher intensity activity did not influence these symptoms, overweight, knee injury or surgery, family history, associations. Conclusion: Daily time spent doing light intensity Heberden’s nodes, repetitive knee bending, or aged 70 to 79 years). physical activity is associated with lower risk of onset and Outcomes: The primary outcome was the onset of disability, which progression of disability in adults with or at risk of knee was defined as difficulty completing instrumental activities (eg, osteoarthritis. cooking, shopping) or basic activities (eg, walking, dressing, bathing) independently, as reported on a questionnaire. The Mark Elkins secondary outcome was disability progression, based on a change Journal of Physiotherapy to a more severe level of disability over 2 years. Levels were none, mild (limitation in instrumental activities only), moderate http://dx.doi.org/10.1016/j.jphys.2014.06.019 (limitation in one or two basic activities) or severe (limitation in three or more basic activities). Potential predictor and covariates: ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved. Commentary physical activity will lead to reduced osteoarthritis-related disability. Second, even if further research does confirm the Lack of physical activity is a major health issue for people with benefits of prescribing light physical activity in reducing disability osteoarthritis of the knee, with only about one in ten people who in this population, it remains to be demonstrated whether light are affected meeting the current physical activity guidelines of physical activity provides a sufficient stimulus to lead to important 150 minutes of at least moderate intensity physical activity in at health benefits associated with physical activity, such as reduced least 10 minute bouts each week.1 Even after total knee risk of cardiovascular disease.3 This could be important because arthroplasty, only about one in two people report exercise levels cardiovascular disease is such a problem for older adults with consistent with the physical activity guidelines.2 People with osteoarthritis of the knee.4 mobility restrictions due to their pain, comorbidities and disabilities associated with knee osteoarthritis may find it very Jason Wallis difficult to achieve these recommended levels at moderate Department of Physiotherapy, Eastern Health, Melbourne, Australia intensity. References The key finding from this study was that for people with or at risk of developing osteoarthritis, completing 255 minutes of light 1. Wallis JA, et al. Osteoarthr Cartil. 2013;21:1648–1659. physical activity per day was associated with a 43% lower risk of 2. Groen J-W, et al. J Physiother. 2012;58:113–116. developing disability than people who averaged 192 minutes. 3. Nelson ME, et al. Circulation. 2007;116:1094–1105. These results are potentially significant, as people with osteoar- 4. Neusch E, et al. BMJ. 2011;342:d1165. thritis of the knee might more easily achieve completion of light physical activity than moderate or vigorous intensity exercise. http://dx.doi.org/10.1016/j.jphys.2014.06.018 However, before the results change practice, a number of factors have to be considered. First, the presence of an association does not imply causation, so it is not certain that prescribing light intensity DOI of original article: http://dx.doi.org/10.1016/j.jphys.2014.06.019 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association.
Journal of Physiotherapy 60 (2014) 164 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Pelvic floor muscle training can reduce prolapse symptoms in women with pelvic organ prolapse Synopsis Summary of: Hagen A, Stark D, Glazener C, Dickson S, Barry S, Outcome measures: The primary outcome was prolapse symptoms Elders A, et al. Individualised pelvic floor muscle training in women at 12 months. Prolapse symptoms were measured by the pelvic with pelvic organ prolapse (POPPY): a multicentre randomised organ prolapse symptom score (POP-SS), with scores ranging from 0 controlled trial. Lancet 2014;383:796-806. (no symptoms) to 28. Secondary outcome measures included: perceived change in prolapse, number of days with prolapse Question: Does individualised pelvic floor muscle training symptoms in the last 4 weeks, and prolapse type and stage. Results: improve self-report of prolapse symptoms in women with 295 (66%) of participants completed the study at 12 months, and 377 symptomatic pelvic organ prolapse? Design: Randomised, con- (84%) completed assessments at 6 months. At 12 months, prolapse trolled trial with concealed allocation and blinded outcome symptoms were significantly less in the intervention group, by 1.5 assessment. Setting: A total of 25 outpatient gynaecology clinics units (95% CI 0.5 to 2.6 units). Participants in the intervention group in the United Kingdom, New Zealand and Australia. Participants: were also more likely than the control group to perceive that their The key inclusion criterion was symptomatic prolapse (stages I – prolapse had improved and reported fewer days with symptoms in III) as the main presenting complaint. Key exclusion criteria the last 4 weeks. There was no difference between the groups in included: previous treatment for prolapse, including surgery, change in their prolapse stage. Conclusion: Individualised pelvic pregnancy, or being less than 6 months postnatal. Randomisation floor muscle training supervised by physiotherapists was effective in of 447 patients allocated 225 to the intervention group and 222 to reducing symptoms in women with pelvic organ prolapse. the control group. Interventions: Patients allocated to the intervention group were invited to receive five one-on-one Nicholas Taylor appointments for pelvic floor muscle training with a women’s Associate Editor, Journal of Physiotherapy health physiotherapist over 16 weeks. Intervention included the prescription of an individualised home exercise program. The http://dx.doi.org/10.1016/j.jphys.2014.06.013 control group received a prolapse lifestyle advice leaflet that did not include any advice about pelvic floor muscle training. ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved. Commentary Pelvic organ prolapse is a common condition found in 40% of Additionally, there appears to be little correlation between women over the age of 50 years.1 Until now, there has been limited prolapse symptoms and stage of prolapse. This assists in evidence to support the use of pelvic floor muscle training (PFMT) transferability to clinical practice, as physiotherapists can admin- as a treatment for women with prolapse.2 This is an important ister the POP-SS but would not commonly assess stage of prolapse study for women and women’s health physiotherapists alike, as it using the prolapse classification (POP-Q) system. provides the strongest evidence to date that an individualised PFMT program can improve prolapse symptoms. Future studies are needed to investigate the use of PFMT for women following failed surgical intervention, or early post As this rigorously designed study is the largest, multicentre trial childbirth, and for PFMT as an adjunct to surgery or pessary of PFMT for prolapse, with the longest follow-up, it is very applicable treatment. to clinical practice. In contrast to some previous work in this area,3 the pragmatic features of this study ensure its feasibility within Sally Sheppard clinical practice. With only five physiotherapy sessions across 16 Department of Physiotherapy, La Trobe University, weeks (initial 60 minutes, review 40 minutes), no equipment such as biofeedback or electrical stimulation, and an easily administered Melbourne, Australia primary outcome measure, the POP-SS, this is very translatable to current physiotherapy practice in women’s health. References The primary outcome measure in this study related to 1. Hendrix SL, et al. Am J Obstet Gynecol. 2002;186:1160–1166. symptoms rather than the impairment of body structure: prolapse 2. Hagen S, et al. Cochrane Database of Syst Rev. 2011;12:CD003882.pub4. stage. The authors justify this patient-centred approach, as 3. Braekken IH, et al. Am J Obstet Gynecol. 2010;203:170.e1–7. symptom reduction is the most important outcome for women, and symptoms are what typically prompt them to seek treatment. http://dx.doi.org/10.1016/j.jphys.2014.06.004 DOI of original article: http://dx.doi.org/10.1016/j.jphys.2014.06.013 1836-9553/Crown Copyright ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. All rights reserved.
Journal of Physiotherapy 60 (2014) 157–162 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research Physiotherapists demonstrate weight stigma: a cross-sectional survey of Australian physiotherapists Jenny Setchell a, Bernadette Watson a, Liz Jones b, Michael Gard c, Kathy Briffa d a School of Psychology, The University of Queensland, Australia; b School of Applied Psychology, Griffith University, Australia; c School of Education, Southern Cross University and School of Human Movement Studies, The University of Queensland, Australia; d School of Physiotherapy and Exercise Science, Curtin University, Australia KEYWORDS ABSTRACT Body weight Question: Do physiotherapists demonstrate explicit and implicit weight stigma? Design: Cross- Ethics sectional survey with partial blinding of participants. Participants responded to the Anti-Fat Attitudes Obesity questionnaire and physiotherapy case studies with body mass index (BMI) manipulated (normal or Physical therapists overweight/obese). The Anti-Fat Attitudes questionnaire included 13 items scored on a Likert-type scale Social stigma from 0 to 8. Any score greater than zero indicated explicit weight stigma. Implicit weight stigma was Stereotyping determined by comparing responses to case studies with people of different BMI categories (where responses were quantitative) and by thematic and count analysis for free-text responses. Participants: Australian physiotherapists (n = 265) recruited via industry networks. Results: The mean item score for the Anti-Fat Attitudes questionnaire was 3.2 (SD 1.1), which indicated explicit weight stigma. The Dislike (2.1, SD 1.2) subscale had a lower mean item score than the Fear (3.9, SD 1.8) and Willpower (4.9, SD 1.5) subscales. There was minimal indication from the case studies that people who are overweight receive different treatment from physiotherapists in clinical parameters such as length of treatment time (p = 0.73) or amount of hands-on treatment (p = 0.88). However, there were indications of implicit weight stigma in the way participants discussed weight in free-text responses about patient management. Conclusion: Physiotherapists demonstrate weight stigma. This finding is likely to affect the way they communicate with patients about their weight, which may negatively impact their patients. It is recommended that physiotherapists reflect on their own attitudes towards people who are overweight and whether weight stigma influences treatment focus. [Setchell J, Watson B, Jones L, Gard M, Briffa K (2014) Physiotherapists demonstrate weight stigma: a cross-sectional survey of Australian physiotherapists. Journal of Physiotherapy 60: 157–162] ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Introduction energy-in versus energy-out (diet and exercise) approach to Weight stigma has been defined as negative attitudes towards weight management. Cochrane reviews have also shown that people who are overweight or obese, and frequently involves exercise5 and diet6 have, at best, only small effects on weight. stereotyping people as lazy, sloppy, less intelligent and unattrac- tive.1 Weight stigma has considerable negative health effects2 and Multiple factors other than diet and exercise may determine is common in healthcare.1 In a recent study, 81% of physiothera- adiposity.7,8 The relationship of body weight to health is also not as pists believed that weight management is part of their scope of practice and 85% reported that they used weight management clear as often thought, as shown in a large systematic review strategies with their patients.3 Considering the prevalence of weight stigma in healthcare, and the focus by physiotherapists on (n = 2.88 million) demonstrating that people of ‘normal’ weight (by weight management, physiotherapists require an understanding of their own attitudes towards people who are overweight and, if body mass index, BMI) have the same mortality rate as people who they are negative, to ensure that they do not harm their patients with these attitudes. Therefore, the aim of this study was to are ‘moderately obese’ and a higher mortality rate than people identify whether physiotherapists demonstrate weight stigma and classified as ‘overweight’.9 The commonly held beliefs that weight the potential effects of this on patient treatment. For the purposes of this article behaviour that is stigmatising or biased is termed is primarily under individual control through diet and exercise, and ‘discriminatory behaviour’ or ‘discrimination’. that high BMI necessarily means ill-health, are considered by some The causes, and health outcomes, of being overweight or obese are complex and less well understood than commonly thought. authors to be a consequence of weight stigma and perhaps a factor Gard and Wright4 demonstrated the limitations of a simplistic that perpetuates it.10 Weight stigma is prevalent, with levels similar to those of racism and sexism.11 Moreover, it is increasingly prevalent, with levels of perceived discrimination having almost doubled in the past decade or so.11 Discrimination has been demonstrated in areas such as employment, education and health,1 is more common in women,12 and increases with the level of obesity.13 Both explicit (overt) and implicit (more subtle) weight stigma has been shown to predict discriminating behaviours.14,15 Puhl and http://dx.doi.org/10.1016/j.jphys.2014.06.020 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
158 Setchell et al: Weight stigma in physiotherapy King16 summarised the potential harmful effects of weight stigma implicit (more hidden/subtle) stigma. To ensure blinding, infor- to include: depression, anxiety, low self esteem, suicidal ideation, mation given to participants before the study mentioned only body dissatisfaction and maladaptive eating behaviours. attitudes generally, not weight. The case studies were presented before the Anti-Fat Attitudes questionnaire with no option to Weight stigma has sometimes been thought to be helpful in review retrospectively. Furthermore, the case studies presented a motivating weight loss behaviours.17 This perspective has been number of patient characteristics including weight, so that the shown to be unfounded,18 as weight stigma negatively influences participants were unaware of the variable of interest. Blinding was motivation to exercise,19 reduces the healthcare seeking beha- confirmed in the pilot study. viours of people who are obese,20 and is positively correlated with increased disordered eating.21 Explicit weight stigma was measured by the total score of the Anti-Fat Attitudes questionnaire, as well as the score on each of the Much of the study of weight stigma has focused on health three subscales: Dislike, Fear and Willpower. The Anti-Fat professionals, with the topic receiving considerable media and Attitudes questionnaire was chosen for its psychometric rigor,30 research attention over the past 10 years.1 People who are its use in other studies investigating health professionals,31–33 and overweight state that they are treated differently by health care the suitability of the questions. The Dislike subscale measures providers.22 A study of 2284 doctors showed both explicit and aversion towards overweight people, the Fear subscale measures implicit weight stigma,23 and other health professions perform fear of one’s own body weight increasing, and the Willpower similarly when tested on weight stigma, including: nurses,24 subscale measures the level of personal control ascribed to body exercise scientists,25 and dieticians.26 Despite the size and impact weight. Cronbach’s alphas were: Dislike (0.81), Fear (0.78) and of the physiotherapy profession,27 there has been little investiga- Willpower (0.73). The Anti-Fat Attitudes questionnaire has 13 tion of physiotherapists’ attitudes towards weight. Sack and questions scored on a Likert-type scale from 0 to 8, with any score colleagues28 reported that physiotherapists had neutral attitudes greater than zero indicating weight stigma. Wording was adapted to people who are obese, despite finding that over 50% of the slightly without altering meaning to make the questions suitable physiotherapists who were studied believing that people who are for professional Australian participants. For example, ‘If I were an obese are weak-willed, non-compliant and unattractive. These employer looking to hire, I might avoid hiring a fat person’ was results suggest that physiotherapists do possess negative stereo- changed to ‘If I were an employer, I might avoid hiring an types of overweight people and may exhibit weight stigma. To the overweight person’. All Anti-Fat Attitudes questionnaire items are authors’ knowledge no study more specific to weight stigma in presented in Appendix 1 (see the eAddenda). physiotherapists has been conducted. This research addressed this gap in the literature. The research questions were: Implicit weight stigma was measured using participants’ responses to three case studies, which are presented in Appendix 1. Do physiotherapists demonstrate explicit weight stigma? 1 (see the eAddenda). Comparisons were made between cases, 2. Do physiotherapists demonstrate implicit weight stigma? which were identical apart from BMI category (normal or overweight/obese), and free-text responses were analysed the- Method matically. Case studies were chosen because they have clinical relevance and can investigate implicit attitudes. Other measures Design such as implicit attitudes tests are available, but their ability to predict behaviours is contested.34 The case studies were designed This cross-sectional study used an online survey formatted in to be typical presentations of various physiotherapy patients from Qualtrics software. A pilot study was completed by a convenience a number of clinical areas, so that most physiotherapists would feel sample of 13 physiotherapists (age range 23 to 55 years; from qualified to comment on them and no one clinical discipline was musculoskeletal, paediatric, women’s health and neurology given preference. The clinical cases were designed by a physio- specialty areas) to confirm blinding, assess for errors and to gauge therapist with 18 years of clinical experience (the primary author). physiotherapists’ thoughts about undertaking the survey. Minor Feedback from the pilot study confirmed similarity of the cases to changes were made in response. Participants consented to real physiotherapy patients. Questions were designed to detect completing the survey after reading an information sheet. The differences in treatment of people of different BMI categories with survey is presented in Appendix 1 (see eAddenda). The survey dependent variables such as (hypothetical) length of initial consisted of demographic questions, the pre-existing Anti-Fat treatment and amount of hands-on treatment time. These clinical Attitudes questionnaire developed by Crandall,29 and three parameters were based on dimensions outlined by Stone and custom-built case studies (see Figure 1). Completion of all sections Werner,26 who identified that treatment of people who are of the survey was not compulsory. Blinding of respondents to the overweight varied from those of normal weight in three areas: fact that BMI was the main variable of interest was necessary for instrumental avoidance (eg, shorter sessions), professional avoid- ance (eg, less energy/effort) or interpersonal avoidance (eg, tg1[)uT(DF_]GIri$e he case study section of the survey because it aimed to measure negative tone, evasive verbal and body language). Informed Demographics Random Case study 1: Random Anti-Fat Exit consent allocation aged care allocation Attitudes survey to into 2 of into 1 of 4 questionnaire provide obtained the case Case study 2: variations of contact musculoskeletal each study details if prior to studies (normal or desired for Case study 3: overweight prize draw entering neurology BMI, male or female) survey Figure 1. Survey flow and system of random allocation (by survey software) into case study presentations.
Research 159 Participants, therapists, centres Table 1 Qualified Australian physiotherapists were recruited via the Participant demographics. Mean (SD) or number (percentage) and comparisons Australian Physiotherapy Association eBulletins and twitter with national data36,37 for each characteristic. posts, and through the primary author’s professional networks. A number of measures were employed to ensure a good response Characteristic Participants National data rate: snowballing was encouraged, an incentive prize was offered for participation and the survey was kept as brief as possible. The Agea (yr), mean (SD) 42 (11) 39 (N/A) exclusion criteria were: not being a qualified physiotherapist, not Time in practicea (yr), mean (SD) 18 (11) 13 (N/A) identifying as Australian and prior knowledge of the research Genderb (female), n (%) 194 (73) 16 474 (70) topic. Specialtya, n (%) 19 (7) 1227 (7) Data analysis neurology 16 (6) 1170 (7) cardiorespiratory 8 (3) 603 (3) A priori calculations estimated that 180 participants were sports 123 (46) 9 534 (53) required for sufficient power for the case study comparisons. musculoskeletal 31 (12) 1004 (6) Power was set at 95%. Descriptive statistics were calculated for the paediatrics 10 (3) 433 (2) Anti-Fat Attitudes questionnaire and its subscales. For the case women’s health 56 (20) 3 429 (19) studies, after assessing assumptions of normality, comparisons other 2 (1) 580 (3) were made using independent sample t-tests to determine the missing/inadequately described 256 (100) 17 980 (100) effect of the independent variable (normal or overweight/obese Total BMI) on parametric dependent variables. Mann-Whitney and chi- Main employment locationa, n (%) 190 (72) 16 129 (80) squared tests were used for comparisons where data were not urban 73 (27) 3 952 (20) normally distributed. Demographic data were used to control for rural confounding factors such as years of experience or area of clinical missing 2 (1) N/A expertise. Analysis of the free-text responses used a theoretical Total 256 (100) 20 081 (100) thematic and count approach.35 After all of the data were analysed Main employment sectora, n (%) using manual coding, responses that had comments relevant to the private practice 96 (36) 7825 (39) research topic were selected as a subset (these were all responses hospital 98 (37) 5788 (28) to case studies of patients who were overweight). Three of the community 20 (8) 2893 (14) authors, including two psychologists (BW, LJ) and one physiother- education facility 30 (11) apist (JS), identified common themes relevant to the research topic other 20 (8) 610 (3) in this subset. These themes were subsequently explored in the not working as physiotherapist 2393 (12) context of current literature on weight stigma. not stated/inadequately stated 1 (0) Total 0 (0) 0 (0) Results 256 (100) 572 (3) 20 081 (100) Flow of participants through the study a National data from Health Workforce Australia37 in 2014. A random sample was not taken for this study, but the b National data from Physiotherapy Board of Australia36 in 2013. demographic data presented in Table 1 show that the participants represented a broad range of physiotherapists similar to national N/A = not available. statistics.36,37 The sample was similar to national statistics in age, gender and area of specialty distribution, but had slightly more Do physiotherapists demonstrate implicit weight stigma? rural participants, more years of experience and some differences in employment sector distribution. A total of 324 surveys were There was minimal indication in the clinical parameters tested commenced and 265 remained after removing responses with in the case studies, such as the total treatment time or the hands- insufficient demographic information (n = 1), countries other than on treatment time, that patients in different BMI categories would Australia (n = 13) or without any responses to at least one case be treated differently. These data are presented in Tables 2, 3 and 4. study (n = 45). A total of 520 case studies were completed. The only differences that reached significance were three (6%) of Although responding to all questions was not mandatory, there the answers to questions about types of treatment likely to be were less than 3% incomplete responses to quantitative questions given. This indicates a minimal difference in (hypothetical) (including the Anti-Fat Attitudes questionnaire) and 31% for free- treatment of patients due to the BMI. Of note, however, for case text responses, which was sufficient for all power calculations. study 2, general health advice was prescribed in 46% of the obese patients, which was significantly greater than 24% in the normal Do physiotherapists demonstrate explicit weight stigma? weight case study presentation (p < 0.01). This could indicate implicit weight stigma, in that physiotherapists may assume Anti-Fat Attitudes questionnaire results, presented in Figure 2, patients who are obese are less well informed about general health indicated negative attitudes by the participants towards people who are overweight, with a mean item score of 3.2 (SD 1.1), where Table 2 results greater than zero indicate weight stigma.29 These results Mean (SD) for continuous outcomes compared between normal BMI and are considerably higher than other Australian and international overweight BMI case studies. Anti-Fat Attitudes questionnaire findings from 2001,38 and similar to Australians tested in 2007.32 The Willpower subscale had a Outcome BMI Significance mean item score of 4.9 (SD 1.5) and the Fear subscale a mean item Normal Overweight p-value (df)a score of 3.9 (SD 1.8), which were relatively higher mean scores than the Dislike subscale of 2.1 (SD 1.2). This finding of overtly Initial treatment time (min) 46 (15) 45 (16) 0.66 (515) negative attitudes towards people who are overweight or obese Hands-on treatment time (min) 19 (10) 19 (11) 0.84 (508) indicates that physiotherapists demonstrate explicit weight Total treatment time (min) 252 (175) 244 (178) 0.62 (505) stigma. Exercises given (n) 3.7 (1.6) 3.8 (1.4) 0.29 (514) a from independent sample t-tests with p < 0.05 as significant. Table 3 Mode for categorical study outcomes compared between normal BMI and overweight BMI case studies. Outcome BMI Significance Normal Overweight p-valuea Similarity to patient not similar not similar 0.05* Enjoyment treating enjoyable enjoyable 0.98 Professional satisfaction enjoyable enjoyable 0.45 a from Mann-Whitney tests with p < 0.05 as significant. * significant at p < 0.05, indicating a difference in perception of similarity.
[(Figure_2)TD]GI$160 Setchell et al: Weight stigma in physiotherapy a) b) 100 90Number of responses (count) Number of responses (count) 100 80 90 70 80 60 70 50 60 40 50 30 40 20 30 10 20 0 10 012345678 0 Total: any score > 0 = explicit weight 012345678 stigma Dislike: any score > 0 = dislike c) d) Number of responses (count) 100 Number of responses (count) 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 012345678 012345678 Fear: any score > 0 = fear Willpower: higher scores = greater percieved controllability Figure 2. Anti-Fat Attitudes questionnaire29 results shown as mean item scores for the a) total questionnaire (13 items) and its subscales; b) Dislike (7 items); c) Fear (3 items); and d) Willpower (3 items). All items were scored on a Likert-type scale from 0 to 8 with 0 indicating no anti-fat attitudes. than their normal weight counterparts. There was no indication of 118 responses, five themes were identified that indicated implicit implicit weight stigma in findings from participants’ responses to weight stigma: negative language when speaking about weight in questions (for wording see Appendix 1) about their level of overweight patients (n = 41, 35%); focus on weight management to professional satisfaction (p = 0.45) or enjoyment (p = 0.98) when the detriment of other important considerations (n = 12, 10%); treating patients in the case studies, with no difference found weight assumed to be individually controllable (n = 69, 58%); between normal and overweight patients. However, when directive or prescriptive responses rather than collaborative participants were asked to rate how similar they felt to case (n = 96, 81%); and complexity of weight management not study patients, participants felt more similar (p = 0.05) to patients recognised (n = 98, 83%). The first theme was illustrated by who are overweight (mode ‘not similar’) in comparison to normal negative terms used about body weight: a patient who was weight (mode ‘not similar’). Feeling similar to someone has been overweight had a ‘weight issue/weight problem’ that ‘needed to correlated with liking them,39 so this finding on its own would not be/must be/should be’ ‘managed/addressed’. The second theme indicate negative attitudes, although this may fit with the ‘jolly fat’ was most evident in the case study of the patient in an aged care stereotype,40 so may indicate weight stigma. setting. Weight management was often mentioned for this patient with a reduced focus (in comparison to the normal weight Analysis of the two questions requiring free-text responses presentation) on other important factors such as social support. identified that conversations about weight are likely to occur. One The third theme (assumed controllability of weight) was evident in hundred and eighteen (59%) of free-text responses to case studies that diet and/or exercise were almost the only weight management for patients who were overweight mentioned weight management strategies mentioned. The fourth theme of directive communica- as part of their treatment or referral strategies. From this subset of tion was demonstrated in the choice of language such as ‘speak to them about weight management’ or ‘he should lose weight’. Table 4 Finally, the fifth theme identified a lack of recognition of the P-values from chi-squared tests comparing normal and overweight BMI categories complexity of weight management. Specifically, only three (3%) by treatment modality in case studies. responses questioned BMI as a measurement of adiposity or health, three (3%) mentioned weight management strategies other than Treatment modality Case study diet or exercise (referral to GP, referral to naturopath, mood), and six (5%) responses considered the psychological sensitivity of 12 3 weight. Joint mobilisations 0.24 0.57 0.31 Discussion Soft tissue massage 0.29 0.23 0.03a Neuromuscular facilitation 0.21 0.29 0.31 This paper explored whether physiotherapists demonstrate Passive stretching 0.09 0.57 0.36 weight stigma and whether this might negatively influence patient Acupuncture 0.21 0.39 0.31 treatment. The total Anti-Fat Attitudes questionnaire scores Electrotherapies 0.57 0.40 0.03a indicated that physiotherapists, in line with studies on many Heat 0.51 0.52 0.11 other health professionals,1 demonstrate explicit weight stigma. Aerobic exercise 0.12 0.14 0.09 Strength exercises 0.27 0.50 0.61 Stretching exercises 0.40 0.32 0.41 General health advice 0.39 0.00a 0.10 Balance 0.57 1.00 0.22 a significant at p < 0.05, indicating a difference in treatment modality chosen.
Research 161 The scores on the subscales provided more insight into the nature relatively large sample size. Although the Anti-Fat Attitudes of this stigma and its likely implications for behaviour towards questionnaire and case studies are both commonly used and patients who are overweight. The Dislike subscale had a relatively standard methods of looking at attitudes, they are inexact low score, however responses were notably high in answer to the measures of attitudes and have limits in application to actual question ‘If I were an employer, I might avoid hiring an overweight discriminatory behaviours. The case study format may have lacked person’, suggesting that physiotherapists’ negative attitudes may sensitivity in examining the more subtle forms of discrimination result in discriminatory behaviours. In contrast, the quantitative that are likely to be the clinical manifestations of weight stigma.26 responses to the case studies showed little evidence of discrimi- The uniformity of the responses suggests that physiotherapists natory behaviours. In fact, responses to one question (feeling may have very set answers to these types of questions, which may similar to a patient) indicated a greater liking of patients who were not reflect actual clinical behaviour. Future studies could test the overweight. A similar effect is noticeable elsewhere in phy- variables in a more direct way (such as conducting focus groups or siotherapists’ attitudes.28 This apparent contradiction is possibly direct observation of clinical encounters). explained by the ‘jolly fat stereotype’,40 which fits with the stereotype content model.41 Participants also scored relatively This research begins a critical conversation about physiothera- highly on the Fear subscale, which measures negative attitudes pists and weight stigma. The findings show that Australian towards one’s own body weight. Importantly, these attitudes have physiotherapists demonstrate weight stigma, especially in the previously been correlated with discriminatory behaviour42 and explicit form, and that this has the potential to negatively affect thus have become a recent focus of intervention studies.43 physiotherapy treatment in patients who are overweight or obese. Participants scored most highly on the Willpower subscale, This conversation is not new to health as it has been the focus of indicating that physiotherapists are likely to blame people for considerable popular and academic discourse in the past decade or their body size.29 This is a common component of weight stigma so. When examining the physiotherapy profession reflexively there and, as a result, a number of intervention studies have attempted are intrinsic elements that may mean that physiotherapists are not to address this issue.44,45 Whilst these intervention studies currently well equipped to consider the psychological aspects of generally showed that these beliefs are modifiable, weight being involved in discussions about body weight. Firstly, phy- stigmatising attitudes overall are not reduced.45 For this reason siotherapists tend to use a ‘treater’ or educator approach rather than intervention studies are now beginning to focus elsewhere.46 a collaborative or empowering approach.48 In relation to body weight this means that physiotherapists may give advice to the The free-text responses to the case studies provided insight into patient that is not relevant or may inadvertently cause offence physiotherapists’ attitudes towards weight in a clinical context, because the patient already knows. Furthermore, physiotherapy has giving further indication of whether physiotherapists were likely to been criticised from within the profession for lacking self- demonstrate discriminatory behaviours. The questions did not reflection.49,50 With regards to weight, this means that physiothera- directly address weight, and thus the participants were likely to have pists may not detect whether their attitudes affect their patients. discussed weight relatively uninfluenced by the researchers’ expectations. A total of 113 participants (96% of the subset with Clinically, it is suggested that physiotherapists consider references to weight) demonstrated some element of the five implementing the following evidence-based strategies to mini- identified weight stigma themes. These forms of weight stigma align mise the negative effects of weight stigma on their patients. There with stigmatising experiences reported by overweight patients.24,47 may be value in physiotherapists reflecting on their own attitudes towards patients who are overweight.49 Stereotyping of patients Generally, most participants’ responses were prescriptive or who are overweight or obese should be avoided, including making directive and it was rarely acknowledged that a two-way assumptions about patients’ healthcare practices and knowl- conversation with patients was needed. Broader discussions that edge.51 Fostering a collaborative environment that moves beyond considered the complexity and/or sensitivity of the subject of patient education may reduce the effects of stigma on patients.52 weight were evident in only rare responses that considered Support or advice could be sought if physiotherapists have patients’ prior knowledge, for example: ‘her weight issues . . . the difficulty understanding how their attitudes may affect patients. patient could already be addressing those issues’. Although explicitly negative responses were unusual, they provide insight What is already known on this topic: Healthcare clinicians into some of the attitudes that may underlie the more subtle often ascribe overweight or obese people with negative char- stigma expressed more commonly. These explicit responses acteristics, such as laziness or low intelligence. Such weight included stereotyping of laziness, for example: ‘less likely to be stigma has considerable negative health effects. The preva- compliant due to BMI’ and assumptions of necessary ill health, for lence of weight stigma among physiotherapists has not been example: ‘she is way too heavy . . . on a one-way train to a poor extensively investigated. quality of life and a short one at that’. What this study adds: Many physiotherapists demonstrate weight stigma, both explicitly but also implicitly in their Overall, the analysis of the free-text responses shows that treatment choices. Physiotherapists could reflect on their physiotherapists have a number of ways of responding to a patient own attitudes towards people who are overweight. who is overweight or obese. Nevertheless, the most common responses were simplistic, implicitly negative and prescriptive Note: Readers who are interested in assessing their own advice. It was rare for responses to indicate a more complex attitudes towards people who are overweight can complete consideration of weight or explicitly negative/stereotyping atti- the Anti-Fat Attitudes questionnaire online and receive a calcu- tudes. These findings align with literature about other health lated score at the following web address: http://weightstigma. professionals.1 Further study is needed to clarify the nature of info/ these attitudes and how they play out in clinical settings. eAddenda: Appendix 1 can be found online at doi:10.1016/ There were a number of limitations to this study. Bias may have j.jphys.2014.06.020 been introduced due to recruitment through professional contacts. However, this is likely to have had a minimal effect due to the small Ethics approval: The University of Queensland (UQ) and Curtin number of people recruited in this way (n = 10, if all participated University (Curtin) Ethics Committees approved this study. All this represents 3.8%) and to the primary author ensuring that these participants gave informed consent before data collection began. contacts had no prior knowledge of the nature of the research topic. Whilst responses could have been made mandatory to Competing interests: None declared. progress through the survey, this may have reduced the sample Source(s) of support: None declared. size by discouraging some participants from completion. The incomplete surveys were unlikely to have had a strong effect, as most participants completed all questions and there was a
162 Setchell et al: Weight stigma in physiotherapy Acknowledgements: Thank you to the physiotherapists who 25. Chambliss H, Finley C, Blair S. Attitudes toward obese individuals among exercise science students. Med Sci Sport Exer. 2004;36(3):468–474. http://dx.doi.org/ participated in the study and its pilot, and for the advice and 10.1249/01.mss.0000117115.94062.e4. support of a number of others. This study was conducted by the 26. Stone O, Werner P. Israeli dietitians’ professional stigma attached to obese patients. Qual Health Res. 2012;22(6):768–776. http://dx.doi.org/10.1177/ primary author as part of the requirements for a MClinPty (Curtin) 1049732311431942. and contributes to her PhD (Psychology, UQ). Thank you to C 27. Higgs J, Refshauge K, Ellis E. Portrait of the physiotherapy profession. J Interprof Care. 2001;15(1):79–89. http://dx.doi.org/10.1080/13561820020022891. Crandall for approving the Anti-Fat Attitudes questionnaire to be 28. Sack S, Radler D, Mairella K, Touger-Decker R, Khan H. Physical therapists’ included as an appendix. attitudes, knowledge, and practice approaches regarding people who are obese. Phys Ther. 2009;89(8):804–815. Correspondence: Jenny Setchell, Psychology, The University of 29. Crandall CS. Prejudice against fat people: Ideology and self-interest. J Pers Soc Queensland, Australia. Email: [email protected] Psychol. 1994;66(5):882–894. References 30. Allison DB, Baskin ML. Handbook of assessment methods for eating behaviors and weight-related problems: Measures, theory and research. 2nd ed. Los Angeles, CA: 1. Puhl RM, Heuer CA. The stigma of obesity: A review and update. Obesity. Sage; 2009. 2009;17(5):941–964. http://dx.doi.org/10.1038/oby.2008.636. 31. Edward H, Marshall S, Vitolins M, Crandall S, Davis S, Miller D, et al. Measuring 2. Puhl RM, Heuer CA. Obesity stigma: Important considerations for public health. medical student attitudes and beliefs regarding patients who are obese. Acad Med. Am J Public Health. 2010;100(6):1019–1028. http://dx.doi.org/10.2105/AJPH.2009. 2013;88(2):282–289. http://dx.doi.org/10.1097/ACM.0b013e31827c028d. 159491. 32. O’Brien KS, Hunter JA, Banks M. Implicit anti-fat bias in physical educators: 3. Carter A, Snodgrass S, Guest M, Collins C, James C, Ashby S, et al. The provision of Physical attributes, ideology and socialization. Int J Obes. 2007;31(2):308–314. weight management and healthy lifestyle advice provided by physiotherapists. In: http://dx.doi.org/10.1038/sj.ijo.0803398. Paper presented at the APA Conference ‘New Moves’. 2013. 33. Puhl RM, Latner JD, King KM, Luedicke J. Weight bias among professionals treating 4. Gard M, Wright J. The obesity epidemic: Science, morality and ideology. London, UK: eating disorders: Attitudes about treatment and perceived patient outcomes. Int J Routledge; 2005. Eat Disord. 2014;47(1):65–75. http://dx.doi.org/10.1002/eat.22186. 5. Shaw K, Gennat H, O’Rourke P, Del Mar C. Exercise for overweight or obesity. 34. Oswald FL, Mitchell G, Blanton H, Jaccard J, Tetlock PE. Predicting ethnic and racial Cochrane Database Syst Rev. 2006;CD003817. discrimination: A meta-analysis of IAT criterion studies. J Pers Soc Psychol. 2013;105(2):179–192. http://dx.doi.org/10.1037/a0032734. 6. Norris SL, Zhang X, Avenell A, Gregg E, Brown T, Schmid CH, et al. Long-term non- pharmacological weight loss interventions for adults with type 2 diabetes mellitus. 35. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. Cochrane Database Syst Rev. 2005;CD004095. 2006;3(2):77–101. 7. Eisenmann JC. Insight into the causes of the recent secular trend in pediatric 36. Physiotherapy Board of Australia. Physiotherapy Registrant Data: October 2013. obesity: Common sense does not always prevail for complex, multi-factorial 2013. phenotypes. Prev Med. 2006;42(5):329–335. http://dx.doi.org/10.1016/j.ypmed. 2006.02.002. 37. Health Workforce Australia. Australia’s health workforce series: Physiotherapists in focus. 2014 8. McAllister EJ, Dhurandhar NV, Keith SW, Aronne LJ, Barger J, Baskin M, et al. Ten putative contributors to the obesity epidemic. Crit Rev Food Sci Nutr. 38. Crandall CS, D’Anello S, Sakalli N, Lazarus E, Nejtardt G, Feather N, et al. An 2009;49(10):868–913. http://dx.doi.org/10.1080/10408390903372599. attribution-value model of prejudice: Anti-fat attitudes in six nations. Pers Soc Psychol B. 2001;27(1):30–37. 9. Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic 39. Byrne D. An overview (and underview) of research and theory within the attraction review and meta-analysis. JAMA. 2013;309(1):71–82. http://dx.doi.org/10.1001/ paradigm. J Soc Pers Relat. 1997;14(3):417–431. jama.2012.113905. 40. Tiggemann M, Rothblum E. Gender differences in social consequences of perceived 10. Lupton D. Fat. New York, NY: Routledge; 2012. overweight in the United States and Australia. Sex Roles. 1988;18(1–2):75–86. 11. Puhl RM, Andreyeva T, Brownell KD. Perceptions of weight discrimination: Preva- http://dx.doi.org/10.1007/BF00288018. lence and comparison to race and gender discrimination in America. Int J Obes. 41. Fiske S, Cuddy A, Glick P, Xu J. A model of (often mixed) stereotype content: 2008;32(6):992–1000. http://dx.doi.org/10.1038/ijo.2008.22. Competence and warmth respectively follow from perceived status and competi- 12. Rothblum E, Miller C, Garbutt B. Stereotypes of obese female job applicants. Int J tion. J Pers Soc Psychol. 2002;82(6):878–902. http://dx.doi.org/10.1037/0022- Eating Disord. 1988;7(2):277–283. 3514.82.6.878. 13. Roehling MV, Roehling P, Pichler S. The relationship between body weight and perceived weight-related employment discrimination: The role of sex and race. 42. Swami V, Pietschnig J, Stieger S, Tove´ e MJ, Voracek M. An investigation of weight J Vocat Behav. 2007;71(2):300–318. http://dx.doi.org/10.1016/j.jvb.2007.04.008. bias against women and its associations with individual difference factors. Body 14. O’Brien KS, Latner JD, Ebneter D, Hunter JA. Obesity discrimination: The role of Image. 2010;7(3):194–199. http://dx.doi.org/10.1016/j.bodyim.2010.03.003. physical appearance, personal ideology, and anti-fat prejudice. Int J Obes. 2013;37(3):455–460. http://dx.doi.org/10.1038/ijo.2012.52. 43. Anesbury T, Tiggemann M. An attempt to reduce negative stereotyping of obesity 15. Bessenoff G, Sherman J. Automatic and controlled components of prejudice toward in children by changing controllability beliefs. Health Educ Res. 2000;15(2):145– fat people: Evaluation versus stereotype activation. Social Cognition. 2000;18(4): 152. http://dx.doi.org/10.1093/her/15.2.145. 329–353. http://dx.doi.org/10.1521/soco.2000.18.4.329. 16. Puhl RM, King KM. Weight discrimination and bullying. Best Pract Res Cl En. 44. Diedrichs PC, Barlow FK. How to lose weight bias fast! Evaluating a brief anti- 2013;27(2):117–127. http://dx.doi.org/10.1016/j.beem.2012.12.002. weight bias intervention. Brit J Health Psych. 2011;16(4):846–861. http:// 17. Ogden J. In: The possible positive consequences of obesity stigma. 2013. dx.doi.org/10.1111/j.2044-8287.2011.02022.x. 18. Carels RA, Young KM, Wott CB, Harper J, Gumble A, Oehlof MW, et al. Weight bias and weight loss treatment outcomes in treatment-seeking adults. Ann Behav Med. 45. Danı´elsdo´ ttir S, O’Brien K, Ciao A. Anti-fat prejudice reduction: A review of 2009;37(3):350–355. http://dx.doi.org/10.1007/s12160-009-9109-4. published studies. Obesity facts. 2010;3(1):47–58. http://dx.doi.org/10.1159/ 19. Vartanian LR, Novak SA. Internalized societal attitudes moderate the impact of 0002770674. weight stigma on avoidance of exercise. Obesity. 2011;19(4):757–762. http:// dx.doi.org/10.1038/oby.2010.234. 46. Vartanian LR. Disgust and perceived control in attitudes toward obese people. Int J 20. Drury C, Louis M. Exploring the association between body weight, stigma of Obes. 2010;34(8):1302–1307. http://dx.doi.org/10.1038/ijo.2010.45. obesity, and health care avoidance. J Am Acad Nurse Prac. 2002;14(12):554–561. http://dx.doi.org/10.1111/j.1745-7599.2002.tb00089.x. 47. Cossrow NH, Jeffery RW, McGuire MT. Understanding weight stigmatization: A 21. Ashmore JA, Friedman KE, Reichmann SK, Musante GJ. Weight-based stigmatiza- focus group study. J Nutr Educ Behav. 2001;33(4):208–214. http://dx.doi.org/ tion, psychological distress, & binge eating behavior among obese treatment- 10.1016/S1499-4046(06)60033-X. seeking adults. Eat Behav. 2008;9(2):203–209. http://dx.doi.org/10.1016/j. eatbeh.2007.09.006. 48. Trede F. A critical practice model for physiotherapy. (Doctoral Dissertation, The 22. Hebl MR, Xu J, Mason MF. Weighing the care: Patients’ perceptions of physician University of Sydney, Sydney, Australia). 2006. Retrieved from http://eresearch.q- care as a function of gender and weight. Int J Obes. 2003;27(2):269–275. http:// mu.ac.uk/1722/1/eResearch_1722.pdf Accessed 28 June 2014 dx.doi.org/10.1038/sj.ijo.802231. 23. Sabin JA, Marini M, Nosek BA. Implicit and explicit anti-fat bias among a large 49. Clouder L. Reflective practice in physiotherapy education: A critical conversation. sample of medical doctors by BMI, race/ethnicity and gender. PLoS ONE. Stud High Educ. 2000;25(2):211–223. 2012;7(11):e48448. http://dx.doi.org/10.1371/journal.pone.0048448. 24. Mulherin K, Miller Y, Barlow FK, Diedrichs PC, Thompson R. Weight stigma in 50. Praestegaard J, Gard G. Ethical issues in physiotherapy: Reflected from the per- maternity care: Women’s experiences and care providers’ attitudes. BMC Pregnan- spective of physiotherapists in private practice. Physiother Theory Pract. cy Childbirth. 2013;13(19). http://dx.doi.org/10.1186/1471-2393-13-19. 2013;29(2):96–112. http://dx.doi.org/10.3109/09593985.2012.700388. 51. Teal C, Street R. Critical elements of culturally competent communication in the medical encounter: A review and model. Soc Sci Med. 2009;68(3):533–543. http:// dx.doi.org/10.1016/j.socscimed.2008.10.015. 52. Trede F. Emancipatory physiotherapy practice. Physiother Theory Pract. 2012;28(6):466–473. http://dx.doi.org/10.3109/09593985.2012.676942. Further reading www.qualtrics.com
Journal of Physiotherapy 60 (2014) 122–129 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Invited Topical Review Physiotherapy management of patellar tendinopathy (jumper’s knee) Aliza Rudavsky, Jill Cook Department of Physiotherapy, School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia KEYWORDS [Rudavsky A, Cook J (2014) Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of Physiotherapy 60: 122–129] Patellar tendinopathy ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article jumper’s knee tendinopathy under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). treatment physiotherapy Introduction Prevalence Patellar tendinopathy (jumper’s knee) is a clinical diagnosis of Patellar tendinopathy is an overuse injury that typically has a pain and dysfunction in the patellar tendon. It most commonly gradual onset of pain. Athletes with mild to moderate symptoms affects jumping athletes from adolescence through to the fourth frequently continue to train and compete. Determining the decade of life. This condition affects health and quality of life by prevalence of overuse injuries such as patellar tendinopathy is limiting sports and activity participation for recreational athletes difficult because overuse injuries are often not recorded when and can be career-ending for professional athletes. Once symptoms injuries are defined exclusively by time-loss from competitions are aggravated, activities of daily living are affected, including and training.2 The time-loss model only records acute injuries and stairs, squats, stand to sit, and prolonged sitting. the most severe overuse injuries, making it difficult to gather an accurate estimate of the prevalence of patellar tendinopathy in the Patellar tendinopathy clinically presents as localised pain at the athletic population. proximal tendon attachment to bone with high-level tendon loading, such as jumping and changing direction. Tendon pain at Studies that have specifically examined the prevalence of the superior patellar attachment (quadriceps tendinopathy) and at patellar tendinopathy showed that the type of sport performed the tibial attachment occurs less frequently, but the diagnosis and affected the prevalence of tendinopathy.3 The highest prevalence management are similar to jumper’s knee. It is commonly clinically in recreational athletes was in volleyball players (14.4%) and the diagnosed in conjunction with imaging (ultrasound or magnetic lowest was in soccer players (2.5%);3 the prevalence was resonance, often to exclude differential diagnoses such as substantially higher in elite athletes. Tendon pathology on imaging patellofemoral pain), where structural disruptions on the scans in asymptomatic elite athletes was reported in 22% of athletes, represent areas of tendon pathology. Importantly, there is a male athletes had twice the prevalence as female athletes, and disconnection between pathology on imaging and pain; it is basketball players had the highest prevalence of pathology (36%) common to have abnormal tendons on imaging in people with amongst the sports investigated: basketball, netball, cricket and pain-free function.1 The term tendinopathy will be used in this Australian football.4 It is not only a condition that affects adults; review to mean painful tendons. The term tendon pathology will the prevalence of patellar tendinopathy in young basketball be used to indicate abnormal imaging or histopathology without players was reported as 7%, but 26% had tendon pathology on reference to pain. imaging without symptoms.4 Treatment of patellar tendinopathy may involve prolonged Patellar tendon rupture, however, is rare. The most extensive rehabilitation and can ultimately be ineffective. Management is analysis of tendon rupture reported that only 6% of tendon limited by a poor understanding of how this condition develops, ruptures across the body occurred in the patellar tendon.5 The limited knowledge of risk factors and a paucity of time-efficient, majority of patellar tendon ruptures that do occur are in the older effective treatments. Many treatment protocols are derived from population (mean age 65 years).5 All those who had a patellar evidence about other tendinopathies in the body and applied to the tendon rupture had pathology in the tendon.6 Because this is a patellar tendon; however, the differences in tendons at a structural relatively rare injury, it will not be discussed in this review. and clinical level may invalidate this transfer between tendons. This review discusses the prevalence of patellar tendinopathy, Aetiology associated and risk factors, assessment techniques and treatment approaches that are based on evidence where possible, supple- The pathoaetiology of tendinopathy is unknown and there are mented by expert opinion. several models that attempt to describe the process.7–9 Of these, http://dx.doi.org/10.1016/j.jphys.2014.06.022 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
]IF$DTG)1_e[(igur Invited Topical Review 123 basketball players.10 Players were imaged with ultrasound each month during the season and those with reactive tendinopathy and tendon dysrepair both progressed (to degenerative tendino- pathy) and regressed (to normal tendon) through the season.10 Whilst it is known that pathology on imaging does not necessarily indicate painful patellar tendinopathy, certain changes (ie, the presence of large hypoechoic regions on ultrasound) may increase the risk of developing patellar tendinopathy.11 It is also unknown at what age a patellar tendon is susceptible to pathology, but it does occur in young athletes.4 Studies have shown that tendon tissue is inert and does not renew after the age of 17, suggesting that once tendon is formed in puberty its structure is relatively stable.12 An early age of onset of patellar tendinopathy is supported by data that shows only two players developing it after the age of 16 in a school for talented volleyball players.13 The aetiology of pain appears somewhat independent of underlying tendon pathology. Pain is frequently associated with pathological tendons, however tendon pain in apparently normal tendons has been demonstrated.14 Overload is reported as the key factor associated with pain onset.15 Overload is defined as activity above what the tendon has adapted to at that point in time, and can occur by a sudden and substantial increase in the volume of jumping or a return from injury/holiday without gradually ramping back into a regular schedule. The use of energy storage and release loads in jumping and change of direction is typically characteristic of overload causing patellar tendinopathy pain. Non- energy-storage loading or non-jumping activity (eg, cycling or swimming) and repetitive low loading (in runners) rarely aggravate the patellar tendon; other pathologies are generally suspected in these cases. Risk and associated factors Figure 1. Continuum model of tendinopathy. Several studies have examined intrinsic and extrinsic risk and associated factors for both pathology and patellar tendinopathy (Table 1). Risk factors for pathology and risk factors for pain are likely to be different and will be distinguished in this section. Biomechanical studies of painful tendons will not be discussed, as altered mechanics may be an outcome of having a painful patellar tendon, however, they would certainly be considered as part of a management paradigm. the continuum model of tendinopathy has the most overt clinical Extrinsic factors correlation.7 The continuum model places tendon pathology in three somewhat interchangeable stages: reactive tendinopathy, An increase in training volume and frequency has been tendon dysrepair and degenerative tendinopathy (Figure 1). Many associated with the onset of patellar tendinopathy in several patellar tendons have a combination of pathology state (reactive studies.16,17 Clinically, this is the most common factor that triggers on degenerative pathology). A degenerative patellar tendon with a patellar tendinopathy. Other factors, such as change in surface circumscribed degenerative area is thought to have insufficient density and shock absorption, may have an effect as well. Although structure to bear load resulting in overload in the normal area of harder surfaces can increase patellar tendinopathy symptoms,8 the tendon, leading to a reactive tendinopathy in this area. they are less likely to be an issue nowadays as most indoor sport is now played on standard sprung wooden floors. Surface density and The capacity for tendon pathology to move forward and back amount of shock absorption in both the shoes and the surface along the continuum was demonstrated in the patellar tendons of should still be considered, as athletes may be vulnerable when Table 1 Risk and associated factors for patellar tendinopathy. Study Factor Risk factor or Patellar tendinopathy Comment associated factor or tendon pathology Visnes16 Gender Men at higher risk Cook25 Both Both Malliaras26 Waist circumference Increased waist circumference associated with increased pathology Cook4 Imaging abnormality Associated Pathology Adolescents only Cook20 Hamstring length Risk Tendinopathy Less extensible hamstrings associated with pathology Witvrouw19 Hamstring length Associated Pathology Less extensible hamstrings increase risk of patellar tendinopathy Witvrouw19 Quadriceps length Risk Tendinopathy Stiffer quadriceps increase risk of patellar tendinopathy Malliaras26 Dorsiflexion Risk Tendinopathy Reduced dorsiflexion associated with increased pathology Edwards22 Altered landing strategies Associated Pathology Less knee bend at landing, altered hip strategies associated with pathology Lian63 Jumping ability Associated Pathology Better jumping ability associated with patellar tendinopathy Culvenor27 Fat pad size Both Tendinopathy Increased fat pad size associated with patellar tendinopathy Gaida15 Loading Associated Tendinopathy Excess loading associated with patellar tendinopathy Jannsen64 Associated Tendinopathy
124 Rudavsky and Cook: Physiotherapy management of patellar tendinopathy training on hard floors, athletic tracks, or surfaces with high Pain behaviour also has a classic presentation: the tendon may horizontal traction. be sore to start activity, respond variably to warm-up (from completely relieving symptoms to not at all) and will then be Intrinsic factors worse the next day, which can persist for several days. The athlete will rarely complain of night pain and morning stiffness (unless Several studies have attempted to identify specific anthropo- symptoms are severe), but will complain of pain with prolonged metric characteristics that may increase the risk of patellar sitting, especially in a car. Pain with sitting can be a good tendinopathy symptoms. These characteristics include: height, reassessment sign as the condition improves. Pain during daily weight, lower limb joint range of motion, leg length, body activity is also common; stairs and squatting are provocative. composition, lower limb alignment, and the length and strength of the hamstring and quadriceps. Thigh muscle length (shorter or Most athletes who present clinically with patellar tendinopathy less extensible quadriceps and hamstrings) has been associated are good power athletes; they will describe being good at jumping with patellar tendinopathy,18–20 whilst greater strength has been and being quick, especially in change of direction.28 They will associated with reduced pain and improved function.18 Converse- complain that their tendon pain affects their performance, ly, better knee extensor strength and jumping ability has been reducing the attributes that allow them to excel at sport. reported in athletes with patellar tendinopathy, especially in jumps involving energy storage.16,21 Young women, but not young When taking a history, it is critical to document all previous men, with tendon pathology have been found to have a better treatment that the patient has explored, including all types of vertical jump performance than those without pathology.20 interventions and rehabilitation strategies, descriptions of the Clinical observation aligns with patellar tendinopathy being more successful and unsuccessful interventions, and details of all prevalent among athletes with better jumping ability. exercises including number of repetitions, sets, weights and frequency. Many people will consult a variety of physiotherapy, Different lower limb kinematics and muscle recruitment order orthopaedic and sports medicine professionals; inconsistency of in horizontal landing phase have been associated with tendon care may prolong the rehabilitation process. The history should pathology.22 Edwards et al demonstrated the horizontal braking document all the known risk factors for tendinopathy, such as force to place the highest load on the patellar tendon. They diabetes, high cholesterol, seronegative arthropathies and the use of suggested that the compression through the patellofemoral joint fluoroquinolones. These are known to contribute to other tendino- and the patellar tendon and the tensile loading with the knee pathies, but their role in the patellar tendon is unknown. Finally, the flexed all contribute to pathology in those with asymptomatic examiner should ask about past injury and medical history, tendon pathology. including previous injuries that have necessitated unloading or time off from sports activity or that may have altered the manner in Lower foot arch height,18 reduced ankle dorsiflexion,23 greater which the athlete absorbs energy in athletic manoeuvres. leg length discrepancy, and patella alta in men24 have each been associated with patellar tendinopathy. Boys and men are two to four Examination times more likely to develop patellar tendinopathy than girls.16,25 The VISA-P (Victorian Institute of Sports Assessment for the Increased waist circumference in men is associated with greater Patellar tendon) should be completed as a baseline measure to prevalence of pathology on ultrasound. It has been reported that allow monitoring of pain and function. The VISA-P is a brief men with a waist circumference greater than 83 cm are more likely questionnaire that assesses symptoms, simple tests of function and to have abnormal changes on imaging (74% versus 15% in those ability to participate in sports. Six of the eight questions are on a with less than 83 cm).26 One study found that athletes with visual analogue scale (VAS) from 0 to 10, with 10 representing patellar tendinopathy were generally younger, taller and weighed optimal health. The maximal score for an asymptomatic, fully more than those without patellar tendinopathy.3 Infrapatellar fat functioning athlete is 100 points, the lowest theoretical score is 0 pad size was significantly larger in those with tendinopathy than in and less than 80 points corresponds with dysfunction.29 It has high controls.27 impedance, so it is best repeated monthly and the minimal clinically significant change is 13 points.30 Tenderness on Assessment palpation is a poor diagnostic technique and should never be used as an outcome measure;31 however, pain pressure threshold, History as measured by algometry, has been found to be significantly lower in athletes with patellar tendinopathy (threshold of 36.8 N) when There are few papers providing evidence on assessment compared to healthy athletes. procedures, therefore this section is based on expert opinion. As with all musculoskeletal conditions, a detailed history is very Observation will nearly always reveal wasting of the quadriceps important and must first identify if the tendon is the likely source and calf muscles (especially gastrocnemius) compared to the of pain. This is determined initially in the history by asking the contralateral side; the degree of atrophy is dependent on the person to indicate where they feel their pain during a patellar length of symptoms. Athletes who continue to train and play, even tendon-loading task (such as jumping and changing direction). at an elite level, are not immune to strength and bulk losses, as they They should point with one finger to the tendon attachment to the are forced to unload because of pain. patella; more widely distributed pain should raise the possibility of a different diagnosis. Second, a history should identify the reason Clinical tests that the tendon has become painful; this is classically due to tendon overload. Two common overload scenarios are seen: a large A key test is the single-leg decline squat. While standing on the increase in overall load from a stable base (eg, beginning affected leg on a 25 deg decline board, the patient is asked to plyometric training or participation in a high-volume tournament) maintain an upright trunk and squat up to 90 deg if possible or returning to usual training after a significant period of (Figure 2).32 The test is also done standing on the unaffected leg. downtime (eg, return to training after 4 to 6 weeks time off for For each leg, the maximum angle of knee flexion achieved is an ankle sprain or holidays). Elite athletes can have repeated recorded, at which point pain is recorded on a visual analogue loading/unloading periods due to injuries and season breaks over scale. Diagnostically the pain should remain isolated to the tendon/ several years, which gradually reduces the capacity of the tendon bone junction and not spread during this test.33 This test is an to tolerate load and leaves it vulnerable to overload with small excellent self-assessment to isolate and monitor the tendon’s changes in training. No identifiable change in load or pain induced response to load on a daily basis. from a load that should not induce patellar tendinopathy (such as cycling) should suggest alternative diagnosis. Kinetic chain function is always affected;15,18,23,33 the leg ‘spring’ has poor function, and is commonly stiff at the knee and
(Figur[]GIe_2)TD$ Invited Topical Review 125 soft at the ankle and hip. The quality of movement can be assessed with various single-leg hop tests and specific change of direction tasks. Record pain (VAS) and function at take off and landing,33 and note if more load induces more pain. If possible, measurement of angles and individual joint moments through video/biomechanical analysis can help with more elite athletes. Hop tests for height and distance can also be used to assess kinetic chain quality, as well as providing an objective means of monitoring progress. Muscle strength, assessed through clinical and functional measures (repeated calf raise and decline squats), is useful to assess the level of unloading in the essential muscles. Dorsiflexion range of movement is a critical assessment, as the ankle and calf absorb much of the landing energy.34 Stiff talocrural joint dorsiflexion,26 general foot stiffness and/or hallux rigidus all contribute to increased load on the musculotendinous complexes of the leg. Imaging Figure 2. Single-leg decline squat. Imaging with traditional ultrasound and magnetic resonance can identify the presence of pathology in the tendon. Ultrasound ([Figure_3)TD$IG] tissue characterisation, a novel form of ultrasound, can quantify the degree of disorganisation within a tendon and may enhance clinical information from imaging (Figures 3 and 4).35 Imaging will nearly always demonstrate tendon pathology, regardless of the imaging modality used. The presence of imaging abnormality does not mean that the pathology is the source of the pain so clinical confirmation, as described above, is essential. More importantly, the pathology is commonly degenerative, often circumscribed and does not change over time, so imaging the tendon as an outcome measure is unhelpful, as pain can improve without positive changes in tendon structure on imaging.35 In elite jumping sports, Figure 3. Ultrasonic tissue characterisation: (A) normal patellar tendon appearance, (B) mild patellar tendon disorganisation and (C) severe patellar tendon disorganisation. Note: green colour represents good tendon structure; blue, red and black represent increasing structural disruption. (Images supplied by SI Docking).
]GF$DT)4_erugi([I126 Rudavsky and Cook: Physiotherapy management of patellar tendinopathy Figure 4. UTC pictures of a degenerative patellar tendon structure (A) progressing to a reactive on degenerative patellar tendon structure (B). Note the increase in blue pixilation in what was previously normal (green) tendon structure. (Images supplied by SI Docking) such as volleyball, patellar tendon changes are nearly the norm, for 2 to 8 hours with heavy sustained isometric contractions. which needs to be considered when interpreting clinical and imaging findings. Voluntary contractions at 70% of maximum, held for 45 to Differential diagnosis 60 seconds and repeated four times is one loading strategy that The history and examination are crucial to distinguish patellar has been shown to have a large hypoalgesic effect. This loading can tendinopathy from other diagnoses including: patellofemoral pain; pathology of the plica or fat pad; patellar subluxation or a be done before a game or training, and can be done several times a patellar tracking problem; and Osgood-Schlatter disease.36 day.38 If the tendon is highly irritable, bilateral exercise, shorter holding time and fewer repetitions are recommended.38 Addition- ally, medication may help to augment pain reduction and/or pathological change in a reactive tendon,39 so consultation with a physician is advised. Physiotherapy management Strengthening Eccentric, heavy slow resistance, isotonic and isometric While pathology in a patellar tendon may not ever completely resolve, symptoms of patellar tendinopathy can generally be exercises have all been investigated in patellar tendinopathy. managed conservatively. This section will draw from the literature Eccentric exercises have generally been shown to have good on therapeutic management of patellar tendinopathy, as well as clinical expertise and emerging areas of research. short-term and long-term effects on symptoms and VISA-P scores. There are several different types of eccentric patellar tendon Active interventions loading exercises; however, there is no difference in the results of a 12-week eccentric training program between the bilateral Intervention is aimed at initially addressing pain reduction, weighted squat (Bromsman device) twice a week and the followed by a progressive resistive exercise program to target unilateral decline squat daily.40 strength deficits, power exercises to improve the capacity in the stretch-shorten cycle, and finally functional return-to-sport Several interventions have used the 25 deg single-leg decline training (Table 2). Daily pain monitoring using the single-leg squat, which has been shown to have better outcomes than a decline squat provides the best information about tendon response single-leg flat squat.41 Two investigations have shown that angles to load; consistent or improving scores suggest that the tendon is above 15 deg are equivocal,42,43 and that the decline board is coping with the loading environment. effective by increasing the moment arm of the knee.44 Pain reduction Two studies have investigated the effect of eccentric exercise in Reducing an athlete’s symptoms requires load management, the competitive season. Visnes et al reported no overall effect and a short-term worsening with decline squat training on function in although it is important to avoid complete cessation of tendon symptomatic athletes continuing a regular training program, loading activities, as that will further reduce the load capacity of compared to a regular training program only.45 Fredberg et al the tendon.33 Removing high-load drills from training, reducing showed an increased risk of injury for asymptomatic athletes with frequency of training (twice a week is tolerable for many tendons) pathology on ultrasound who completed a prophylactic eccentric and decreasing volume (reducing time of training) are all useful decline squat training program.46 This suggests that the addition of means of reducing load on the tendon without resorting to eccentric exercise while an athlete is in a high-load environment is complete rest. detrimental to the tendon. When comparing an eccentric decline squat protocol to a patellar tenotomy, there was no difference in Sustained isometric contractions have been shown to be the outcomes and both showed improvement.47 Surgical inter- analgesic.37 In painful patellar tendinopathy (usually a reactive vention is not recommended over an exercise rehabilitation or reactive on degenerative pathology), pain relief can be obtained program in the first instance. Heavy slow resistance exercises were investigated by Kongsgaard and colleagues,48 who compared the effects of a Table 2 Suggested rehabilitation progression for patellar tendinopathy. Phase of rehabilitation Aim of treatment Intervention Example exercises Pain management Reduce pain Isometric exercises in mid-range as tolerated. Sustained holds on leg extension; 45 s, Strength progression Reduce loading and activity modification 4 repetitions, 2 times/day. Improve strength Heavy slow resistance as tolerated (isotonic) Leg extension/press, 4 sets of 6-8 repetitions, Energy-storage/ 3-5 times/wk stretch-shorten cycle Functional strengthening Progressive resistance exercise program, Walk lunge with body weight or extra weight, functional tasks, address movement patterns, stair walking Maintenance Increase power kinetic chain and endurance training as required Increase speed of muscle contraction, lower the Split squats, faster stairs, skipping exercises Develop stretch-shorten cycle number of repetitions Training sport-specific Plyometric exercises, graded gradually Jumping, deceleration and change of direction tasks Management of symptoms Drills specific to sport including endurance training Sports specific drills at set intensity and duration and prevention of flare ups Education, continue strength training and manage Continue leg extension strength or Spanish squat loading as tolerated exercise while training and playing
Invited Topical Review 127 peritendinous corticosteroid injection to the proximal patellar and ability to moderate activity, this absence of symptoms has tendon to a decline squat eccentric exercise protocol and a heavy been associated with poorer outcomes and is not advised in slow resistance protocol in people with patellar tendinopathy. All season.38 three groups showed improvements at 12 weeks; however, at 6 months only the groups using the eccentric exercises and the Studies of the efficacy of platelet-rich plasma injections as a heavy slow resistance exercises still showed improved VISA-P and treatment for tendinopathy show little effect.54 A literature review VAS scores. The heavy slow resistance group showed improved in 2011 showed positive outcomes for several injection-based tissue normalisation of the collagen and also demonstrated better studies with small sample sizes;55 further research is needed. clinical presentations than the eccentric group within the 12-week Surgical interventions including arthroscopic shaving and scleros- follow-up. ing injections are improving in their ability to reduce pain and amount of time out of sports.56 When considering surgery, it is Combined exercises with eccentrics, concentrics and plyomet- important to factor in stage of tendinopathy and treat it as part of a ric training for the Achilles tendon were studied by Silbernagel and well-rounded rehabilitation program involving kinetic chain colleagues.49 Athletes were allowed to continue training in their exercises, education in proper landing technique and management sports during the first 6 weeks of rehabilitation, as long as their of load and return to sports.38 pain did not go over 5/10 on the VAS during activity and returned to normal by the next morning.49 While this study was Education investigating Achilles tendinopathy, this combined approach is often used clinically with patellar tendinopathy and should be It is important for the athlete to have realistic expectations of considered as a treatment option. the rehabilitation process and to understand that management of their symptoms is required throughout their sports career, Functional strengthening and return to sports whether recreational or professional. The athlete must know Functional strengthening must address high-load tendon how to monitor symptoms and adjust participation and loading appropriately throughout the rehabilitation process and in return capacity as well as kinetic chain deficits and movement patterns. to sport, and should always maintain strength exercises twice Once these patterns have improved, the athlete should begin weekly throughout their sporting careers. sports-specific training. Faster contractions can progress loads towards the stretch-shorten cycle that forms the basis for return to Tendons generally have a delayed response to load and will sports. Early drills should include: skipping, jumping and hopping, cause minimal pain during activity, but flare 24 hours later. progressing to agility tasks, direction changes, sprinting and Regular pain monitoring will help guide and progress the exercise bounding movements. It is important to quantify these tasks and program and should be maintained after return to sport. The best use a high-low-medium-load day approach in early reintroduction monitoring is the single-leg decline squat, which an athlete can use of high-load activities and return to sports. Also, include training to self-assess symptoms in order to determine response to specificity when returning an athlete back to their sport, including rehabilitation and participation in their sport. A journal of movement assessment for optimal kinetic chain loading. symptoms and pain on decline squat will help the athlete to identify triggers, monitor loading response and learn to manage Passive interventions symptoms independently. Other techniques may be useful in augmenting an exercise Factors affecting prognosis program; however, there is little evidence for effect of passive treatments for patellar tendinopathy. Exercise, pulsed ultrasound Return to sport can be slow and is often dependent on severity and transverse friction massages have been compared, and of the pain and dysfunction, the quality of rehabilitation, and exercise had the best effects in the short and long term.50 Manual intrinsic and extrinsic factors. Gemignani et al associated mild therapy techniques, including myofascial manipulation of the knee pathology in the tendon to 20 days of rehabilitation before return extensor muscle group, have had a positive effect on reducing pain to sports, and more severe pathology with approximately 90 days in patellar tendinopathy patients in short-term and long-term until return to sport.57 However, these imaging-based guidelines follow-up.51 Other passive therapies, including braces and taping may underestimate return-to-sport time, considering that other techniques, are often used clinically to help unload the patellar factors affect prognosis. The athlete who presents with a high level tendon, however, no evidence supports their efficacy. Passive of kinetic chain dysfunction, regardless of pain level, will take therapies are best used to reduce symptoms in season so the considerable time (6 to 12 months) to recover both muscle and athlete can continue to participate in rehabilitation and sport. tendon capacity. This is complicated if the athlete aspires to return to a high level of performance, for example an elite high jumper Other interventions will require much more rehabilitation than a recreational football player, as the jumping demands differ greatly.58 Even within elite Extracorporeal shockwave therapy, corticosteroid injections, sport there are levels of loading for the patellar tendon, a volleyball platelet-rich plasma and other injections are interventions player will jump and land much more than a basketball player and frequently used in the clinical setting, yet have limited evidence will also require greater rehabilitation time. Regardless, impa- supporting their use in patellar tendinopathy. There was no benefit tience with rehabilitation creates a poorer prognosis; time, proper of extracorporeal shockwave therapy compared to placebo for in- rehabilitation and appropriate graded return to sports are an season athletes with chronic patellar tendinopathy.52 A direct effective treatment. comparison between platelet-rich plasma and extracorporeal shockwave therapy showed significantly better outcomes in the Factors affecting response to therapy platelet-rich plasma group at 6-month and 12-month follow-up, compared to the extracorporeal shockwave therapy group; Pain in tendinopathies is poorly understood, however, there is however, both groups showed similar and significant improve- emerging evidence in support of an element of central sensitisation ments at the 2-month follow-up.53 Peritendinous corticosteroid or pathophysiological up-regulation of the central nervous injection, oral steroidal medication, or iontophoresis may be useful system.59,60 A small study has demonstrated that athletes with and effective at quickly reducing cell response and pain in a patellar tendinopathy have a lower mechanical pain threshold and reactive tendon,38 however, the long-term outcomes are worse greater sensitivity to vibration disappearance than non-injured than those obtained with exercise.48 Corticosteroid injection, athletes.61 Local pathology, such as neovascularisation, lacks however, is not indicated in degenerative tendinopathy.38 evidence as the primary pain driver,62 which is yet to be Analgesic injections may alter an athlete’s perception of pain determined.
128 Rudavsky and Cook: Physiotherapy management of patellar tendinopathy Avenues for further research 16. Visnes H, Bahr R. Training volume and body composition as risk factors for developing jumper’s knee among young elite volleyball players. Scand J Med Sci More research is required to fully understand how a tendon fails Sports. 2013;23:607–613. in adaptive capacity and pathology develops, and what causes the pain in the tendons that is so specific to loading. Intervention 17. Janssen I, Steele JR, Munro BJ, Brown NA. Sex differences in neuromuscular studies to clarify an optimal loading program, as well as the recruitment are not related to patellar tendon load. Med Sci Sports Exerc. eventual development of a prevention program would also be 2014;46:1410–1416. beneficial. 18. Crossley KM, Thancanamootoo K, Metcalf BR, Cook JL, Purdam CR, Warden SJ. Conclusions Clinical features of patellar tendinopathy and their implications for rehabilitation. J Orthop Res. 2007;25:1164–1175. Research has increased our understanding of patellar tendino- pathy and pathology but there is still more to discover. Currently, 19. Witvrouw E, Bellemans J, Lysens R, Danneels L, Cambier D. Intrinsic risk factors for the most important factors in managing athletes with patellar the development of patellar tendinitis in an athletic population. A two-year tendinopathy are to educate them about how to modify loading prospective study. Am J Sports Med. 2001;29:190–195. according to symptoms, to ensure that they understand how to increase or decrease loading appropriately, and to assess and 20. Cook JL, Kiss ZS, Khan KM, Purdam CR, Webster KE. Anthropometry, physical modify intrinsic and extrinsic factors that may be contributing to performance, and ultrasound patellar tendon abnormality in elite junior basketball overload. players: a cross-sectional study. Br J Sports Med. 2004;38:206–209. Ethics approval: Nil 21. Lian O, Engebretsen L, Ovrebo RV, Bahr R. Characteristics of the leg extensors in Competing interests: Nil male volleyball players with jumper’s knee. Am J Sports Med. 1996;24:380–385. Source(s) of support: Professor Cook is supported by the Australian Centre for Research into Sports Injury and its Preven- 22. Edwards S, Steele JR, McGhee DE, Beattie S, Purdam C, Cook JL. Landing strategies of tion, which is one of the International Research Centres for athletes with an asymptomatic patellar tendon abnormality. Med Sci Sports Exerc. Prevention of Injury and Protection of Athlete Health supported by 2010;42:2072–2080. the International Olympic Committee (IOC). Prof. Cook is supported by a NHMRC practitioner fellowship (1058493). 23. Malliaras P, Cook JL, Kent P. Reduced ankle dorsiflexion range may increase the risk Acknowledgements: We thank SI Docking for the supply of the of patellar tendon injury among volleyball players. J Sci Med Sport. 2006;9:304– tendon ultrasound figures. 309. Correspondence: Aliza Rudavsky, Department of Physiothera- py, Monash University, Australia. Email: aliza.rudavsky@monash. 24. Kujala UM, Osterman K, Kvist M, Aalto T, Friberg O. Factors predisposing to patellar edu chondropathy and patellar apicitis in athletes. Int Orthop. 1986;10:195–200. References 25. Cook JL, Khan KM, Kiss ZS, Purdam CR, Griffiths L. Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players. J Ultrasound 1. Cook JL, Khan KM, Harcourt PR, Kiss ZS, Fehrmann MW, Griffiths LR, et al. Patellar Med. 2000;19:473–479. tendon ultrasonography in asymptomatic active athletes reveals hypoechoic regions: a study of 320 tendons. Clin J Sport Med. 1998;8:73–77. 26. Malliaras P, Cook JL, Kent PM. Anthropometric risk factors for patellar tendon injury among volleyball players. Br J Sports Med. 2007;41:259–263. 2. Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology: the Oslo Sports 27. Culvenor AG, Cook JL, Warden SJ, Crossley KM. Infrapatellar fat pad size, but not Trauma Research Centre (OSTRC) overuse injury questionnaire. Br J Sports Med. patellar alignment, is associated with patellar tendinopathy. Scand J Med Sci Sports. 2013;47:495–502. 2011;21:e405–e411. 3. Zwerver J, Bredeweg SW, van den Akker-Scheek I. Prevalence of Jumper’s knee 28. Visnes H, Aandahl HA, Bahr R. Jumper’s knee paradox–jumping ability is a risk among nonelite athletes from different sports: a cross-sectional survey. Am J Sports factor for developing jumper’s knee: a 5-year prospective study. Br J Sports Med. Med. 2011;39:1984–1988. 2013;47:503–507. 4. Cook JL, Khan KM, Kiss ZS, Griffiths L. Patellar tendinopathy in junior basketball 29. Visentini PJ, Khan KM, Cook JL, Kiss ZS, Harcourt PR, Wark JD. The VISA score: an players: a controlled clinical and ultrasonographic study of 268 patellar tendons in index of severity of symptoms in patients with jumper’s knee (patellar tendinosis). players aged 14-18 years. Scand J Med Sci Sports. 2000;10:216–220. J Sci Med Sport. 1998;1:22–28. 5. Kannus P, Natri A. Etiology and pathophysiology of tendon ruptures in sports. Scand 30. Hernandez-Sanchez S, Hidalgo MD, Gomez A. Responsiveness of the VISA-P scale J Med Sci Sports. 1997;7:107–112. for patellar tendinopathy in athletes. Br J Sports Med. 2014;48:453–457. 6. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a 31. Cook JL, Khan KM, Kiss ZS, Purdam CR, Griffiths L. Reproducibility and clinical tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991;73:1507– utility of tendon palpation to detect patellar tendinopathy in young basketball 1525. players. Br J Sports Med. 2001;35:65–69. 7. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to 32. Purdam CR, Cook JL, Hopper DM, Khan KM. VIS tendon study group. Discriminative explain the clinical presentation of load-induced tendinopathy Br J Sports Med. ability of functional loading tests for adolescent jumper’s knee. Phys Ther Sport. 2009;43:409–416. 2003;4:3–9. 8. Ferretti A. Epidemiology of jumper’s knee. Sports Med. 1986;3:289–295. 33. Kountouris A, Cook J. Rehabilitation of Achilles and patellar tendinopathies. Best 9. Peers KH, Lysens RJ. Patellar tendinopathy in athletes: current diagnostic and Pract Res Clin Rheumatol. 2007;21:295–316. therapeutic recommendations. Sports Med. 2005;35:71–87. 34. Fong CM, Blackburn JT, Norcross MF, McGrath M, Padua DA. Ankle-dorsiflexion 10. Malliaras P, Cook J, Ptasznik R, Thomas S. Prospective study of change in patellar range of motion and landing biomechanics. J Athl Train. 2011;46:5–10. tendon abnormality on imaging and pain over a volleyball season. Br J Sports Med. 35. Docking SI, Daffy J, van Schie HT, Cook JL. Tendon structure changes after maximal 2006;40:272–274. exercise in the Thoroughbred horse: use of ultrasound tissue characterisation to 11. Comin J, Cook JL, Malliaras P, McCormack M, Calleja M, Clarke A, et al. The detect in vivo tendon response. Vet J. 2012;194:338–342. prevalence and clinical significance of sonographic tendon abnormalities in asymptomatic ballet dancers: a 24-month longitudinal study. Br J Sports Med. 36. Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: Part 2013;47:89–92. II. Differential diagnosis. Am Fam Physician. 2003;68:917–922. 12. Heinemeier KM, Schjerling P, Heinemeier J, Magnusson SP, Kjaer M. Lack of tissue renewal in human adult Achilles tendon is revealed by nuclear bomb (14)C. FASEB J. 37. Naugle KM, Fillingim RB, Riley 3rd JL. A meta-analytic review of the hypoalgesic 2013;27:2074–2079. effects of exercise. J Pain. 2012;13:1139–1150. 13. Gisslen K, Gyulai C, Nordstrom P. Alfredson H Normal clinical and ultrasound findings indicate a low risk to sustain jumper’s knee patellar tendinopathy: a longitudinal study 38. Cook JL, Purdam CR. The challenge of managing tendinopathy in competing on Swedish elite junior volleyball players Br J Sports Med. 2007;41:253–258. athletes. Br J Sports Med. 2014;48:506–509. 14. Malliaras P, Cook J. Patellar tendons with normal imaging and pain: change in imaging and pain status over a volleyball season. Clin J Sport Med. 2006;16: 39. Fallon K, Purdam C, Cook J, Lovell G. A ‘‘polypill’’ for acute tendon pain in athletes 388–391. with tendinopathy? J Sci Med Sport. 2008;11:235–238. 15. Gaida JE, Cook JL, Bass SL, Austen S, Kiss ZS. Are unilateral and bilateral patellar tendinopathy distinguished by differences in anthropometry, body composition, 40. Frohm A, Saartok T, Halvorsen K, Renstrom P. Eccentric treatment for patellar or muscle strength in elite female basketball players? Br J Sports Med. 2004;38: tendinopathy: a prospective randomised short-term pilot study of two rehabilita- 581–585. tion protocols. Br J Sports Med. 2007;41:e7. 41. Purdam CR, Jonsson P, Alfredson H, Lorentzon R, Cook JL, Khan KM. A pilot study of the eccentric decline squat in the management of painful chronic patellar tendino- pathy. Br J Sports Med. 2004;38:395–397. 42. Zwerver J, Bredeweg SW, Hof AL. Biomechanical analysis of the single-leg decline squat. Br J Sports Med. 2007;41:264–268. 43. Richards J, Thewlis D, Selfe J, Cunningham A, Hayes C. A biomechanical investiga- tion of a single-limb squat: implications for lower extremity rehabilitation exer- cise. J Athl Train. 2008;43:477–482. 44. Kongsgaard M, Aagaard P, Roikjaer S, Olsen D, Jensen M, Langberg Hm Magnusson SP. Decline eccentric squats increases patellar tendon loading compared to stan- dard eccentric squats. Clin Biomech. 2006;21:748–754. 45. Visnes H, Hoksrud A, Cook J, Bahr R. No effect of eccentric training on jumper’s knee in volleyball players during the competitive season: a randomized clinical trial. Clin J Sport Med. 2005;15:227–234. 46. Fredberg U, Bolvig L, Andersen NT. Prophylactic training in asymptomatic soccer players with ultrasonographic abnormalities in Achilles and patellar tendons: the Danish Super League Study. Am J Sports Med. 2008;36:451–460. 47. Bahr R, Fossan B, Loken S, Engebretsen L. Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper’s Knee). A randomized, con- trolled trial. J Bone Joint Surg Am. 2006;88:1689–1698. 48. Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resis- tance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19:790–802. 49. Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendino- pathy: a randomized controlled study. Am J Sports Med. 2007;35:897–906.
Invited Topical Review 129 50. Stasinopoulos D, Stasinopoulos I. Comparison of effects of exercise programme, 57. Gemignani M, Busoni F, Tonerini M, Scaglione M. The patellar tendinopathy in pulsed ultrasound and transverse friction in the treatment of chronic patellar athletes: a sonographic grading correlated to prognosis and therapy. Emerg Radiol. tendinopathy. Clin Rehabil. 2004;18:347–352. 2008;15:399–404. 51. Pedrelli A, Stecco C, Day JA. Treating patellar tendinopathy with Fascial Manipula- 58. Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite tion. J Bodyw Mov Ther. 2009;13:73–80. athletes from different sports: a cross-sectional study. Am J Sports Med. 2005; 33:561–567. 52. Zwerver J, Hartgens F, Verhagen E, van der Worp H, van den Akker-Scheek I, Diercks RL. No effect of extracorporeal shockwave therapy on patellar tendinopathy in 59. Webborn AD. Novel approaches to tendinopathy. Disabil Rehabil. 2008;30: jumping athletes during the competitive season: a randomized clinical trial. Am J 1572–1577. Sports Med. 2011;39:1191–1199. 60. Rio E, Moseley L, Purdam C, Samiric T, Kidgell D, Pearce AJ, et al. The pain of 53. Vetrano M, Castorina A, Vulpiani MC, Baldini R, Pavan A, Ferretti A. Platelet-rich tendinopathy: physiological or pathophysiological? Sports Med. 2014;44:9–23. plasma versus focused shock waves in the treatment of jumper’s knee in athletes. Am J Sports Med. 2013;41:795–803. 61. van Wilgen CP, Konopka KH, Keizer D, Zwerver J, Dekker R. Do patients with chronic patellar tendinopathy have an altered somatosensory profile? A Quanti- 54. de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA, Weinans H, et al. tative Sensory Testing (QST) study Scand J Med Sci Sports. 2013;23:149–155. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA. 2010;303:144–149. 62. Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med. 2009;37:1855–1867. 55. van Ark M, Zwerver J, van den Akker-Scheek I. Injection treatments for patellar tendinopathy. Br J Sports Med. 2011;45:1068–1076. 63. Lian O, Refsnes PE, Engebretsen L, Bahr R. Performance characteristics of volleyball players with patellar tendinopathy. Am J Sports Med. 2003;31:408–413. 56. Willberg L, Sunding K, Forssblad M, Fahlstrom M. Alfredson H. Sclerosing polido- canol injections or arthroscopic shaving to treat patellar tendinopathy/jumper’s 64. Janssen I, Brown NA, Munro BJ, Steele JR. Variations in jump height explain the knee? A randomised controlled study Br J Sports Med. 2011;45:411–415. between-sex difference in patellar tendon loading during landing. Scand J Med Sci Sports. 2014. http://dx.doi.org/10.1111/sms.12172. [Epub ahead of print].
Journal of Physiotherapy 60 (2014) 174–175 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Correspondence Prophylactic stretching is unlikely to prevent nocturnal leg cramps In order to reduce the frequency of nocturnal leg cramps, leg not stretch leg muscles). This trial didn’t find a trend to benefit. stretching before sleep is commonly recommended. A little over a This lack of benefit is consistent with a recent survey in which year ago in this journal, Hallegraeff et al1 authored the first cramp sufferers were asked to rate the effectiveness of any randomised controlled trial to support this practice – demonstrat- therapies they had tried.5 Of the 21 patients who tried prophylactic ing 1.2 fewer cramps per night and less-severe cramp pain in the stretching, the vast majority (n = 18) found it to be ‘useless’ or ‘a stretching group, compared to those receiving no treatment. little help’ and only three found it to be ‘quite helpful’ or ‘very Missing from the analysis of this trial, however, was an explanation helpful’. This compares to the 18 users of quinine, the vast majority of why (despite similar recruitment methods and similar inclu- of whom (n = 16) found it to be ‘quite helpful’, ‘very helpful’ or sion/exclusion criteria) the cramp rate in the control group differed ‘100% effective’, with only two subjects reporting it to be ‘useless’ so dramatically from what had been observed in other randomised or ‘a little help’. While it was reported that the stretching technique trials. Cochrane systematic reviews of both quinine (13 trials with of some patients was clearly inappropriate (eg, plantarflexing the 952 subjects) and magnesium (4 trials with 213 subjects) for the foot), there were still very few people who rated prophylactic prophylaxis of rest cramps show mean cramp rates in placebo stretching as an effective therapy. controls of 4.4 and 4.35 cramps/week.2,3 In contrast, the control group cramp rate in the trial by Hallegraeff et al was 16.8 cramps/ The only randomised trial to compare prophylactic stretching week (2.4 cramps/night) – a cramp rate that is nearly fourfold with a sham intervention in a typical population of crampers higher. Is the population from which these subjects were derived remains with Coppin.4 Given that Coppin found no trend to benefit, unique? Were there extreme outliers skewing the distribution? and given the vast majority of surveyed crampers who have tried Can we be confident of the diagnosis? prophylactic stretching report it to be ineffective, I believe that the current body of evidence does not support bedtime stretching for An additional problem in interpreting the results of the trial by the prophylaxis of nocturnal leg cramps. Hallegraeff et al1 is the comparison of an intervention group to unblinded controls who were offered no treatment. This is Scott R Garrison problematic because there is potential subjectivity in the reporting Department of Family Medicine, University of Alberta, Canada of cramps. For example, is a brief cramp worth reporting? Was a long cramp episode really one single cramp, or multiple individual References cramps occurring in close succession? Given that the subjects in this trial were unblinded and can be assumed to have had different 1. Hallegraeff JM, et al. J Physiother. 2012;58:17–22. expectations of potential benefit (an intervention versus no 2. El-Tawil S, et al. Cochrane Database Syst Rev. 2010;12:CD005044. treatment), might those expectations have influenced the reporting 3. Garrison SR, et al. Cochrane Database Syst Rev. 2012;9:CD009402. of cramps? 4. Coppin RJ, et al. Br J Gen Pract. 2005;55:186–191. 5. Blyton F, et al. J Foot Ankle Res. 2012;5:7. The only other randomised controlled trial that has evaluated prophylactic stretch is by Coppin et al,4 in which 191 quinine users http://dx.doi.org/10.1016/j.jphys.2014.05.004 used either bedtime stretch or control (ie, leg movements that did A clear definition of nocturnal leg cramps is essential for comparability of research In 2012, our randomised trial demonstrated that stretching assist sleep, or who had orthopaedic problems, severe medical before sleep reduces the frequency and severity of nocturnal leg conditions, or comorbidities known to cause muscular spasms or cramps in older adults.1 These episodic cramp attacks are cramps. The homogeneity of our study cohort is important, characteristic: painful, sustained, involuntary muscle contractions because, for example, nocturnal leg cramps are more prevalent in of the calf muscles, hamstrings or feet. The sharp and intense pain older adults6,8 and medications can affect the frequency of may last from seconds to several minutes, accompanied by firm cramps.6 The two Cochrane reviews,6,7 however, include data and tender muscles, and in some cases, with plantar flexion of feet from participants of any age with ‘idiopathic’, ‘rest’ or ‘pregnancy- and toes.2–5 In his letter, Garrison argues that prophylactic associated’ cramps, with no clear eligibility criteria being applied stretching is unlikely to prevent nocturnal leg cramps. that are diagnostic of nocturnal leg cramps. This permits a heterogeneous population with different types of muscular Garrison’s first point is that the frequency of nocturnal leg cramps, affecting any body part, from any cause, in any setting cramps in our trial was higher than would be anticipated from the and at any time of day. Also, these cramps were measured at data from the study populations in two recent Cochrane reviews of weekly intervals and cramp diaries were not commonly used, so medications for cramps.6,7 The participants in our study were a recall bias may have caused underestimation of the true frequency. homogeneous group of adults aged over 55 years with regular Finally, quinine users were excluded from our study and most episodes of nocturnal leg cramps occurring at least once per week. participants in our study had tried quinine without success, We excluded people who were using quinine or medication to 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 60 (2014) 167 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinimetrics QuickDASH Summary Description: The shortened Disabilities of the Arm, Shoulder and into a scaled score (0–100) using a formula; a higher score Hand Questionnaire (QuickDASH) is an 11-item questionnaire that rates physical function and symptoms in people with upper limb corresponds to greater disability and reduced function. A scaled musculoskeletal disorders.1 It is an abbreviated version of the 30- item original DASH. The 11 items of QuickDash address daily score can be derived for each section/module, even if one item is activities, house/yard work, shopping, recreation, self-care, eating, sleep, friends, work, pain and tingling/numbness.1 Like the DASH, the not answered, but all items must be answered to attain a scaled QuickDASH version also contains two optional four-item modules (sport/music or work), which are calculated separately to form a score for the optional modules. scaled score that measures symptoms and functions in certain high- performing populations (eg, athletes and performing artists). Reliability and validity: Internal consistency (a = 0.92–0.95) Instructions for scoring: Each item in the QuickDASH disability/ and test-retest reliability (ICC = 0.93) of the QuickDASH are symptom section and the optional modules are scored from a five- excellent.1,2 In addition, the QuickDASH has a high construct point Likert scale (1–5); a higher value corresponds to greater disability/severity of symptoms. The tallied scores for the validity (p = 0.84) when compared to the Shoulder Pain and disability/symptom section and optional modules are converted Disability Index (SPADI).3 The overall effect size and standardised response mean of the DASH and QuickDASH are similar, indicating that the QuickDASH has high construct validity and good responsiveness.2 Several studies confirm that the QuickDASH is highly responsive and valid for different patient populations with upper limb pathologies such as breast cancer survivors, burns, paediatric and adolescent patients, and more.4–6 Commentary The QuickDASH tends to score subjects higher than the DASH, provides an objective measure of treatment responses.2 The thereby underestimating the severity of symptoms and disability QuickDASH has been validated in many patient populations and compared to the DASH.3,7 It is also less specific than the DASH upper limb musculoskeletal conditions. It has also been translated when the different types of upper limb symptoms and activities into several languages and is freely available at www.dash. that the questionnaire covers are considered. Hence, some studies iwh.on.ca. All these initiatives and features of the QuickDASH make do not recommend it for research purposes. it readily accessible to clinicians worldwide and a commonly used tool with a wide scope of clinical applications for the upper limb. Another drawback is that the QuickDASH measures the function and symptoms of the upper limb complex as a whole and also Yunfeng Su emphasises motor tasks involving the larger joints. These features Department of Physiotherapy, Singapore General Hospital, Singapore of the QuickDASH are useful when assessing poly-articular conditions such as polytrauma where it is difficult to consider References and evaluate the different upper limb segments separately. However, these features can also be limiting when assessing 1. Beaton DE, et al. J Bone & J Surg. 2005;87–A 5:1038–1046. specific wrist or finger conditions. In these cases, a joint-specific 2. Gummesson. et al. BMC Musculoskelet Disord. 2006;7:44. outcome measure may be more appropriate (eg, patient-rated 3. Angst F, et al. Qual Life Res. 2009;18(8):1043–1051. wrist evaluation questionnaire). 4. Quatman-Yates CC, et al. J Pediatr Orthoped. 2013;33:838–842. 5. Wu A, et al. Burns. 2007;33:843–849. The QuickDASH is quick and easy to administer and can be used 6. LeBlanc M, et al. Arch Phy Med Rehabil. 2014;95(3):493–498. to evaluate a wide range of upper limb musculoskeletal dysfunc- 7. Angst F, et al. Arthritis Care Res. 2011;63:S174–S188. tions, making it especially useful in the clinical setting. It also http://dx.doi.org/10.1016/j.jphys.2014.06.003 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 60 (2014) 176–177 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Correspondence Review of Kinesio Taping ignored other models and techniques A systematic review of randomised trials of Kinesio Taping Elastic therapeutic tape can be used in many ways and the was recently published in Journal of Physiotherapy by Parreira results of other models (eg, skin model) have recently been and colleagues.1 The methods used were very thorough and I published. For example, elastic tape applied to the knee can have congratulate the authors for their great job and for having had the profound effects on neuromuscular control.6 Guimberteau7 has insight to look at all the available evidence in as many languages shown that skin always returns to its original shape and size after as possible. being manipulated, and Fukui8 has demonstrated that the skin moves in a specific physiological direction in the extremities and My main problem with the title and conclusion is that only two trunk. Taping the skin affects these skin properties. of the more than 10 taping possibilities were used in the appraised articles. One was the ‘muscle technique’, which involves taping Currently, numerous professionals persist in using this tape from origin to insertion or vice versa to stimulate or inhibit the because of the perceived positive effect in the daily clinic. On the underlying muscle. The other was the ‘star application’, which is other hand, researchers are telling us that it doesn’t work. We must intended to lift the skin. These taping methods are examples of the be missing something. Is it time for clinician and researchers to original model of taping developed by Kenzo Kase. However, the team up? authors used this evidence to mistakenly conclude that all Kinesio Taping techniques and models do not work. It seems that the Esther de Ru authors have not taken into account that there are many other GoPhysio, Zutphen, The Netherlands schools of thought as to how and why Kinesio Taping works. This tape is used and applied in many different ways around the world. References For at least a decade, allied health professionals have been using 1. Parreira PdCS, et al. J Physiother. 2014;60:31–39. tape in a number of ways: according to the original ideas of Kenzo 2. Lee Y-Y, et al. The effect of applied direction of kinesio taping in ankle strength and Kase (original model); using the concept that the fascia is involved through ‘biotensegrity’ to tape according to ‘fascia lines’ and ‘muscle flexibility. In: 30th Annual Conference of Biomechanics in Sports, Melbourne. 2012; trains’ (fascia model); using the concept that skin and brain are 140–143. involved through mechanical and sensory stimuli (skin model); 3. Luque Saurez A, et al. Man Ther. 2013;18:573–577. using alternative methods such as taping meridians, Chi and chakras 4. Ferna´ ndez Rodrı´guez JM, et al. Apunts Med Esport. 2010;45:61–67. (energy model); and combining Mulligan, Maitland and McConnell 5. Aguado Jodar X, et al. Mechanical behaviour of functional tape: implications for tape applications in various manners (combination model). functional taping preparation. In: 13th Annual Congress European College of Sports Science, Portugal. 2008. Recent studies of the hypotheses of the original model have 6. Konishi Y. J Sci Med Sport. 2013;16:45–48. found no significant differences in effect due to direction of tape.2,3 7. Guimberteau J-C. The skin excursion. Sept 2009. http://www.endovivo.com/en/ No evidence of a skin-lifting effect of the star application has been [accessed 17-05-2014] found. Two studies have shown that tape properties differ by brand 8. Fukui T. Skin movement of the trunk during trunk rotation. In: World Congress of and colour.4,5 Physical Therapy Conference. 2011; RR-PO-203-1-Thu. http://dx.doi.org/10.1016/j.jphys.2014.06.014 Different models and techniques of Kinesio Taping have never been tested We appreciate the opportunity to comment on de Ru’s opinions population was included. Our conclusions are based upon these and interpretations of our systematic review, which aimed to 12 eligible randomised controlled trials and our interpretation was evaluate the efficacy of Kinesio Taping in people with musculo- balanced using the GRADE recommendations. skeletal conditions,1 and to respond to the issues that she raised. These other Kinesio Taping models, to the best of our In her letter to the editor, de Ru claims that there are multiple knowledge, have never been tested in randomised controlled Kinesio Taping models and techniques that can be used, and that trials (therefore these models were not even mentioned in our the eligible articles included in our study just evaluated the review). The seven references provided by de Ru are conference ‘original Kinesio Taping developed by Kenzo Kase’ and we presentations (ie, not published in peer-reviewed journals), ‘mistakenly concluded that all Kinesio Taping techniques and studies of mechanisms, and a randomised trial conducted in models do not work’. She then presents references for supporting asymptomatic subjects (the results cannot be generalisable for these other models, claiming that they might work. people with musculoskeletal conditions). Therefore, the arguments that these other models might work are not based upon high- We do not support the idea that we ignored other Kinesio quality, clinical research. These models and techniques are only Taping models, as we selected all articles that used any model of theoretical and not evidence-based. As responsible researchers, we Kinesio Taping in people with musculoskeletal conditions. We would never recommend something that has never been tested. used comprehensive search strategies, following the recommen- dations from the Cochrane Collaboration, and we are confident that Finally, the statement ‘Currently, numerous professionals all available evidence on the use of Kinesio Taping for this persist in using this tape because of the perceived positive effect 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
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