Australian Journal Of Physiotherapy

]GIF$DT)5_erugi([ Research 79 Figure 5. Meta-regression scatter plot of 26 trials showing the relationship between exercise duration (minutes per week) and the effect on fatigue (effect size, 95% CI). [(Figure_6)D$IG]T Figure 6. Meta-regression scatter plot of 12 trials showing the relationship between aerobic exercise intensity (% relative intensity) and the effect on walking endurance (effect size, 95% CI), fitted with quadratic regression line. influence the effectiveness of high-intensity training, which this that high-intensity or prolonged exercise duration can cause review was unable to assess. It should also be noted that there were immune suppression and increase susceptibility to infection in no trials included in this review that assessed low-intensity healthy people.115 This is a major consideration, given that people exercise. So, while there is evidence that moderate-intensity with cancer are often immunocompromised. exercise may reduce fatigue and improve mobility more effectively than high-intensity, it cannot be concluded that moderate- The current recommendations for exercise for people with intensity exercise is superior to low-intensity exercise for cancer are that they complete at least 150 minutes of moderate- improving these outcomes. intensity exercise per week.6 It is also recommended that people with cancer complete a combination of aerobic and resistance A dose-response relationship for exercise in relation to exercise to achieve this goal. Results from this review support the inflammatory markers was unable to be established. Previous recommendation to complete moderate-intensity exercise, partic- literature has suggested that inflammatory biomarkers’ response ularly in relation to aerobic exercise and the benefits of combined to exercise is dependent on the volume of mechanical work aerobic and resistance exercise programs for improving cancer- completed.117 There were too few trials to establish a dose- related fatigue.19,38–40 The recommendation for the amount of response relationship and a lack of variation in exercise intensity exercise required to achieve benefits for fatigue and activity is less levels in the trials that measured inflammation. There is evidence clear. As such, cancer survivors should follow the recommendation

r_giF([7)TD$IG]eu80 Dennett et al: Dose-response of exercise for cancer survivors Figure 7. Meta-regression scatter plot of 11 trials showing the relationship between exercise duration (minutes per week) and the effect on walking endurance (effect size, 95% CI). to avoid inactivity6 and complete as much moderate-intensity findings demonstrated greatest effect in people with solid exercise as tolerated. tumours, with no significant effect evident for people with haematological malignancies. It is believed that this was the first review that analysed the effect of dose on fatigue in cancer survivors using meta-regression What is already known on this topic: For people with analysis across exercise modalities. It was also the first to cancer, exercise has beneficial effects on strength, cardiovas- investigate the effects of exercise on inflammatory biomarkers cular function, fatigue and quality of life. However, the ideal in people with cancer using meta-analysis. It included only mode and intensity of exercise for people with cancer is randomised, controlled trials, which reduced the risk of selection unclear. bias and increased confidence in the results. What this study adds: Exercise is safe and reduces fatigue and increases endurance in cancer survivors. Moderate-inten- There were some limitations to this review. The search strategy sity exercise appears to be the most appropriate aerobic included only four databases and was restricted to the English exercise for benefits on fatigue and walking endurance. language, which posed some risk of publication bias. However, relatively few articles were located through additional methods eAddenda: Appendix 1 can be can be found online at doi:10. and forest plots were analysed for publication bias. The results for 1016/j.jphys.2016.02.012 activity outcomes were based on trials where fatigue and/or inflammation were also measured among the outcomes, so the Ethics approval: Not applicable. results for activity may not be based on a complete set of available Competing interests: Nil. trials. However, previous reviews on exercise interventions for Sources of Support: Nil. adults with cancer have reported similar results in relation to Acknowledgements: Nil. activity outcomes such as walking endurance.5,7 The overall Provenance: Not invited. Peer reviewed. quality of the evidence was moderate to high, but there were high Correspondence: Amy Dennett, School of Allied Health, La levels of unexplained heterogeneity in the meta-analyses; this is Trobe University and Allied Health Clinical Research Office, Eastern consistent with previous meta-analyses.5,19,38–40 This may have Health, Victoria, Australia, Email: Amy.Dennett@easternhealth. limited the confidence in the size of the pooled effect. To account org.au for this, subgroup and sensitivity analyses were completed based on tumour stream and treatment phase. There was also evidence of References unequal variances between groups, which influence the way in 1. World Health Organisation (WHO). NCD mortality and morbidity. 2012; http:// which the differences of means should be standardised; Glass’ D www.who.int/gho/ncd/mortality_morbidity/en/. Accessed October 9, 2015. effect size was used to overcome this. The analyses were also 2. Australian Institute of Health and Welfare (AIHW) Cancer in Australia: an conducted using Cohen’s d and the main findings remained intact. overview 2012. 2012; Canberra, Cancer Series: Cat. No. Can70. Combining a number of relative-intensity measures (eg, maximum heart rate, VO2max and Borg) may also be a limitation. However, 3. Pinto BM, Trunzo JJ. Health behaviours during and after a cancer diagnosis. Cancer. since these are effective measures of intensity and standardised 2005;104:2614–2623. effects were used, this was unlikely to be an issue. 4. McCorkle R, Ercolano E, Lazenby M, Schulman-Green D, Schilling LS, Lorig K, et al. In conclusion, this review of 42 randomised, controlled trials Self-management: Enabling and empowering patients living with cancer as a supports the growing body of evidence that exercise is a safe and chronic illness. CA Cancer J Clin. 2011;61:50–62. effective intervention for reducing fatigue and improving mobility in adult cancer survivors. It was also able to establish a dose- 5. Fong DYT, Ho JWC, Hui BPH, Lee AM, Macfarlane DJ, Leung SSK, et al. Physical response relationship of intensity for aerobic exercise, supporting activity for cancer survivors: meta-analysis of randomised controlled trials. BMJ current recommendations emphasising moderate-intensity aero- (Clinical Research Ed). 2012;344:e70. bic training in exercise programs for cancer survivors. These 6. Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galva˜o DA, Pinto BM, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42:1409–1426.

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58 Editorial Ethics approval: Not applicable. 2. Duff JM, et al. J Natl Cancer Inst. 2010;102:702–705. Competing interests: Tammy Hoffmann is an author of the 3. Glasziou P, et al. BMJ. 2008;336:1472–1474. TIDieR checklist. The other authors declare that they have no 4. Hoffmann TC, et al. BMJ. 2013;347:f3755. competing interests. 5. Yamato TP, et al. Physiotherapy. D$[_F25IT] 016. http://dx.doi.org/10.1016/j.physio.2016. Source of support: Nil. Acknowledgements: Nil. 03.001. in [6FTp_D$]I ress. Provenance: Not invited. Not peer reviewed. 6. Chalmers I, et al. Lancet. 2014;383:1–56. Correspondence: Mark Elkins, Editor, Journal of Physiotherapy, 7. Ioannidis JP, et al. Lancet. 2014;383:166–175. Australian Physiotherapy Association, Melbourne, Australia. 8. Hoffmann TC, et al. BMJ. 2014;348:g1687. D$TIF[]E4_ mail: scientifi[email protected] 9. Schulz KF, et al. BMJ. 2010;340:c332. 10. Chan AW, et al. Ann Intern Med. 2013;158:200–207. References Websites 1. Herbert R, et al. Practical Evidence-based Physiotherapy. 2nd ed. London: Churchill Livingstone; 2012. www.equator-network.org/wp-content/uploads/2014/03/TIDieR-Checklist-PDF. pdf http://dx.doi.org/10.1016/j.jphys.2016.02.015 Paper of the Year 2015 The Editorial Board is pleased to announce the 2015 Paper of the Year Award. The winning paper is judged by a panel of members of the International Advisory Board who do not have a conflict of interest with any of the papers under consideration. They vote for the paper published in the 2015 calendar year that, in their opinion, has the best combination of scientific merit and application to the clinical practice of physiotherapy. The winning paper is ‘Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: a systematic review’.1 The authors are Davide Corbetta and Roberto Gatti from San Raffaele Hospital and the private practitioner, Federico Imeri, from Milan, Italy. High repetition of tasks connected to locomotion improve mobility in people with motor deficits following stroke.2 Researchers have achieved some augmentation of the benefit obtained from repetitive task practice by incorporating additional measures such as cyclical electrical stimulation3 and cueing of cadence.4 The winning study by Corbetta et al1 shows that incorporating virtual reality into rehabilitation augments several of its benefits: walking speed by a mean of 0.15 m/s (95% CI 0.10 to 0.19), balance by a mean of 2.1 points on the Berg Balance Scale (95% CI 1.8 to 2.5), and mobility by a mean of 2.3 seconds on the Timed Up and Go test (95% CI 1.2 to 3.4). Incorporating virtual reality may augment the benefits of rehabilitation by enabling simulated practice of functional tasks at a higher dosage than traditional therapies.5,6 Other mechanisms contributing to the extra benefit may include immediate feedback about performance on simulated real-life activities7 and improved motivation to complete higher numbers of exercise repetitions.8 The evidence generated by Corbetta and colleagues is an important step in a pathway of research about stroke rehabilitation. In several of the randomised trials that were included in the winning systematic review,1 treadmill training was the form of rehabilitation into which the virtual reality was incorporated. The winning paper therefore builds on existing evidence that treadmill training is effective rehabilitation among ambulatory adults with stroke,9 especially those whose comfortable walking speed is faster than 0.4 m/s before the training.10 The members of the Editorial Board congratulate Davide Corbetta and his co-authors on their success. References 1. Corbetta D, Imeri F, Gatti R. Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: a systematic review. J Physiother. 2015;61:117–124. 2. French B, Thomas L, Leathley M, Sutton C, McAdam J, Forster A, et al. Repetitive task training for improving functional ability after stroke. Cochrane Datab Syst Rev. 2007;4:CD006073. 3. Nascimento LR, Michaelsen SM, Ada L, Polese JC, Teixeira-Salmela LF. Cyclical electrical stimulation increases strength and improves activity after stroke: a systematic review. J Physiother. 2014;60:22–30. 4. Nascimento LR, de Oliveira CQ, Ada L, Michaelsen SM, Teixeira-Salmela LF. Walking training with cueing of cadence improves walking speed and stride length after stroke more than walking training alone: a systematic review. J Physiother. 2015;61:10–15. 5. Kwakkel G, Van Peppen R, Wagenaar R, Wood Dauphinee S, Richards C, Ashburn A, et al. Effects of augmented exercise therapy time after stroke. A meta-analysis. Stroke. 2004;35:1–11. 6. Merians A, Jack D, Boian R, Tremaine M, Burdea G, Adamovich S, et al. Virtual reality augmented rehabilitation for patients following stroke. Phys Ther. 2002;82:898–915. 7. Sveistrup H. Motor rehabilitation using virtual reality. J Neuroeng Rehabil. 2004;1:10. 8. Rizzo A, Kim G. A SWOT analysis of the field of virtual reality rehabilitation and therapy. Presence. 2005;14:119–146. 9. Polese JC, Ada L, Dean CM, Nascimento LR, Teixeira-Salmela LF. Treadmill training is effective for ambulatory adults with stroke: a systematic review. J Physiother. 2013;59: 73–80. 10. Dean CM, Ada L, Lindley RI. Treadmill training provides greater benefit to the subgroup of community- dwelling people after stroke who walk faster than 0.4 m/s: a randomised trial. J of Physiother. 2014;60:97–101. http://dx.doi.org/10.1016/j.jphys.2016.02.008

Journal of Physiotherapy 62 (2016) 60–67 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Invited Topical Review Physiotherapy management of lung cancer Catherine L Granger a,b,c a Department of Physiotherapy, University of Melbourne; b Department of Physiotherapy, Royal Melbourne Hospital; c Institute for Breathing and Sleep, Melbourne, Australia KEY WORDS [Granger CL (2016) Physiotherapy management of lung cancer. Journal of Physiotherapy 62: 60–67] Lung cancer ß 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article Physiotherapy under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Exercise Physical activity Rehabilitation Introduction people with lung cancer, multi-morbidities are common.7 The most common of these is COPD, occurring in 40 to 70% of people with lung Lung cancer is associated with significant morbidity and cancer.3,4 Due to the aetiology of lung cancer, the older age of mortality and is a substantial burden to healthcare systems. patients, and presence of multi-morbidities, people with lung cancer Physiotherapists play an important role in the management of DF$IcT_4]0[ onstitute a complex patient population to manage. people with lung cancer. Advances in research over the past decade, particularly supporting the use of exercise training, have Medical management of lung cancer rapidly progressed the role of physiotherapy in lung cancer. This review summarises the burden associated with lung cancer, the The medical treatment of lung cancer has improved over recent management of lung cancer with a particular focus on physiother- decades; however, lung cancer remains the leading cause of cancer apy interventions, and future directions for research and clinical death worldwide and the overall 5-year survival rate is 14%.2F_IT]9D[3$ practice. Medical treatments include surgical resection, chemotherapy, radiotherapy and targeted agents, each of which is associated with What is lung cancer? several side effects (Box 1). The choice of treatment combination depends on the histological type, tumour location, cancer stage and Cancer is a generic term for a heterogeneous group of diseases the patient’s degree of frailty.8 that occur when abnormal cells are not destroyed by normal metabolic processes, but instead proliferate and metastasise out of Surgical resection control.1 Lung cancer is the leading type of cancer diagnosed in males worldwide.2 In females, lung cancer is the fourth most Surgical resection of the tumour provides the best potential common cancer diagnosed behind breast cancer, colorectal cancer chance of cure; however, approximately 70% of people present and cancer of the cervix uteri.2 Multiple factors are understood to with advanced inoperable disease and 25% of people with operable play a role in the induction of lung carcinogenesis. Tobacco disease are unfit for surgery.8 For those people who are able to smoking is the leading cause.3 Other risk factors include exposure undergo surgery, surgical options include pneumonectomy, to environmental or occupational carcinogens, pulmonary inflam- lobectomy or sub-lobar resection.9 Lobectomy is the preferred mation, airflow limitation, chronic obstructive pulmonary disease surgical approach over limited pulmonary resection in early stage (COPD) and genetic predisposition.1,3,4 Weaker evidence links NSCLC as it is associated with lower rates of loco-regional physical inactivity and poor nutrition to an increased risk of lung recurrence and improved survival.9 However, limited pulmonary cancer.5 Non-small cell lung cancer (NSCLC) is the most common resection is advantageous in terms of preserving a greater amount type of lung cancer and accounts for 85% of new lung cancer of lung volume, limiting postoperative physiological impairment diagnoses.6 Small cell lung cancer accounts for a small proportion and, consequently, reducing postoperative complications and of lung cancer diagnoses and is remarkably different to NSCLC in hospital length of stay.9 Video-assisted thoracoscopic surgery is terms of aetiology, prognosis and treatment.6 This review mainly the preferred approached over a thoracotomy incision and is focuses on NSCLC, which is where the majority of physiotherapy associated with: less pain, better shoulder range of motion and research exists. improved function early after surgery; fewer postoperative complications; decreased risk of intensive care readmission; Lung cancer is a disease predominantly seen in the elderly shorter hospital length of stay; and less need for inpatient population; more than 80% of people diagnosed with lung cancer are rehabilitation.8,10,11]F14[I_D$T Following lung resection, clinically important aged 60 years or older.68F]D$3I[_T Due to the high incidence of smoking among http://dx.doi.org/10.1016/j.jphys.2016.02.010 1836-9553/ß 2016 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/4.0/).

Invited Topical Review 61 Box 1. Common side effects resulting from lung cancer cough, pain and insomnia. These often occur as symptom clusters treatments. and result in high patient distress and interference with daily Surgery Chemotherapy Radiotherapy Molecular activities.21,22 Distress due to symptoms at the time of diagnosis is targeted predictive of mortality.20 Avoidance of symptom triggers (namely  pain  fatigue  f]FID$T_12[ atigue therapies physical activity) promotes a vicious cycle of inactivity and  [FD8]cI_T$ ough 1_TD$[F]I nausea  1[7_FTD$c]I ough  fatigue [2]_TD$IF infection  o]FID$T2[_ esophagitis  f]FID$_92[T atigue functional decline; a phenomenon that is becoming well described  DTv]FI_9[$ omiting  nID$T_32[F] ausea  n]FID$T03[_ ausea in the lung cancer literature and a cycle that is important for  01_TD$I][aF naemia  [2_TD$IF]v4 omiting  [vF31_TD$]I omiting physiotherapists to address.23  DIF]dT_1[$ iarrhoea  25_T[D$IF]skin  [32_TD$IF]loss oITD_F[$]3 f  FID$_]c[12T onstipation Cancer cachexia is a multi-factorial syndrome defined by an  loss of [26_TD$IF]erythema 43[a]FID$T_ ppetite  F]dI[27_TD$ iarrhoea  35_TD$IF]d[ iarrhoea ongoing loss of skeletal muscle mass that cannot be fully reversed appetite  loss of  c]FID$T_63[ onstipation by conventional nutritional support and leads to progressive  D$T_3IF]h1[ air lDTF$]I[_41 oss  [37_TD$]sIF kin and hair functional impairment.24 Clinically, cancer cachexia presents as a  IDF[15_]mT$ outh 6FDuTI1[$_] lcers appetite combination of anorexia, metabolic alterations, loss of fat mass,  $DIT7F1[]w_ eight D[F8ITg_1]$ ain  hair loss changes  r]FID$T_32[ igors loss of skeletal muscle protein, loss of weight, impaired muscle [19_TD$IF]or []l2DTI_F0$ oss  ID$FT_82[fl] u-like strength and fatigue.24 Important implications include reduced symptoms ability to tolerate surgery, poor response to chemotherapy or radiotherapy, impaired resilience to treatment, worse health- immediate postoperative pulmonary complications (PPCs) can related quality of life and increased mortality.24 At diagnosis, include respiratory failure (prolonged mechanical ventilation, people with lung cancer have reduced peripheral muscle strength re-intubation or acute respiratory distress syndrome), pneumonia compared to healthy aged-matched peers.23 Skeletal muscle and atelectasis requiring bronchoscopy.12 Reported rates of PPCs dysfunction is likely to significantly contribute to exercise vary from 3 to 15%; this is partly due to a lack of consensus on a PPC definition.13,14 Postoperative pulmonary complications are associ- intolerance, particularly given that 70% of preoperative peak ated with increased hospital length of stay, intensive care exercise tests are stopped due to leg discomfort rather than readmissions and mortality.13 dyspnoea, and functional capacity is not related to spirometric Chemotherapy measures of lung function in this population.25,26 Peripheral Chemotherapeutic agents inhibit cell division in both cancerous muscle strength declines further during and after lung cancer and non-cancerous cells and therefore result in side effects due to treatment.23 Given the importance of peripheral muscle strength the damage caused to normal cells.15 These side effects include bone marrow suppression and resultant immunosuppression, to overall physical function, this impairment is an important which are worst 2 weeks following treatment,16 and impaired feature of lung cancer for physiotherapists to manage. respiratory function, particularly diffusing capacity.17 Following diagnosis, functional decline is common and rapid, Radiotherapy and activity limitations and participation restrictions commonly ensue.23,27,28 At diagnosis, functional capacity is reduced com- External beam radiotherapy works by producing radiation, pared to healthy aged-matched peers.23 Functional capacity which is targeted at the tumour, and results in apoptosis of the cancerous cells. Side effects of radiotherapy occur due to the measured preoperatively is predictive of postoperative outcomes, associated formation of free radicals, widespread inflammatory response and release of cytokines.15 Respiratory function, particu- including: respiratory failure, hospital length of stay, health- larly diffusing capacity, is impaired following radiotherapy.18 related quality of life and survival.29 Functional capacity is also Molecular-targeted agents predictive of survival in advanced lung cancer. FW[_I43D]$T ith every 50 m improvement in the 6-minute walk test, survival improves by 13% Tumours are driven by genomic mutations and, increasingly, the different genomes in NSCLC are being recognised and targeted and people who walk at least 400 m before chemotherapy have in the treatment of the disease. Targeted agents differ from greater survival time.30,31ID2F$]_4[T A number of studies have reported that chemotherapy agents because they inhibit ‘pathways outside of functional capacity progressively declines after diagnosis; howev- the nucleus that are required for malignant proliferation chemo- er, it is possible that this decline may be limited to the inoperable therapy agents to act’, whereas chemotherapy agents act in the nucleus by inhibiting the division of any rapidly dividing cells.19 population. In the surgical literature, most studies report functional capacity to temporarily decline after lung resection In summary, lung cancer is associated with adverse physiologi- and then return to baseline by 3 to 6 months postoperatively.32,33 cal impairments that arise from multiple causative factors, Conversely, people undergoing a pneumonectomy experience including: the disease, treatment, multi-morbidities and pre- sustained reductions in functional capacity postoperatively.33 existing harmful lifestyle behaviours. Consequently, this leads to Deterioration in functional capacity is also observed during significant disease burden. chemotherapy. An Australian study, including people with Burden of lung cancer operable and inoperable lung cancer, found an overall large Lung cancer is associated with higher disease burden, more clinically and statistically significant mean decline of 78 m in the 6- physical hardship and greater symptom distress than other cancer minute walk test over 6 months from diagnosis, suggesting that in types.6,20,21 Important symptoms include dyspnoea, fatigue, many people, functional capacity does not recover back to pre- treatment levels in the short term.23 Not surprisingly, functional capacity is the most common endpoint targeted by lung cancer exercise trials to date.29 Physical inactivity is common and prevalent in lung cancer. Studies have demonstrated that before surgery or treatment, physical activity levels are low and less than those of healthy aged- matched peers; this is based on self-report and objective measures.23,34,35 United States and Australian data show that only 26% and 40% of people with lung cancer meet cancer-specific recommended physical activity levels, respectively.23,34 Impor- tantly, before treatment, higher physical activity levels are seen in people with better functional capacity, muscle strength, physical function, nutritional status and self-determination to exercise, and less anxiety, depression, distress, fatigue and symptoms.23,35 There are many reasons why people with lung cancer may be inactive at diagnosis: they might have been inactive for a large proportion of their life (this is a risk factor for developing cancer) or physical

62 Granger: Physiotherapy management of lung cancer activity levels may have already declined as the cancer progressed colon, pancreatic, endometrial and prostate cancer.42 Excessive prior to detection; the latter is more likely in the inoperable (more sedentary time, independent of moderate and vigorous physical advanced cancer) group. The cancer cachexia process starts early activity, is associated with increased risk of developing cancer.44 and many of the features can progress significantly before Higher physical activity levels after cancer diagnosis are associated diagnosis.24 Following surgery and treatment, physical activity with reduced cancer-specific and all-cause mortality in breast, levels decline further. Agostini and colleagues36 found very low colon and prostate cancer.45,46 Additionally, there is emerging levels of physical activity immediately postoperatively during the evidence linking post-diagnosis sedentary time with reduced inpatient stay (3% of preoperative steps/day); and Novoa and cancer-specific mortality as well.44 It is important to note that the colleagues37 found 25% and 49% reductions in steps per day evidence, to date, in the general cancer population is limited by compared to preoperative values 30 days after lobectomy and lack of prospective research designs, longitudinal repeated pneumonectomy, respectively. During cancer treatment, only 26% measurement of physical activity and control for other important of people meet the recommended activity levels27 and higher prognostic factors. The mechanisms between these associations physical activity levels are seen in people with better physical are not well understood. It is hypothesised that exercise modulates function and health-related quality of life, and with lower circulating metabolic and sex-steroid hormone concentrations, symptoms and depression.23 Importantly, it is unknown if this immune surveillance, and reduces systemic inflammation/oxida- is a causal relationship. It is possible that people are able to be more tive damage.47 In lung cancer specifically, there are only a small active because they have fewer symptoms and better health- number of studies investigating the link between physical activity related quality of life; conversely, being active can reduce and development of lung cancer, and they report conflicting symptoms (or desensitise the person to the symptoms) and results. There is a strong rationale for more research to be enhance quality of life.38 Six months after diagnosis, physical conducted in this area, given the high potential clinical significance activity levels remain reduced, with only 31% of survivors meeting of physiotherapy and exercise to target lung cancer prevention and the recommendations.23 Survivors of lung cancer have long-term survival as outcomes. reductions in physical activity and health-related quality of life, and even experience fatigue 5 years following surgery.39,40 There is growing evidence for exercise interventions to reduce cancer morbidity in lung cancer. The role of exercise in this In summary, the physical and psychological implications of situation is to prevent deterioration and to maximise or restore lung cancer are severe, disabling and long-standing. They have physical status prior to, during and following treatment. A previous significant ramifications for the patient, the family/carers and the Cochrane review and three systematic reviews have been healthcare system. Physiotherapy management is important to conducted in the area of lung cancer specifically.48–51 The majority address these issues in lung cancer. of research, to date, has been performed in the preoperative or postoperative treatment stage of lung cancer, with a smaller Physiotherapy management of lung cancer number of studies investigating the role of exercise during treatment or in advanced disease. The evidence supporting A summary of the physiotherapy interventions that are used in exercise at these different time points is summarised in subse- the management of lung cancer, along with the level of evidence quent sections. that underpins their use, is provided in Figure 1. Physiotherapy interventions vary depending on the stage in disease trajectory and Prehabilitation timing relative to treatment. Physiotherapy services for lung cancer have historically been hospital-based and focused on PPCs Prehabilitation is exercise delivered prior to surgery or after surgery.41 Other physiotherapy interventions, such as treatment. There are two clinical rationales for this. Prehabilitation exercise training, are less frequently performed as routine clinical can be used for: operable patients (assessed to be fit for surgery) to practice, despite the rapid growth of evidence supporting these maximise their physical status prior to the insult of surgery and interventions over the last decade. reduce postoperative morbidity; or inoperable patients (deemed unfit for surgery based on cardiovascular impairment) to improve The cornerstone of physiotherapy management in lung cancer their physical status enough for them to become operable. The should be prescription and delivery of exercise intervention. evidence supporting prehabilitation is still in its infancy. Most of Physical activity and exercise are vital components targeting three the research to date has been conducted in patients already main aspects of the cancer continuum: prevention, mortality and deemed operable and, generally, studies are small and limited by morbidity. The American Cancer Society recommends that adults lack of randomisation and/or control groups. Prehabilitation is not with cancer engage in at least 150 minutes of moderate-intensity yet part of routine clinical practice worldwide. Until further aerobic exercise and two sessions of resistance exercise per week, research suggests otherwise, in already operable patients, it is which is the same as the guidelines for the general adult currently not recommended to delay surgery in order to undertake population.42,43 These recommendations are supported by strong prehabilitation, but rather use the time waiting for surgery evidence derived predominantly from other cancer populations. opportunistically to deliver prehabilitation as able. Higher physical activity levels are protective against developing [(Figure_1)TD$IG] Benefit from the intervention No benefit from the intervention Several high-quality RCTs Exercise-based rehabilitation after surgery or curative treatment Single high-quality RCT Prehabilitation Early palliative care Prophylactic postoperative or several low-quality respiratory physiotherapy RCTs Shoulder and thoracic cage ROM exercises Uncontrolled trials or Exercise in advanced disease Mobility training expert opinion Breathlessness management Figure 1. Interventions for the management of lung cancer with associated levels of evidence. ROM = range of motion, RCT = randomised, controlled trial.

Invited Topical Review 63 The three systematic reviews in this area include a small Physiotherapy management of this cohort has changed over the number of studies and an even smaller number of randomised, last decade due to improvements in pain management and the controlled trials. There are nine studies inclusive of five random- increasing use of video-assisted thoracic surgery and clinical ised trials delivering exercise preoperatively and two studies pathways. Thoracic surgery clinical pathways incorporate physio- inclusive of one randomised trial delivering exercise both therapy principles and early mobilisation in daily nursing care and preoperatively and postoperatively.48,49,51 To date, meta-analyses are associated with reduced hospital length of stay (Box 2).58 The have not been conducted due to lack of robust trials and landmark randomised trial by Reeve and colleagues14 demon- heterogeneity of measures and interventions.48,49,51 One random- strated no difference in PPC rate or hospital length of stay for ised trial was stopped early due to poor recruitment (n = 9);52 participants treated with prophylactic targeted respiratory phys- three other randomised trials reported that prehabilitation was iotherapy (deep breathing and coughing, mobilisation, progressive associated with reduced hospital length of stay,53,54 PPCs,53,54 and/ shoulder/thoracic mobility exercises) plus usual care, compared to or days needing a chest tube postoperatively,52 as well as improved usual care alone (no physiotherapy). Usual care included a clinical respiratory function immediately post intervention.53,54 One pathway with early mobilisation. The PPC rate was low at 3.9% and randomised trial 52 found conflicting results (no effect for hospital hospital length of stay was short at a median of 6 days.14 Whilst length of stay or PPCs between groups) and currently the evidence this study is from a single centre in New Zealand and practice may is not definitive. The systematic reviews, inclusive of the evidence differ in other countries, it is the most definitive study conducted from non-randomised trials (mostly single-group studies), dem- to date and the only randomised trial in this area with a ‘no onstrate that people who undergo prehabilitation experience physiotherapy’ control group.51 A number of other studies have improved functional capacity immediately after interven- demonstrated that there is no added benefit of adjuncts to tion.48,49,51 There is limited research regarding the impact of physiotherapy (incentive spirometry, intermittent positive pres- prehabilitation for inoperable patients and only one article sure breathing, flutter, positive pressure devices, or breathing and included in the systematic reviews addressed this: Fang and coughing exercises) on PPCs or length of stay.51 Therefore, for colleagues55 included both participants who were deemed hospitals using clinical pathways, physiotherapy services should operable and inoperable. Notably, their results demonstrated that be focused on assessment (with or without mobilisation) of 59% (n = 10/17) of the inoperable group were re-classified as thoracotomy patients on the first postoperative day and ongoing operable after exercise training and postoperatively there was no respiratory physiotherapy for high-risk patients or those who fall statistical difference in PPC rate between the (initially) operable off the clinical pathway (ie, do not achieve set pathway goals or group (34%) and (initially) inoperable group (40%). Since the develop a PPC) (Box 2). Currently, there is no gold standard risk- systematic reviews, one further randomised trial has been prediction tool with which to identify high-risk patients or those published,56 as well as seven more non-randomised trials (mostly who will develop a PPC; however, the known independent risk single-group studies), which confirm the previous findings. The factors for PPC are being aged ! 75 years, having a body mass index interventions tested in studies to date were predominantly ! 30 kg/m2, an Anesthesiologists score ! 3, a current smoking individual, supervised, outpatient-based and delivered five times history and COPD.13 Independent factors predictive of lower a week for a median of 4 weeks (range: 1 to 10 weeks). All studies postoperative physical activity are being aged ! 75 years, having a included aerobic exercise training and over half also included resistance training. Whilst the evidence suggests that prehabilita- Box 2. Example clinical pathway for patients after tion is safe, questions remain regarding the feasibility. Generally, thoracotomy.59TD7F[$I_] the time between lung cancer diagnosis and surgery is short (< 1 month). Whilst some studies have shown successful effects of Day 1 postoperative short-term exercise training, the challenge exists in both clinical  Sit out of bed in ward chair and research settings to recruit, assess and commence exercise as  Ambulate ! 20 m on ward soon as possible after diagnosis, to maximise the length of time available for exercise training. This issue may challenge the Æ portable supplemental oxygen if required to keep SpO2 ! translation of evidence supporting prehabilitation into clinical 95% practice. Æ portable suction if large air leak present In summary: the evidence supporting prehabilitation in lung Æ assistance from one person if required cancer is emerging, particularly for people already deemed fit for Æ gait aid if patient is unable to ambulate despite assistance surgery. The small number of randomised trials conducted to date provide preliminary evidence that prehabilitation may be benefi- from one person cial in improving postoperative outcomes such as reduced hospital  Teach supported cough with towel wrap length of stay and PPCs. The evidence in this area is limited by lack  Commence respiratory physiotherapy if indicated (high-risk of randomised trials and further work is required before prehabilitation should be translated into routine clinical practice patient or presence of PPC) for people undergoing surgery for lung cancer. Day 2 postoperative Perioperative management  Ambulate ! 50 m on ward Physiotherapy management in the immediate postoperative Æ portable supplemental oxygen if required to keep SpO2 ! period aims to treat PPCs, prevent musculoskeletal sequelae, and 95% facilitate early and safe discharge home. Hospital length of stay after lung resection is generally short (5 to 6 days), although length Æ portable suction if large air leak present of stay is longer for patients who develop a PPC.14 Physiotherapy Æ assistance from one person if required principles include early mobilisation commenced on the first Æ gait aid if patient unable to ambulate despite assistance postoperative day, sitting out of bed and supported coughing. Shoulder/thoracic cage exercises are prescribed after removal of from one person the intercostal catheter and are associated with reduced pain and  Encourage supported cough improved function in the short term.14,57  Commence or continue respiratory physiotherapy if There is a lack of evidence to support to use of prophylactic indicated (high risk or presence of PPC) targeted respiratory physiotherapy interventions for routine patients managed on a clinical pathway following lung resection.51 Day 3+ postoperative  Review by physiotherapist only if patient requires ongoing mobility assistance or respiratory physiotherapy Once intercostal catheters are removed  Teach upper limb and thoracic mobility range of motion exercises  Physiotherapy completes a discharge mobility assessment and provides any discharge planning as required for safety

uTgi$Fr_I)G]2[(eD64 Granger: Physiotherapy management of lung cancer predicted forced expiratory volume in one second (FEV1) < 70% Study SMD (95% CI) and lower self-reported preoperative physical activity;36 this Arbane32 a Random suggests that these patients may be the ones to not meet clinical Brocki62 b pathway goals. Physiotherapy interventions used to treat PPCs Edvardsen59 b related to low lung volumes or sputum production/retention Stigt61 c include additional mobilisation, thoracic expansion exercises, sustained maximal inspirations, active cycle of breathing techni- Pooled ques and continuous positive airway pressure. –2 –1 0 1 2 Physiotherapists are involved in the assessment of patients’ safety related to mobility for hospital discharge. Most patients Favours control Favours exercise following lung resection are able to be discharged directly home; however, a small proportion of patients (2% in an Australian Figure 2. Effect of exercise after lung resection on health-related quality of life. study)59 do not regain a satisfactory degree of independence a Global function of the European Organization for Research and Treatment of required for their social situation and home environment. These Cancer Quality of Life Questionnaire core 30. patients can be transferred to a sub-acute inpatient rehabilitation b Physical component of the Medical Outcomes Study Short Form 36 General Health facility for a period of intensive physiotherapy/rehabilitation Survey. targeting function and mobility. c Total score of the St George’s Respiratory Questionnaire. Exercise following treatment Exercise following surgery or treatment aims to restore physical associated with reduced cancer symptoms, anxiety and depres- sion.48,63 status (addressing loss of functional capacity and muscle strength, The interventions examined in studies to date are generally which may occur during treatment) and to maximise function, derived from the COPD and pulmonary rehabilitation literature, physical activity, psychological status and health-related quality of which has been extensively tested and implemented into clinical practice.65 Hence, the majority of studies include both aerobic life in the long term. The Cochrane review of exercise training after (ground walking, treadmill and/or stationary cycle) and resistance lung resection included three randomised trials involving 178 par- training components and, currently, this combined training approach is recommended. The addition of other components ticipants; it found significant improvements in functional capacity such as breathing exercises, dyspnoea management, balance in favour of the intervention group (MD 50 m on the 6-minute walk exercises and stretches are used occasionally; however, the test, 95% CI 15 to 85).50 A large number of single-group studies independent contribution of these training components to the have confirmed this finding and demonstrated reduced symptoms resultant outcomes is unknown.48–51 The randomised trial by Salhi immediately after the intervention.48–51 Since the Cochrane review and colleagues investigated the impact of whole body vibration there has been another randomised trial published;60 this trial training as an alternative to resistance training.64 Results demonstrated significant improvements in functional capacity investigated the benefit of high-intensity aerobic and resistance and quadriceps muscle strength in the resistance training group; training in people 5 to 7 weeks following surgery and similarly however, this was not seen in either the whole body vibration found improvements in functional capacity (peak oxygen uptake) training group or control group, suggesting that whole body in favour of the intervention group.60 The Cochrane review of post- vibration training is not an alternative to resistance training.64 lung resection exercise on the outcomes of health-related quality Generally, exercise programs are supervised, run for 8 to 12 weeks of life and FEV1 was inconclusive.50,61,62 The addition of the (range 4 to 14 weeks) and occur in an outpatient setting, although subsequently published trial60 to the meta-analysis continues to inpatient and home-based programs have also been used.48–51F]DI[3$_T The exercise program should be individually tailored to the patient and show no significant between-group difference for health-related there are a number of factors to consider when prescribing exercise quality of life (SMD 0.34, 95% CI –0.14 to 0.81) (Figure 2; see for this population (Table 1).66 Careful pre-exercise screening and Figure 3 on the eAddenda for the detailed forest plot). Exercise following treatment with curative intent has also been researched in two randomised trials63,64 and a number of single-group studies.48,63 Exercise in this situation is also associated with improvements in functional capacity but not health-related quality of life.48 Improvements in muscle strength are observed in people who undergo resistance training.48 Exercise is also Table 1 General contraindications and precautions to exercise training. Exercise Patient cohort Details All All Avoid exercise if: Aerobic Upper or lower limb lymphoedema  haemoglobin level < 80 g/l Resistance Peripheral limitation such as severe cancer cachexia  neutrophil count 0.5 x 109/microlitre or muscle atrophy  platelet count < 50 x 109/microlitre Known or high risk for bony metastases  fever > 38 8C  extreme fatigue or severe nausea High risk for osteoporosis Wear compression garment during exercise High risk for bone fracture Commence with resistance training and then progress to incorporate Cardiorespiratory limitation such as chemotherapy-induced aerobic training once muscle bulk and strength is improved left ventricular dysfunction or severe anaemia Prescribe with caution (recommend medical clearance before Postoperative patients commencement particularly for unstable bone or spinal metastases/fractures) Prescribe with caution Stretches Postoperative patients Prescribe with caution Generally contra-indicated (recommend medical clearance before commencement) Care with wound healing – often requires 6 to 8 weeks postoperatively for healing prior to commencement of resistance exercises (recommend medical clearance before commencement) Avoid upper-limb stretches until removal of intercostal catheter

Invited Topical Review 65 assessment, and monitoring throughout the exercise program is monitored and supervised by health professionals located advised;66 this includes consideration of the patient’s co-morbid- elsewhere.81,82 Whilst the efficacy of telerehabilitation has ities. Tai Chi has been tested as an alternative form of exercise not been investigated in lung cancer,48 recently, Hoffman and training;67,68 a randomised trial involving patients following lung colleagues reported that seven patients with lung cancer resection found a 16-week Tai Chi program to be associated with successfully used a movement-sensing gaming consolea at improved blood immune function.67,68 home to complete walking and balance exercises.83 Further research should investigate whether home-based exercise In summary, growing evidence suggests that exercise following training is effective in advanced lung cancer and methods to surgery/treatment is associated with improvements in physical promote adherence to unsupervised exercise. and physiological outcomes. Exercise in this setting is not yet routine clinical practice. In Australia and New Zealand, < 25% of Physiotherapy involvement in palliative care patients are referred to pulmonary rehabilitation after lung resection.41 Further randomised trials to strengthen the meta- Early palliative care is important in advanced lung cancer. A analyses conducted to date will assist in the translation of evidence landmark study published in 2010 examined early palliative care into routine clinical practice. consisting of: structured meetings with palliative care clinicians discussing physical and psychosocial symptoms; goals; decisions Exercise in advanced disease about treatment; and coordination of care. Compared with aggressive end-of-life care, this early palliative care improved Exercise for people with advanced lung cancer aims to prevent survival, health-related quality of life and mood for people with deterioration in physical and psychological status and maximise metastatic lung cancer.84 Physiotherapy management of this independence. This is an area that is currently being actively population includes management of breathlessness with breath- investigated. Several randomised trials are in progress in Australia, ing retraining, relaxation techniques and activity pacing. In an Denmark, Germany, Belgium and Spain, and they will significantly uncontrolled study, this was associated with improved breath- add to the body of literature in the near future.69–72 The lessness, functional capacity, physical activity levels and health- preliminary data from two randomised trials73,74 and five non- related quality of life, and less distress.85 Commonly, patients randomised trials (mostly single-group studies)75–79 published to are admitted to hospital with significant functional decline date are promising. The randomised trial by Henke and colleagues (to a point where the patient or carer cannot manage at home), demonstrated significant differences in favour of the intervention or to a hospital/hospice in the end-of-life period for palliation. group for functional capacity, physical function, muscle strength, At this point in the disease trajectory, the focus of symptoms and health-related quality of life, despite 63% of the physiotherapy is on maximising the patient’s physical indepen- participants completing the trial (n = 29/46).73 Results from some dence and should be driven by his/her own goals and of the other studies have confirmed these findings and demon- wishes. Physiotherapy interventions include assistance with strated improvements in functional capacity and muscle strength mobilisation, provision of gait aids, and function-directed in study completers. The exception to this are the studies by Temel exercises such as sit-to-stand practice to optimise daily physical and colleagues78 and Jastrze˛ bski and colleagues,79 which found no functioning. statistically significant change in these outcomes; although given the rapid functional decline that occurs in advanced lung cancer, Future directions for research and practice maintenance is a positive result. Consistently, studies report no change in global health-related quality of life.75–77 All studies The landscape of cancer research and treatment has changed included patients during treatment. One randomised trial investi- significantly over the past two centuries. Commencing as an gated the benefit of exercise during targeted therapy and incurable disease with rising incidence and mortality rates, demonstrated that exercise was safe and associated with improved research and healthcare now allow cancer to be a curable disease functional capacity, dyspnoea and fatigue.74 The exercise programs for many, with mortality rates declining and a rise in the number of tested were combined aerobic and resistance exercise delivered in people living as cancer survivors in our communities. Unfortu- either outpatient,74,75,78 inpatient,73,79 or both in-patient and out- nately, the picture for lung cancer specifically is remarkably less patient settings.76,77 Neuromuscular electrical stimulation may be favourable, and despite slight advances in medical treatment, an option for patients with severe symptoms that limit exercise survival rates remain dreadful. Research is urgently needed to performance, although a recent randomised trial demonstrated address the efficacy of new treatments to improve the chance of poor feasibility and no benefit when administered during palliative cure in lung cancer. In 2005, the first paper was published showing chemotherapy.80 Unfortunately, study completion rates in the that exercise improved survival in people with breast cancer.86 studies published to date are poor and range from 44 to 77%.75–78 Exercise has the potential to influence inflammation, tumour Research involving people with advanced lung cancer is particu- morphology, tumour growth and cancer recurrence.87,88 The larly challenging, given the progressive nature of disease and short question of whether exercise improves survival in lung cancer is survival time following diagnosis. A proportion of non-completion important and remains unanswered. The challenge over the next in these studies is due to deaths. few decades is to test and establish the potential role that exercise may play in treating lung cancer with the ultimate aim of Adherence to exercise training is an important issue in improving survival. advanced lung cancer. Adherence rates vary greatly. Adherence to the exercise training sessions is higher for supervised There are a number of limitations and gaps in the current hospital-based training (inpatient setting 95%,76 outpatient literature. The exercise studies are generally small, lack randomi- setting 44 to 77%)75–78 than for unsupervised home training sation and control groups, and rarely include long-term follow-up. (9%).77 However, these adherence rates are from a small number The interventions tested vary in terms of timing, exercise type, of pilot studies and home-based training has not been tested in duration and delivery. There is an abundance of studies in progress isolation. Home-based training is a highly appealing option. that seek to address these questions (55 open studies on People with lung cancer are already required to attend the ClinicalTrials.gov). Exercise in lung cancer is a growing area of hospital frequently for appointments, investigations and treat- practice and has the potential to minimise the debilitating physical ment, and therefore the ability to deliver physiotherapy/exercise and psychological decline that often occurs with lung cancer. As treatment away from the hospital is important. Home-based evidence emerges, an important target for physiotherapy over the training also allows increased access for people living in rural next decade will be to rapidly translate findings of research studies areas and those without the ability to commute to the hospital. into clinical physiotherapy practice. Telerehabilitation also poses a potential alternative model of delivery, where patients exercise at home whilst being

66 Granger: Physiotherapy management of lung cancer Footnotes: aNintendo Wii Fit plus, Nintendo Co, Ltd, Kyoto, 26. Morice R, Peters E, Ryan M, Putnam J, Ali M, Roth J. Exercise testing in the evaluation of patients at high risk for complications from lung resection. Chest. Japan. 1992;101:356–361. eAddenda: Figure 3 can be found online at doi:10.1016/j.jphys. 27. Schmitz K, Courneya K, Matthews C, Demark-Wahnefried W, Galvao D, Pinto B, et al. ACSM roundtable on exercise guidelines for cancer survivors. Med Sci Sports 2016.02.010 Exercise. 2010;42:1409–1426. Ethics approval: Not applicable. 28. Pan H, Lin K, Ho S, Liang C, Lee S, Wang K. Factors related to daily life interference in lung cancer patients: A cross-sectional regression tree study. Eur J Oncol Nurs. Competing interests: Nil. 2012;16:345–352. Source(s) of support: Dr Granger is supported in part by a 29. Granger C, McDonald C, Parry S, Oliveira C, Denehy L. Functional capacity, physical activity and muscle strength assessment of individuals with non-small cell lung National Health and Medical Research Council (NHMRC) Translat- cancer: a systematic review of instruments and their measurement properties. BMC Cancer. 2013;13:135. ing Research Into Practice Fellowship, Australia, co-funded by 30. Kasymjanova G, Correa J, Kreisman H, Dajczman E, Pepe C, Dobson S, et al. Cancer Australia. Prognostic value of the six-minute walk in advanced non-small cell lung cancer. J Thoracic Oncol. 2009;4:602–607. Acknowledgements: Professor Linda Denehy. 31. Jones L, Hornsby W, Goetzinger A, Forbes L, Sherrard E, Quist M, et al. Prognostic Provenance: Invited. Peer reviewed. significance of functional capacity and exercise behavior in patients with meta- static non-small cell lung cancer. Lung Cancer. 2012;76:248–252. Correspondence: Catherine Granger, Department of Physio- 32. Arbane G, Tropman D, Jackson D, Garrod R. 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Journal of Physiotherapy 62 (2016) 118–119 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Correspondence Research requires deep knowledge of the modality to be tested As associates of Dr Kenzo Kase, Founder and Chairman of the swelling at the ankle may not have been properly measured.5 We Kinesio Taping Association International, we feel called upon to do not know whether these people continued to participate in the respond to published research and correspondence with regard to sport that caused the injury in the first place. ‘Kinesio Taping does not decrease swelling in acute, lateral ankle sprain of athletes: a randomised trial’]F[_DIT$5 by Nunes and colleagues.1F]DI[4$T_ Tape measurement can have huge variability depending on who is measuring, and consistent tension is extremely difficult. We are Nunes claims that the taping application used was drawn from not talking about litres of fluid in these patients, but something Dr Kase’s book,2 but they only ‘partially’ followed the book’s more like tablespoons of fluid that are sufficient to cause pain and instructions. They tested two pieces of tape; they did not test the change biomechanics of a joint. As for placement, the appropriate Kinesio Taping Method. As Kinesio Taping educators we found both question to ask is: do you want direct or indirect draw of fluid? the study itself and the follow-up communication puzzling. For many years, any Kinesio Taping research at all was valued It is evident to anyone who is trained and experienced in the for providing guidelines for further study. We have now gone past assessment and application protocols for lymphatic Kinesio Taping that point, and we expect to see studies performed in a responsible that the process used was simply wrong. The team does not appear and informed manner. This study does not meet the lowest to include anyone certified or extensively trained in the Kinesio standard of responsible scientific researchD$[ITF1_]. Taping Method. Kim Rock Stockheimera,*, Gu¨ l BaltacıbDF_],$T2I[ Graceann G. Forresterc, Both the contents of the initial article1 and the subsequent Stefano Frassined and Andrea Wolkenbergc published correspondence3,4 with Dr Lee indicate significant weaknesses. We share Lee’s skepticism as to whether these aKinesio Taping Association International, Wisconsin, USA researchers possess a solid understanding of the principles behind bKinesio Taping Association International, Ankara, Turkey lymphatic Kinesio Taping. Their reply to him reinforces these doubts. cKinesio Taping Association International, New York, USA The study is replete with troubling details. The subjects dKinesio Taping Association International, Legnano, Italy were varied in activity and condition. The applications were not blinded. Twenty minutes of icing and exercise with the Kinesio *Corresponding author Taping treatment could have affected compliance and caused E-mail address: [email protected] (K.R. Stockheimer). additional trauma. Many subjects did not complete the study. References The technique used1 suggests a formation of crisscross patterns around the lateral malleolus for lateral ankle sprain and around the 1. Nunes GS, et al. J Physiother. 2015;61:28–33. medial malleolus for medial ankle sprain. However, with Kinesio 2. Kase K, et al. Clinical Therapeutic Applications of the Kinesio Taping1 Method. Tokyo, Taping the pressure decreases due to lifting of the superficial skin, and blood and lymphatic circulation increase due to an increase in Japan: Kenı´-Kai information; 2003. subcutaneous space. 3. Lee J-H. J Physiother. 2015;61:231. 4. Nunes GS, et al. J Physiother. 2015;61:231–232. The ‘control’ taping was not inert but had 20% tension, and was 5. Kase K, et al. Kinesio Taping for Lymphoedema and Chronic Swelling. Tokyo, Japan: applied on the anterior pathway of the lymphatics. As a control they had no no-treatment group. Multiple different investigators Kenı´-Kai Ltd; 2006. may have applied tape with no specifics on their training in Kinesio Taping. Voltmeter for the lower extremity is from foot to knee, so http://dx.doi.org/10.1016/j.jphys.2016.02.003 Knowledge of the modality comes from rigorous research $DIF]WT_3[ e are grateful for the opportunity, once again, to discuss Stockheimer and colleagues’ letter states, in accordance with science and further explain our trial of Kinesio Taping for ankle Dr Kenzo Kase’s book,3 that ‘with Kinesio Taping the pressure sprain.1_2[TD$F]I We understand the disappointment shown by Stock- decreases due to lifting of the superficial skin, and blood and heimer and colleagues that the results did not favour Kinesio lymphatic circulation increase due to an increase in subcutaneous Taping; however, we feel that it is important to show our study to space’. We really would like to have a reference to a published study demonstrating that this in fact occurs; however, we are yet the physiotherapy community and let them judge whether the to find such a study. Kinesio Taping method should be used or not. Stockheimer and colleagues seem to be ‘troubled’ by the fact As correctly identified by Stockheimer and colleagues, and that our sample was drawn from athletes from varied sports as mentioned in our previous correspondence,2 we partially modalities, giving the impression that they expect Kinesio Taping to be effective for sprained ankles that occur in some sports but not followed the figure from the book Clinical Therapeutic Applications in others. We would need further clarification before any further of the Kinesio Taping1 Method to be consistent with the descrip- comments could be made about this. tion on how the lymphatic correction (channelling) should be applied.3 1836-9553/ß 2016 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/4.0/).

Journal of Physiotherapy 62 (2016) 117 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinimetrics Stroke Impact Scale Summary Description: Several outcome measures are available to assess experienced with the task, except for three items from the emotion domain (3f, 3h and 3i). The scores for these three item scores the physical impact of stroke; however, the types of problems should be reversed (6 – item score) to compute the emotion domain score. experienced by stroke patients are multidimensional. The Stroke Four of the domains are highly correlated (strength, hand Impact Scale (SIS) is a disease-specific, self-report questionnaire function, ADL/IADL and mobility) and can be aggregated to produce a composite physical domain.1,3 Subsequently, a shorter that evaluates disability and health-related quality of life after composite physical scale (SIS-16) was developed with minimal stroke.1 The SIS was developed in collaboration with stroke loss of reliability.4 patients, informal caregivers and experienced healthcare profes- Reliability and validity: The SIS shows excellent internal sionals, ensuring that all aspects of stroke that may influence consistency with Cronbach’s a ranging from 0.80 to 0.95.1,3,5 health-related quality of life were incorporated.1,2 Test-retest reliability was investigated with reported ICCs The first published SIS included 64 items, but Rasch Analysis ranging from 0.70 to 0.94. Only the SIS-Emotion showed a lower reproducibility (ICC = 0.48 to 0.57).1,6 Excellent concur- identified five redundant items that were subsequently removed, rent validity was reported for SIS-ADL/IADL (r = À0.64 to creating the current SIS 3.0.2 The SIS 3.0 takes approximately 15 to 0.85 with Lawton IADL; Barthel Index; Functional Independence Measure motor; National Institutes of Health Stroke Scale; 20 minutes to administer and requires no formal training. It Modified Rankin Scale; Short Form-36 (SF-36) physical func- tioning) and the composite physical domain (r = 0.73 to assesses self-reported impact of stroke in eight domains: strength, 0.87 with SF-36 physical functioning, Barthel Index and Lawton IADL).1,6 In general, all other domains have adequate concurrent memory and thinking, emotion, communication, (instrumental) validity with established outcome measures. Furthermore, the hand function domain suffers from a floor effect of 28 to 46% and activities of daily living (ADL/IADL), mobility, hand function and the communication domain suffers from a ceiling effect of 17 to 55%.1,6,7 participation. In addition, a visual analogue scale ranging from 0 to 100 measures general perceived recovery since the onset of stroke. Domain scores range from 0 to 100 and are calculated using the following equation: Domain score ¼ Mean item scoreÀ1Ã100 4 All items within each domain are scored on a 1 to 5-point Likert scale. Higher item scores indicate a lower level of difficulty Commentary Marijn Muldera and Rinske Nijlandb aDepartment of Rehabilitation Medicine, Although there is some evidence for the ability of the SIS to measure change, limited data are available on responsiveness of MOVE Research Institute Amsterdam, the SIS.1 Further research is necessary to determine clinically VU University Medical Centre relevant change and minimal detectable change values, since limited data are currently available from a small trial investigating bDepartment of Neurorehabilitation, an upper extremity intervention in the chronic phase after stroke.8 Amsterdam Rehabilitation Research Centre j Reade, It is suggested that, if a patient is unable to complete the Amsterdam, Netherlands questionnaire (ie, cognitive problems or aphasia), the SIS can be proxy-administered. This could be a valuable practical advantage, References since these patients are often excluded from quality of life assessment. Patient-proxy agreement is best in the physical 1. Duncan PW, et al. Stroke. D$T_IF[41] 999;30:2131–2140. domains (ICC = 0.61 to 0.83). However, proxies scored patients 2. Duncan PW, et al. Arch Phys Med Rehabil. F2D]$[5IT_ 003;84:950–963. as significantly more severely affected in strength and ADL/IADL 3. Edwards B, et al. Qual Life Res. 6[_2T]D$IF 003;12:1127–1135. domains compared with patients themselves.9,10 A significant 4. Duncan PW, et al. Neurology. F_DT$7I[2] 003;60:291–296. difference was also observed for SIS-Hand function and SIS- 5. Jenkinson C, et al. Stroke. 2$DIFT_8][ 013;44:2532–2535. Mobility.9 Proxy assessment may thus be acceptable for the 6. Carod-Artal FJ, et al. Stroke. T_8[]D$FI2008;39:2477–2484. physical domains but there may be systematic bias towards more 7. Geyh S, et al. Clin Neuropsychol. D2FT_$]I[9 009;23:978–995. limitations in function. 8. Lin K, et al. Neurorehab Neural Res. 1_TIF2]$[D0 010;24:486–492. 9. Duncan PW, et al. Stroke. _1IF[TD$2] 002;33:2593–2599. Provenance: Invited. Not peer reviewed. 10. Carod-Artal FJ, et al. Stroke. _DF2$4T[I] 009;40:3308–3314. http://dx.doi.org/10.1016/j.jphys.2016.02.002 1836-9553/ß 2016 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/4.0/).

Journal of Physiotherapy 62 (2016) 116 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinimetrics The Roland Morris Disability Questionnaire Summary Description: The Roland Morris Disability Questionnaire is a self- no weighting applied to the statements, therefore the score can reported outcome measure that was first published in 1983. It provides a tool for measuring the level of disability experienced by a range from 0 (no disability) to 24 (maximal disability). No training person suffering from low back pain.1 Since then, it has become one of the most widely used outcome measures for low back pain.2 The is required to administer or score the questionnaire. A slight original 24-item measure has been shortened to create 18-item and 23-item versions and has been cross-culturally adapted or modification of the scoring method is to have yes/no boxes to be translated for use in other countries. The original and the different language/cultural versions are available at www.rmdq.org; no ticked. In this way it is possible to distinguish a missing value from permissions are required for their use or reproduction. Despite the various adaptions of the Roland Morris Disability Questionnaire, the a deliberate ‘no’ response. If this method is used, the 0 to 24 score original is still the most widely used and validated. Therefore, the original version will be $2][T_DtIF he fF3D_T]$[I ocus of this summary. should be converted to a percentage score, dropping unanswered The Roland Morris Disability Questionnaire consists of 24 state- questions from the total when more than a single question is left ments relating to the person’s perceptions of their back pain and unanswered.3DTF_1[$I] associated disability. This includes items on physical ability/ activity (15), sleep/rest (3), psychosocial (2), household manage- Clinimetric properties: Both internal consistency (Cronbach’s ment (2), eating (1) and pain frequency (1). It is designed to take approximately 5 minutes to complete, without any assistance from a = 0.84 to 0.96) and test-retest reliability (r = 0.83 to 0.91) of the the administrator. Roland Morris Disability Questionnaire are good.4 It has a Instructions and scoring: The Roland Morris Disability moderate to large5 correlation with other self-reported disability Questionnaire can be administered face-to-face, electronically or over the phone. The respondent is presented with each statement questionnaires such as the Quebec Back Pain Disability Scale and asked if they feel the statement is descriptive of their own circumstance on that day. For example, the first statement is ‘I stay (Quebec Scale) (r = 0.6) and the Oswestry Disability Index (r = 0.5). at home most of the day because of the pain in my back’. If the respondent feels that this statement applies to them they ‘tick’ the There is a small to moderate correlation with physical performance statement, otherwise they leave it blank. To score the responses, a practitioner need only add up the number of items ticked. There is assessments such as the Progressive Isoinertial Lifting Evaluation (r = –0.32; the negative sign is because the two measures are scored in different directions) or the Back Performance Scale (r = 0.44).6 The Roland Morris Disability Questionnaire also has moderate to large correlation with pain intensity (r = 0.34 to 0.57)7 and the responsiveness against global perceived effect scales is generally rated as good (area under the curve = 0.77).8 This responsiveness is similar to other disability questionnaires such as the Oswestry Disability Index and the Quebec Scale.8 However, one study reported the Oswestry Disability Index as superior to the Roland Morris Disability Questionnaire,9[F$_4DT]I (area under the curve = 0.75 and 0.69, respectively)F]IDT$_.5[ Commentary Low back pain is an extremely common condition with global Provenance: Invited. Not peer reviewed. significance. Of the many disability questionnaires for low back pain, the Roland Morris Disability Questionnaire is the most validated,4 Matthew L Stevens, Christine C-W Lin and Chris G Maher second most widely used2 and has been suggested as a core outcome The George Institute for Global Health, Sydney Medical School, measure for low back pain.10 Other strengths of the Roland Morris Disability Questionnaire include its ease of use and acceptability by The University of Sydney, Australia users, and its availability in a variety of different languages, many of which have been validated. Clinimetric properties are acceptably References high and similar to alternate disability questionnaires.8 Although some newer questionnaires have a greater focus on disability (eg, the 1. Roland M, et al. Spine (Phila Pa 1976). 1983;8:145–150. Quebec Scale) the widespread use of the Roland Morris Disability 2. Chapman JR, et al. Spine (Phila Pa 1976). 2011;36(21S):S54–S68. Questionnaire allows for easier comparison with the literature. 3. Kent P, et al. Spine (Phila Pa 1976). 2011;36(22):1878–1884. However, due to the numerous versions, translations and cultural 4. Smeets R, et al. Arthritis Care Res. 2011;63(S11):S158–S173. adaptions, care must be taken to ensure that the version being used 5. Cohen J. Psychol Bull. 1992;112(1):155–159. has been properly validated. Overall, the Roland Morris Disability 6. Strand LI, et al. Phys Ther. 2011;91(3):404–415. Questionnaire is a useful tool for assessing back-related disability 7. Kovacs FM, et al. Spine (Phila Pa 1976). 2004;29(2):206–210. and is easy to use for patients and clinicians, meaning that it can be 8. Davidon M, et al. Phys Ther. 2002;82(1):8–24. readily adopted in clinical practice. 9. Frost H, et al. Spine (Phila Pa 1976). 2008;33(22):2450–2457. 10. Deyo RA, et al. Spine (Phila Pa 1976). 1998;23(18):2003–2013. http://dx.doi.org/10.1016/j.jphys.2015.10.003 1836-9553/ß 2015 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/4.0/).

Journal of Physiotherapy 62 (2016) 57–58 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Editorial The TIDieR checklist will benefit the physiotherapy profession Tie P Yamato a, Chris G Maher a, Bruno T Saragiotto a, Anne M Moseley a, Tammy C Hoffmann b, Mark R Elkins c a The George Institute for Global Health, The University of Sydney, Sydney; b Bond University, Faculty of Health Sciences and Medicine, Gold Coast; c Journal of PhysiotherapyI,D$FT_2[] Australia Evidence-based practice involves physiotherapists incorpo- strategies to reduce waste in clinical research.6 When the list of rating high-quality clinical research on treatment efficacy into resources involved in a single study is considered, improving the their clinical decision-making.1_1TFD$[]I However, if clinical interventions reproducibility of interventions through better reporting could are not adequately reported in the literature, physiotherapists markedly reduce waste in research.7 face an important barrier to using effective interventions for their patients. Previous studies have reported that incomplete The TIDieR checklist and guide were developed to improve the description of interventions is a problem in reports of random- reporting of interventions in any evaluative study, including ised, controlled trials in many health areas.2,3,4 One of these randomised trials.8 The checklist contains 12 items and was studies4 examined 133 trials of non-pharmacological interven- developed as an extension to the CONSORT 2010 Statement9 and tions; the experimental intervention was inadequately described SPIRIT 2013 Statement10 to provide further guidance for authors in over 60% of the trials and descriptions of the control on the key information to include in trial reports. TIDieR items interventions were even worse. include: name of the intervention; intervention rationale for essential elements; intervention materials and details about how A recent study5 evaluated the completeness of descriptions of to access them; description of the intervention procedures; the physiotherapy interventions in a sample of 200 randomised, details of intervention providers; mode of delivery of interven- controlled trials published in 2013. Overall, the interventions tion; location of intervention delivery and key infrastructure; were poorly described. For the intervention groups, about one- details about the number, duration, intensity and dose of quarter of the trials did not fulfil at least half of the criteria. intervention sessions; details of any intervention tailoring; any Reporting for the control groups was even worse, with around intervention modifications throughout the study; and details of three-quarters of trials not fulfilling at least half of the criteria. intervention fidelity assessment, monitoring and level achieved. In other words, for the majority of the physiotherapy trials, The TIDieR checklist will help to further improve the quality of clinicians and researchers would be unable to replicate the intervention reporting if it is used not only by study authors, but interventions that were tested. also journal editors, peer reviewers, ethics committees and funding agencies. Describing a treatment may seem like a simple task, but physiotherapy interventions can be very complex. Some inter- In summary, incomplete reporting of interventions in physio- ventions are multi-modal, involving the use of manual techniques, therapy studies is an important problem and we endorse the use of consumable materials, equipment, education, training and feed- the TIDieR checklist as a potential solution. The responsibility for back. Some interventions are tailored to each patient’s specific improving intervention reporting extends beyond the authors of health state, including the patient’s immediate response to the individual trials to journal editors and others who can mandate the application of the treatment. When the intervention involves a use of the TIDieR checklist to combat this problem. Mandating course of treatments, the intensity or dose may be progressed over the use of the TIDieR checklist would guide authors to better time. The descriptions of physiotherapy interventions in trial describe their interventions and, consequently, help clinicians to reports often do not capture all of these components of the use the interventions and researchers to synthesise and replicate interventions or detail their complexity. the evidence. If researchers fail to comprehensively report all aspects of the At Journal of Physiotherapy, submitting authors will be interventions, the trial results cannot be incorporated into clinical encouraged to use the TIDieR checklist to ensure that any practice or the intervention could be implemented incorrectly. interventions described in their manuscript are fully reported. Incorrect implementation may make the treatment ineffective, Submitting authors will also be invited to submit a completed wasting the clinician’s and patient’s time and healthcare resources. checklist when they submit their manuscript, although this is not Inadequate reporting of interventions also poses a barrier to compulsory. The editor will make an initial decision about the incorporating a trial’s results into synthesis research such as suitability of the manuscript for peer review. For manuscripts that systematic reviews and clinical practice guidelines, as well as the are suitable for review, the editor will check the manuscript usability of these resources. This means that the resources that against the checklist to ensure that all items are fully reported. were invested in undertaking the trial have been wasted. Such Manuscripts that do not report all relevant aspects of the resources are extensive, including: direct trial costs (eg, payment intervention will be returned to the authors to address the gaps of researchers, consumables); use of infrastructure (eg, clinic in reporting before the manuscript will progress to peer review. space, equipment); human resources (eg, ethics committee review, The checklist can be downloaded from the website below. granting body review); and the goodwill of patients who agree to Submitting authors with questions about the checklist are invited participate. Currently, there is a growing realisation that we need to email the editor at the address below. 1836-9553/ß 2016 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/4.0/).

58 Editorial Ethics approval: Not applicable. 2. Duff JM, et al. J Natl Cancer Inst. 2010;102:702–705. Competing interests: Tammy Hoffmann is an author of the 3. Glasziou P, et al. BMJ. 2008;336:1472–1474. TIDieR checklist. The other authors declare that they have no 4. Hoffmann TC, et al. BMJ. 2013;347:f3755. competing interests. 5. Yamato TP, et al. Physiotherapy. D$[_F25IT] 016. http://dx.doi.org/10.1016/j.physio.2016. Source of support: Nil. Acknowledgements: Nil. 03.001. in [6FTp_D$]I ress. Provenance: Not invited. Not peer reviewed. 6. Chalmers I, et al. Lancet. 2014;383:1–56. Correspondence: Mark Elkins, Editor, Journal of Physiotherapy, 7. Ioannidis JP, et al. Lancet. 2014;383:166–175. Australian Physiotherapy Association, Melbourne, Australia. 8. Hoffmann TC, et al. BMJ. 2014;348:g1687. D$TIF[]E4_ mail: scientifi[email protected] 9. Schulz KF, et al. BMJ. 2010;340:c332. 10. Chan AW, et al. Ann Intern Med. 2013;158:200–207. References Websites 1. Herbert R, et al. Practical Evidence-based Physiotherapy. 2nd ed. London: Churchill Livingstone; 2012. www.equator-network.org/wp-content/uploads/2014/03/TIDieR-Checklist-PDF. pdf http://dx.doi.org/10.1016/j.jphys.2016.02.015 Paper of the Year 2015 The Editorial Board is pleased to announce the 2015 Paper of the Year Award. The winning paper is judged by a panel of members of the International Advisory Board who do not have a conflict of interest with any of the papers under consideration. They vote for the paper published in the 2015 calendar year that, in their opinion, has the best combination of scientific merit and application to the clinical practice of physiotherapy. The winning paper is ‘Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: a systematic review’.1 The authors are Davide Corbetta and Roberto Gatti from San Raffaele Hospital and the private practitioner, Federico Imeri, from Milan, Italy. High repetition of tasks connected to locomotion improve mobility in people with motor deficits following stroke.2 Researchers have achieved some augmentation of the benefit obtained from repetitive task practice by incorporating additional measures such as cyclical electrical stimulation3 and cueing of cadence.4 The winning study by Corbetta et al1 shows that incorporating virtual reality into rehabilitation augments several of its benefits: walking speed by a mean of 0.15 m/s (95% CI 0.10 to 0.19), balance by a mean of 2.1 points on the Berg Balance Scale (95% CI 1.8 to 2.5), and mobility by a mean of 2.3 seconds on the Timed Up and Go test (95% CI 1.2 to 3.4). Incorporating virtual reality may augment the benefits of rehabilitation by enabling simulated practice of functional tasks at a higher dosage than traditional therapies.5,6 Other mechanisms contributing to the extra benefit may include immediate feedback about performance on simulated real-life activities7 and improved motivation to complete higher numbers of exercise repetitions.8 The evidence generated by Corbetta and colleagues is an important step in a pathway of research about stroke rehabilitation. In several of the randomised trials that were included in the winning systematic review,1 treadmill training was the form of rehabilitation into which the virtual reality was incorporated. The winning paper therefore builds on existing evidence that treadmill training is effective rehabilitation among ambulatory adults with stroke,9 especially those whose comfortable walking speed is faster than 0.4 m/s before the training.10 The members of the Editorial Board congratulate Davide Corbetta and his co-authors on their success. References 1. Corbetta D, Imeri F, Gatti R. Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: a systematic review. J Physiother. 2015;61:117–124. 2. French B, Thomas L, Leathley M, Sutton C, McAdam J, Forster A, et al. Repetitive task training for improving functional ability after stroke. Cochrane Datab Syst Rev. 2007;4:CD006073. 3. Nascimento LR, Michaelsen SM, Ada L, Polese JC, Teixeira-Salmela LF. Cyclical electrical stimulation increases strength and improves activity after stroke: a systematic review. J Physiother. 2014;60:22–30. 4. Nascimento LR, de Oliveira CQ, Ada L, Michaelsen SM, Teixeira-Salmela LF. Walking training with cueing of cadence improves walking speed and stride length after stroke more than walking training alone: a systematic review. J Physiother. 2015;61:10–15. 5. Kwakkel G, Van Peppen R, Wagenaar R, Wood Dauphinee S, Richards C, Ashburn A, et al. Effects of augmented exercise therapy time after stroke. A meta-analysis. Stroke. 2004;35:1–11. 6. Merians A, Jack D, Boian R, Tremaine M, Burdea G, Adamovich S, et al. Virtual reality augmented rehabilitation for patients following stroke. Phys Ther. 2002;82:898–915. 7. Sveistrup H. Motor rehabilitation using virtual reality. J Neuroeng Rehabil. 2004;1:10. 8. Rizzo A, Kim G. A SWOT analysis of the field of virtual reality rehabilitation and therapy. Presence. 2005;14:119–146. 9. Polese JC, Ada L, Dean CM, Nascimento LR, Teixeira-Salmela LF. Treadmill training is effective for ambulatory adults with stroke: a systematic review. J Physiother. 2013;59: 73–80. 10. Dean CM, Ada L, Lindley RI. Treadmill training provides greater benefit to the subgroup of community- dwelling people after stroke who walk faster than 0.4 m/s: a randomised trial. J of Physiother. 2014;60:97–101. http://dx.doi.org/10.1016/j.jphys.2016.02.008

Appraisal Journal of Physiotherapy 62 (2016) 120 Media Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Virtual psychology clinic helps the hard to reach https://mindspot.org.au/ Assessment and advice Mindspot caters for the user who wants to dip their toes into the In clinical practice, physiotherapists often treat people who experience stress, anxiety and low mood and who might benefit from website, with an anonymous 2-minute ‘Brief Anxiety’ or ‘Brief psychological management such as cognitive behavioural therapy Depression’ quiz, which provides immediate feedback. For the user (CBT). However, people in need of psychological services can’t always who wants to jump right in and access a course, there is a more access them, for reasons including cost and lack of local services. detailed assessment, which requires logging in and sharing personal Moreover, not everyone that may benefit from mental healthcare information. Physiotherapists can directly refer to the Mindspot Clinic, services will agree to see a psychologist. The online Mindspot Clinic with the patient’s consent, by filling in the online referral form in the targets these people by offering an entirely new model of mental ‘Health Professionals’ section of the website. While Mindspot healthcare based on emerging evidence that internet-delivered CBT guarantees complete confidentiality, users can decide whether they programs are as effective as CBT delivered face to face.1 Mindspot is a want their GP to be informed about the assessment or not. Some confidential, online mental health service that offers information, people using this website may not want to notify their GP for fear of assessment and CBT programs for Australians with anxiety, depression, being labelled or stigmatised, but they will still have full access to the obsessive compulsive disorder and post-traumatic stress disorder. The clinic. Once the person has been assessed, the results are fed back and website is funded by the Australian government and is available free of the user is advised which Mindspot course would meet their needs, or charge to adults who are eligible for Medicare and who have a telephone they may be informed of more appropriate local services. and the Internet. The purpose of the website is to improve access and uptake of psychological services for Australians who suffer from stress, High fidelity, online psychological treatments that get results anxiety and depression who can’t or won’t seek professional help. Cognitive behavioural therapy is a first-line talking and behavioural Excellent education on anxiety and depression therapy for stress, anxiety and depression. It is based on the simple The Mindspot website provides information about psychological premise that what we think (our cognitions) and what we do (our behaviours) affect how we feel (our emotions). Challenging unhelpful conditions such as anxiety and depression in a simple language that thoughts and T[$D]I2F_practising helpful behaviours is a powerful way to reduce members of the public can easily understand. Particular care has been stress, anxiety and depression, and is the main focus of CBT. taken to ensure that the user can understand the topics and successfully navigate the site on their own. For example, on the ‘About Anxiety’ page, Mindspot currently provides six different CBT courses: the Mood rather than use the clinical terminology of generalised anxiety disorder Mechanic Course, for 18 to 25 year olds; the Wellbeing Course, for or post-traumatic stress disorder, the user can click onto statements that 18 to 64 year olds; the Wellbeing Plus Course, for people who are over describe their concerns in layman’s language, such as ‘I worry about 60 years old; the Post-Traumatic Stress Disorder course; the Obsessive everything’ and ‘I get really worked up and upset every time I think of Compulsive Disorder Course; and the Indigenous Wellbeing Course. A what happened to me’. Much of the content in the education pages aims recent prospective, non-controlled cohort study showed that people to reassure the user that their symptoms can be treated successfully and who completed the Mindspot courses had significant reductions in to give them simple, easy-to1F-TD$][_I understand options for seeking help. depression and anxiety symptoms.2]1[FID$_T The material on these courses can Mindspot is unsuitable for people with severe depression or anxiety and be read and understood by most 11 year olds, so they can be accessed does not offer crisis services, but every page has a link to the ‘I need by those with lower levels of literacy. The courses run for 8 weeks but Urgent Help’ page; this can be accessed at any time and does not require users have access to the website material for 3 months, so they can the user to be logged in. For people who do not need urgent mental review the course as they develop their skills. The user accesses online health services, but would benefit from more than online support, this tutorials, completes worksheets and receives weekly telephone and e- page also has a ‘Non-Urgent Help’ section. It reminds the user that their mail follow-ups with a psychologist. Like exercise, the cognitive GP can assess and treat mental health disorders, as well as refer them to behavioural strategies that are covered in Mindspot courses require mental health services. Other online and telephone services are detailed, consistent practice for the user to see positive changes. Cognitive such as Beyond Blue and Mensline Australia. behavioural therapy can be a useful remedy for the immediate problem of anxiety and depression, but, with consistent application Physiotherapists can also learn about anxiety and depression in the over months and years, it can become a valuable life skill. This website ‘About Anxiety’ and ‘About Low Mood and Sadness’ pages, in particular provides an excellent, free mental health resource for patients and how anxiety and depression is conceptualised within the cognitive- healthcare professionals alike. While it is currently limited to those behavioural model. The role of unhelpful thinking and maladaptive living in Australia, it may be available in the future to people overseas. behaviours in contributing to symptoms of anxiety and depression is outlined in plain English. Another valuable resource is the ‘10 Things Provenance: Invited. Not peer reviewed. That Help’ two-page fact sheet, which includes helpful practical strategies that patients can try immediately, and includes the Kelly McLaughlin Mindspot Clinic web address and phone number. The ‘About the Western Health Physiotherapy, Melbourne, Australia Mindspot Clinic’ fact sheet is another easy-to-follow two-page handout with information about the Mindspot Clinic, as well as References details of the courses it provides. 1. Andersson G, et al. World Psychiatry. 2014;13:288–295. 2. Titov N, et al. Psychiatric Services. 2015;66:1043–1050. http://dx.doi.org/10.1016/j.jphys.2016.02.007 1836-9553/ß 2016 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/4.0/).

Journal of Physiotherapy 62 (2016) 112 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Wait and see, heel raise and eccentric exercise may be equally effective treatments for children with calcaneal apophysitis Synopsis Summary of: Wiegerinck JI, Zwiers R, Sierevelt IN, van Weert of the calcaneal apophysitis using a pressure algometer and a HC, van Dijk N, Struijs PA. Treatment of calcaneal apophysitis: wait pressure of 5 kg. Secondary outcome measures were Oxford Ankle and see versus orthotic device versus physical therapy: a and Foot Questionnaire child and parent report of foot-specific pragmatic therapeutic randomized clinical trial. J Pediatr Orthop. disability and a satisfaction score. Results: Ninety-eight partici- FIDT_]2[2$ 016;36:152-157. pants completed the study. The reduction in pain was statistically significant and similar for all three groups at each time point, but Question: Do wait and see, wearing a heel raise or eccentric there were no between-group differences. At 6 weeks, the child- exercise improve pain and foot-specific disability in children with reported foot-specific disability improved more in the heel raise calcaneal apophysitis? Design: Randomised trial with concealed group than the wait-and-see group by 4.5 points (95% CI 0.2 to allocation and blinded outcome assessment. Setting: One outpa- 8.7 points), and the parent-reported foot-specific disability tient clinic in The Netherlands. Participants: Children aged 8 to improved more in the eccentric exercise group than the wait- 15 years with calcaneal apophysitis (positive squeeze test, normal and-see group by 5.9 points (95% CI 1.1 to 10.5 points). There were x-ray, pain for at least 4 weeks with a rating of > 30 mm on the no differences between the groups for child and parent reported Faces Pain Scale-Revised). Exclusion criteria were other leg injuries foot specific disability at 3 months. Patient satisfaction was higher in the previous 12 months and previous treatment with one of the in the heel raise group compared with the other two groups at evaluated inventions. Randomisation of 101 participants allocated 6 weeks only. Conclusion: Wait and see, wearing a heel raise and 32 to the wait-and-see group, 33 to the heel raise group and 33 to eccentric exercise each resulted in a significant reduction in pain the eccentric exercise group. Interventions: The heel raise group and foot-specific disability due to calcaneal apophysitis. Patients wore a prefabricated inlay in both shoes daily. The eccentric and parents should be consulted about their preferred treatment exercise group performed eccentric calf strengthening, supervised option. by a physiotherapist, and daily ‘at home’ exercises. The wait-and- see group ceased pain-inducing activities and restarted activities Provenance: Invited. Not peer reviewed. once their symptoms subsided. The heel raise and eccentric exercise groups had no limits placed on their activity. Outcome Nora Shields measures: The primary outcome was change in the Faces Pain School of Allied Health, La Trobe University, Australia Scale-Revised at 6 weeks and 3 monthsFID$]3_[T after randomisation. The average of three measurements on a scale of 0 to 10 (maximal pain) http://dx.doi.org/10.1016/j.jphys.2015.12.004 was taken for pressure pain at the point of maximal pain in the area Commentary There is limited evidence supporting many commonly the protocol was poorly described within the paper. Fourth, pain employed treatment options aimed at reducing the pain associated reduced at 3 months in the wait-and-see group, who ceased pain- with calcaneal apophysitis in children.1 This condition is self- inducing activities and only restarted activities after their symptoms limiting but has a negative impact on children’s quality of life.2 It is subsided, and this may not be an acceptable pain management thought that calcaneal apophysitis may develop from traction at strategy with which to maintain physical activity in children. the calcaneal apophysis from the gastrocnemius/soleus or impact forces at the open apophysis.3 It is promising to see research guiding clinicians to consider parents’ and children’s treatment preferences based on satisfac- Treatment options researched to date have included non- tion, particularly regarding pain management in light of multiple steroidal anti-inflammatory medication, rest, ice, stretching, effective management strategies. When managing calcaneal taping, heel lifts and different orthotic designs; all are aimed at apophysitis, clinicians should continue individualising treatment decreasing traction or impact at the calcaneal apophysis. Study options to reduce impact or traction on the apophysis. designs, concurrently applied therapies within trials and inconsis- tent reporting of results have made it difficult for clinicians to Provenance: Invited. Not peer reviewed. determine which treatment provides the best pain relief. Cylie Williams There are a number of points that clinicians should be aware of Community Health, Peninsula Health, DF[3_MT$I] elbourne, Australia when interpreting the results of the Wiegerinck et al trial. First, adherence to the intervention was not described for any group. References Second, the prefabricated inlay used as an intervention was the ViscoHeel, which is a gel-based product designed to absorb impact, 1. James AM, et al. J Foot Ankle Res. 2013;6:16. not to raise the heel, as implied by the researchers. Third, effective 2. Scharfbillig RW, et al. Foot. 2009;1936–1943. utilisation of eccentric exercise is a new management strategy, but 3. James AM, et al. J Pediatr. 2015;167:455–459. http://dx.doi.org/10.1016/j.jphys.2015.12.003 1836-9553/ß 2016 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/4.0/).

Journal of Physiotherapy 62 (2016) 112 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Wait and see, heel raise and eccentric exercise may be equally effective treatments for children with calcaneal apophysitis Synopsis Summary of: Wiegerinck JI, Zwiers R, Sierevelt IN, van Weert of the calcaneal apophysitis using a pressure algometer and a HC, van Dijk N, Struijs PA. Treatment of calcaneal apophysitis: wait pressure of 5 kg. Secondary outcome measures were Oxford Ankle and see versus orthotic device versus physical therapy: a and Foot Questionnaire child and parent report of foot-specific pragmatic therapeutic randomized clinical trial. J Pediatr Orthop. disability and a satisfaction score. Results: Ninety-eight partici- FIDT_]2[2$ 016;36:152-157. pants completed the study. The reduction in pain was statistically significant and similar for all three groups at each time point, but Question: Do wait and see, wearing a heel raise or eccentric there were no between-group differences. At 6 weeks, the child- exercise improve pain and foot-specific disability in children with reported foot-specific disability improved more in the heel raise calcaneal apophysitis? Design: Randomised trial with concealed group than the wait-and-see group by 4.5 points (95% CI 0.2 to allocation and blinded outcome assessment. Setting: One outpa- 8.7 points), and the parent-reported foot-specific disability tient clinic in The Netherlands. Participants: Children aged 8 to improved more in the eccentric exercise group than the wait- 15 years with calcaneal apophysitis (positive squeeze test, normal and-see group by 5.9 points (95% CI 1.1 to 10.5 points). There were x-ray, pain for at least 4 weeks with a rating of > 30 mm on the no differences between the groups for child and parent reported Faces Pain Scale-Revised). Exclusion criteria were other leg injuries foot specific disability at 3 months. Patient satisfaction was higher in the previous 12 months and previous treatment with one of the in the heel raise group compared with the other two groups at evaluated inventions. Randomisation of 101 participants allocated 6 weeks only. Conclusion: Wait and see, wearing a heel raise and 32 to the wait-and-see group, 33 to the heel raise group and 33 to eccentric exercise each resulted in a significant reduction in pain the eccentric exercise group. Interventions: The heel raise group and foot-specific disability due to calcaneal apophysitis. Patients wore a prefabricated inlay in both shoes daily. The eccentric and parents should be consulted about their preferred treatment exercise group performed eccentric calf strengthening, supervised option. by a physiotherapist, and daily ‘at home’ exercises. The wait-and- see group ceased pain-inducing activities and restarted activities Provenance: Invited. Not peer reviewed. once their symptoms subsided. The heel raise and eccentric exercise groups had no limits placed on their activity. Outcome Nora Shields measures: The primary outcome was change in the Faces Pain School of Allied Health, La Trobe University, Australia Scale-Revised at 6 weeks and 3 monthsFID$]3_[T after randomisation. The average of three measurements on a scale of 0 to 10 (maximal pain) http://dx.doi.org/10.1016/j.jphys.2015.12.004 was taken for pressure pain at the point of maximal pain in the area Commentary There is limited evidence supporting many commonly the protocol was poorly described within the paper. Fourth, pain employed treatment options aimed at reducing the pain associated reduced at 3 months in the wait-and-see group, who ceased pain- with calcaneal apophysitis in children.1 This condition is self- inducing activities and only restarted activities after their symptoms limiting but has a negative impact on children’s quality of life.2 It is subsided, and this may not be an acceptable pain management thought that calcaneal apophysitis may develop from traction at strategy with which to maintain physical activity in children. the calcaneal apophysis from the gastrocnemius/soleus or impact forces at the open apophysis.3 It is promising to see research guiding clinicians to consider parents’ and children’s treatment preferences based on satisfac- Treatment options researched to date have included non- tion, particularly regarding pain management in light of multiple steroidal anti-inflammatory medication, rest, ice, stretching, effective management strategies. When managing calcaneal taping, heel lifts and different orthotic designs; all are aimed at apophysitis, clinicians should continue individualising treatment decreasing traction or impact at the calcaneal apophysis. Study options to reduce impact or traction on the apophysis. designs, concurrently applied therapies within trials and inconsis- tent reporting of results have made it difficult for clinicians to Provenance: Invited. Not peer reviewed. determine which treatment provides the best pain relief. Cylie Williams There are a number of points that clinicians should be aware of Community Health, Peninsula Health, DF[3_MT$I] elbourne, Australia when interpreting the results of the Wiegerinck et al trial. First, adherence to the intervention was not described for any group. References Second, the prefabricated inlay used as an intervention was the ViscoHeel, which is a gel-based product designed to absorb impact, 1. James AM, et al. J Foot Ankle Res. 2013;6:16. not to raise the heel, as implied by the researchers. Third, effective 2. Scharfbillig RW, et al. Foot. 2009;1936–1943. utilisation of eccentric exercise is a new management strategy, but 3. James AM, et al. J Pediatr. 2015;167:455–459. http://dx.doi.org/10.1016/j.jphys.2015.12.003 1836-9553/ß 2016 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/4.0/).