DGT]I$F)1_[(igure Research 135 Records identified through databases (n = 285) Fear avoidance: Physiotherapists’ fear avoidance scores were examined in one study28 and were positively correlated with • CINAHL (n = 175) • Medline (n = 62) increased certification of sick leave (RR 2.0, 95% CI 0.74 to 4.19) and • PsychINFO (n = 22) advice to avoid return to work and return to normal activity (RR • Embase (n = 15) • PubMed (n = 11) 1.71, 95% CI 0.07 to 2.57). Physiotherapists with a higher fear Duplicates removed (n = 23) avoidance score also had less confidence in determining the long- term disability due to low back pain (RR 1.5, 95% CI 0.84 to 2.35). Records screened by title and abstract (n = 262) Three of the five quantitative studies conducted regression Excluded after screening (n = 217) analyses to further determine whether treatment orientation Full-text articles assessed for eligibility (n = 45) predicted clinical practice. Figure 2 summarises the relationships Excluded after evaluation of full text (n = 35) found between treatment orientation and return to activity advice. Derghazian et al10_2[]TD$FI3 performed a stepwise linear regression to • did not assess association between determine whether the PABS-PT was predictive of recommenda- attitudes/beliefs and practice (n = 22) tion of activity. The PABS-PT-Behavioral score accounted for 12% of • development of a measure of the variance (R2 = 0.12, 95% CI 0.06 to 0.18). The ABS-mp Biomedical attitude/belief (n = 5) and ABS-mp Confidence and Concern subscores explained a further 6% variance for the moderate-risk patient. The ABS-mp • did not include physiotherapists (n = 4) • review article (n = 3) Biomedical score accounted for 12% variance for the low-risk • conference abstract (n = 1) patient. Studies included in quantitative synthesis (n = 5) Houben et al29 performed regression analyses to determine if Studies included in qualitative synthesis (n = 5) the PABS-PT scores were predictive of recommendation for work Figure 1. Flow of studies through the review. and activity. This analysis showed that both treatment orientation several measures to measure beliefs and attitudes, including fear avoidance, treatment orientation and intolerance of uncertainty. factors of the PABS-PT score were significant predictors of work (PABS-PT-Biomedical R2 = 0.28, 95% CI 0.11 to 0.44 and PABS-PT- Behavioural R2 = 0.23, 95% CI 0.09 to 0.36) and activity recom- mendations (PABS-PT-Biomedical R2 = 0.27, 95% CI 0.11 to 0.42 and PABS-PT-Behavioural R2 = 0.26, 95% CI 0.11 to 0.40). Simmonds et al31]F$DI[24T_ performed stepwise linear regression analyses to determine if PABS-PT scores were predictive of treatment and activity recommendations. They found PABS-PT- Behavioural scores to be a significant predictor of treatment (R2 = 0.158, 95% CI 0.06 to 0.25) and activity recommendation (R2 = 0.117, 95% CI 0.05 to 0.18) for moderate-risk patient vignettes. In addition, PABS-PT-Behavioural score together with postgraduate training in chronic pain was a significant predictor of treatment (R2 = 0.108, 95% CI 0.03 to 0.18) and activity recommendation (R2 = 0.109, 95% CI 0.04 to 0.18) for low-risk patient vignettes. Measures of clinical practice Qualitative studies Clinical practice was measured using patient vignettes in three Table 5 summarises the descriptive characteristics of included of the five10,29,31 included quantitative studies. All three of these qualitative studies and the main findings from each study. studies used vignettes presenting a moderate-risk and low-risk case for the physiotherapist to assess and indicate level of spinal Qualitative studies (n = 5) revealed two main themes attributed pathology, risk of developing low back pain disability, return to to beliefs and attitudes of physiotherapists that have a relationship work advice and return to activity advice. One study28 developed a to the clinical practice of physiotherapists in chronic low back pain: clinical practice questionnaire to indicate three items regarding: treatment orientation and patient factors. sick leave, advice regarding return to activity and confidence in predicting long-term disability. Another study30 developed a work Table 6 presents the two main themes and their subthemes, behaviour questionnaire that asked about workplace visits, with examples of supporting statements, the number of times each support of sick leave, recommendations of short breaks, and subtheme was identified by a study, and the total number of times prescription of exercise suitable in the workplace. it was supported by a statement in any of the included studies. Table 6 demonstrates that when discussing chronic low back pain, Association between attitudes and belief measures and clinical physiotherapists have a consistent bias towards a biomedical practice approach, which is contrasted by the preoccupation of the ‘passive’ patient. Correlation coefficients for association between attitudes and beliefs of physiotherapists and clinical practice measures were Theme 1: Treatment orientation extracted from all five quantitative studies (Table 4). Meta-analysis Five subthemes were derived relating to the theme of treatment was not conducted due to the heterogeneity of measures used in the studies. orientation. Chronic low back pain was approached with a strong biomedical model, and clinical practice was aimed at addressing Treatment orientation: A higher biomedical orientation score biomedical factors. Physiotherapists classified patients according was associated with advice to delay return to work (correlation to a biomedical approach, and clinical practice decisions were coefficients ranging from r = 0.19 to 0.24 for low-risk patient made according to the classification. Therapists expressed a lack of vignettes, and r = 0.08 to 0.27 for moderate-risk vignettes) and confidence in their ability to follow and implement a biopsycho- advice to delay return to activity (correlation coefficients ranging social model in clinical practice. Therapists disliked treating from r = 0.00 to 0.25 for low-risk vignettes, 2aT_]F[ID$ nd r = 0.21 to 0.28 for difficult patients and had poor self-efficacy and outcome moderate-risk vignettes). One study302FD$]1I_[T reported that a biomedical expectancies regarding their treatment of these patients. Thera- orientation was associated with a tendency to not limit number of pists thought that assessment of psychosocial factors was not their treatment sessions (rs = 0.23). role.
Table 3 Study characteristics of included quantitative studies (n = 5). Study Design Aim Random sample Response rate Measur Sample size yes 74% an Country Populationa PABS-P ABS-m Derghazarian10 Surveyb Examine relationships Canada n = 108 between PTs’ attitudes/ Public and private PTs beliefs about LBP and judgments and treatment recommendations via two patient vignettes Houben29 Surveyb Examine PABS-PT yesc N/R PABS-P Netherlands n = 295 prediction of judgments no 68%a HC-PA PTs of the harmfulness of no BBQ-H Surveyb daily activities depicted TSK-HC Linton28 n = 71 in photographs and Sweden recommendations for Ten qu PTs Surveyb physical activity for addres n = 113 three patient vignettes avoida Pincus30 Compare physicians’ and UK PTs’ beliefs, and assess 32% ABS-m Private PTs views on recommending interac sick certificates and orienta providing advice about activities and pain Work-r management questio Examine the beliefs and reported clinical behaviours of chiropractors, osteopaths and PTs regarding patients’ work.
res of attitudes Measures of clinical Measure of Results 136 Gardner et al: Physiotherapists’ attitudes in chronic low back pain nd beliefs practice attitudes/beliefs Association with practice PT Moderate-risk and Biomedical orientation mp low-risk vignettes versus biopsychosocial Level of spinal pathology: higher orientation biomedical score more likely to rate for Questions about level spinal pathology of spinal pathology, Risk of developing low back pain: low risk of developing low correlation with treatment orientation back pain disability, and rate of disability and advice to return to Return to work advice: higher biomedical work and activity score more likely to recommend a delay in return to work PT Vignette Biomedical orientation Return to activity advice: higher AIRSd PHODA – rate of versus biopsychosocial biomedical score more likely to HCd orientation recommend a delay to normal activity harmfulness of activity Recommendations of return to work and Cd activity: higher biomedical score more likely to recommend limits on work and uestions Clinical practice Fear avoidance beliefs activity questionnaire Harmfulness of activity: higher ssing fear (3 items) biomedical score more likely to view ance beliefse activities of daily living as harmful mp, personal Work-related Personal interaction Sick leave: higher levels of fear avoidance ction, treatment behaviour Treatment orientation more likely to support sick leave ation questionnaire certificationf related beliefs Advice to return to activity: higher levels onnaire of fear avoidance more likely to recommend limits on work and activityf Confidence in predicting long-term disability: higher levels of fear avoidance less confident in predicting long-term disabilityf Visit workplace: those who visit workplace more likely to limit sessionsgDT$_5[I]F Support sick leave: higher biomedical score, higher belief that work is a threat, higher belief that work is not beneficial, did not limit sessions and felt disconnected from healthcare network more likely to certify sick leaveg5[FD]$IT_ Recommend short break: Nil significant correlationsg[DIF$]6_T Prescribe exercise suitable in workplace: low belief that work is a threat and work not beneficial, did limit sessions, did not feel disconnected from healthcare network and believed goal was to reactivate patient more likely to prescribe exercise suitable for the workplacegD$F[I]_T7
Table 3 (Continued ) Design Aim Random sample Response rate Measu Sample size yes 74% a Study Examine how PTs’ Country Surveyb intolerance of PABS-P Populationa n = 108 uncertainty, fear of pain, IUS and treatment FPQ Simmonds31 h orientation predict work Canada and activity Public and private PTs recommendations in LBP ABS-mp = Attitudes to Back Pain Scale for musculoskeletal practitioners, BBQ-HC = Back Beliefs Questionnaire adapted for Pain and Impairment Relationship Scale, IUS = Intolerance of Uncertainty Scale, LBP = low back pain, N/R = not reported, PA Scale for Physiotherapists, PHODA = Photographic Series of Daily Activities, PT = physiotherapist, TSK-HC = Tampa Scale f a Physiotherapist data only. b Cross-sectional questionnaire survey. c One random sample and several samples of convenience. d Not investigated for association between practice measures. e Derived from items on the Tampa Scale for Kinesiophobia, Fear Avoidance Behaviour Questionnaire, and Pain and f Pooled results for physiotherapists (n = 71) and general practitioners (n = 60). g Pooled results for physiotherapists (n = 113), osteopaths (n = 126) and chiropractors (n = 112). h Subsequent report of additional data collected in the Derghazarian10 study.
ures of attitudes Measures of clinical Measure of Results and beliefs practice attitudes/beliefs Association with practice PT Moderate-risk and Biomedical orientation Level of spinal pathology: higher low-risk vignettes versus biopsychosocial biomedical score more likely to rate for orientation spinal pathology Questions about level Risk of developing low back pain: low of spinal pathology, correlation with treatment orientation risk of developing low and rate of disability back pain disability, Return to work advice: higher biomedical and advice to return to score more likely to recommend a delay work and activity in return to work Return to activity advice: higher biomedical score more likely to Research recommend a delay to normal activity Fear of pain Level of spinal pathology: higher fear IUS avoidance score more likely to rate for spinal pathology Risk of developing low back pain: higher fear avoidance score more likely to rate for disability Nil correlation with IUS and practice High correlation with IUS and biomedical orientation paramedical therapists, FPQ = Fear of Pain Questionnaire, HCP = healthcare professionals, HC-PAIRS = Health Care Providers ABS-BM = Pain Attitudes and Beliefs Scale for Physiotherapists-Biomedical orientation, PABS-PT = Pain Attitudes and Beliefs for Kinesiophobia adapted for paramedical therapists. Impairment Relationship Scale. 137
138 Gardner et al: Physiotherapists’ attitudes in chronic low back pain Table 4 Key correlational findings for quantitative studies (n = 5). Study analysed Measure of beliefs and attitudes Correlation with Correlation with return to work advice return to activity advice Derghazarian10$8_TD[IF] Low-risk vignette: PABS-PT-BM r = 0.24a r = 0.25a n = 108 Low-risk vignette: PABS-PT-BH r = 0.26b r = 0.26a Low-risk vignette: ABS-mp r = 0.29b r = 0.36b Houben29 Moderate-risk vignette: PABS-PT-BM r = 0.27b r = 0.28b n = 273 Moderate-risk vignette: PABS-PT-BH r = 0.40b r = 0.33b Linton28 Moderate-risk vignette: ABS-mp r = 0.16 r = 0.35b n = 71 PABS-BM r = 0.32b r = 0.30b Pincus30 PABS-BH r = –0.27b r = –0.37b n = 113 Fear avoidance beliefsc Relative risk quotient = 2.00 Relative risk quotient = 1.71 (95% CI 0.74 to 4.19) (95% CI 1.07 to 2.57) Simmonds31,DF_]9IT[d$ Work-related beliefs: work is not beneficial or work is a threat Increase sick leave: rs = 0.19b n = 102 Limit sessions of treatment: rs = 0.23b Prescribe exercise: rs = 0.23b Work-related beliefs: work is beneficial r = 0.00 Low-risk vignette: PABS-PT-BM r = 0.19 r = –0.02 Low-risk vignette: PABS-PT-BH r = 0.14 r = 0.08 Low-risk vignette: IUS r = –0.09 r = 0.00 Low-risk vignette: FPQ r = –0.06 r = 0.21a Moderate-risk vignette: PABS-PT-BM r = 0.08 r = 0.24a Moderate-risk vignette: PABS-PT-BH r = 0.14 r = –0.14 Moderate-risk vignette: IUS r = –0.12 r = –0.14 Moderate-risk vignette: FPQ r = 0.01 ABS-mp = Attitudes to Back Pain Scale for musculoskeletal practitioners, FPQ = Fear of Pain Questionnaire, IUS = Intolerance of Uncertainty Scale, PABS-PT-BH = Pain Attitudes and Beliefs Scale for Physiotherapists-Behavioural orientation, PABS-PT-BM = Pain Attitudes and Beliefs Scale for Physiotherapists-Biomedical orientation, r = Pearson’s correlation, rs = Spearman’s correlation. a p < 0.05. b p < 0.01. c Based on ]F[11I_TD$ 0 questions derived from items on the Tampa Scale for Kinesiophobia, Fear Avoidance Behaviour Questionnaire, and Pain and Impairment Relationship Scale. d Subsequent report of additional data collected in the Derghazarian100_1[FTI]D$ study. Theme 2: Patient factors measures and give an extra dimension of understanding of Three subthemes were derived relating to the theme of patient complex conditions and interventions.36 Understanding why an intervention failed is just as important as understanding why it factors. Intervention that was provided was influenced by patient was a success, and qualitative investigation into such complex and beliefs and treatment expectations. Patient characteristics and layered factors such as beliefs, attitudes and behaviour change is consideration of the therapist-patient relationship influenced the important.36,37 A degree of concordance was shown between therapist’s choice of intervention. Physiotherapists often chose qualitative and quantitative studies, both revealing that treatment interventions that facilitated a relationship with and satisfied the orientation was associated with clinical practice in chronic low patient. Clinical decisions were based on the classification of the back pain. This finding is consistent with a previous review that patient according to the perceived ‘passivity of patient’. The degree investigated the association of attitudes and beliefs of various to which a therapist thought a patient would engage in treatment other healthcare professional groups with clinical management of and/or self-management influenced the treatment provided and chronic low back pain in a range of settings.20 The inclusion of led to an individual approach for each patient. qualitative studies further revealed patient-related factors that influence physiotherapists’ beliefs and attitudes, and subsequent Discussion clinical practice in chronic low back pain. These factors included patients’ beliefs and treatment expectations, the patient-therapist This systematic review synthesised, for the first time, both relationship and the perceived ‘passivity’ of the patient. quantitative and qualitative studies investigating the influence of beliefs and attitudes on clinical practice by physiotherapists in The strength of this review was that both quantitative and chronic low back pain. High-quality quantitative and qualitative qualitative studies were included. This approach provides a much studies are considered to contribute equally to evidence.35 richer perspective, and has previously been used in similar systematic reviews.20,26 The present review included three ]GIF$DT)2_erugi([Qualitative studies can provide a validation of quantitative Figure 2. Regression quotients for the association between treatment orientation and advice to return to activity.
Table 5 Study characteristics of included qualitative studies (n = 5). Study Qualitative methods Participants Sample size Data collection Data analysis Country Daykin 11 Semi-structured interviews Grounded theory To ex PT withi n=6 cLBP UK Jeffrey 14 Semi-structured interviews Hermeneutic circle PT To un Josephson 32 Focus group Content analysis n = 11 exper UK influe treati PT n = 21 To ex Sweden know to ma Josephson 33 Focus group Discourse analysis PT To inv n = 21 of int Sweden partic mana exper Poitras 8 Semi-structured interviews Content analysis PT To ev n = 16 recom GP low b n=8 and P OT and d n=8 profe Canada cLBP = chronic low back pain, GP = general practitioner, OT = occupational therapist, PT = physiotherapist, UK = United K
Aim Main findings Research xamine PTs’ pain beliefs their role Experience and development of work craft skills was important in the in the management of patients with treatment of cLBP and PTs sort biomedically focused knowledge and skills to enhance their own treatment repertoire nderstand how the personal riences and feelings of PTs might Patients are classified into ‘good’ and ‘bad’ patients, with poor outcome ence their decision making when often attributed to the passive nature of the patient; a belief that ‘bad’ ing patients with cLBP patients will have a poor outcome often leads to clinical practice and xplore and describe what PTs need to communication being modified w about patients with cLBP to be able ake decisions about intervention PTs had biomedical view and this informed clinical practice reasoning and explanations given to the patient as well as attributions regarding vestigate how PTs talk about choice the patient tervention for patients with cLBP, cularly regarding how professionals PT believe cLBP has an underlying mechanical and recurring nature age clinical encounters that may be PTs attitude toward managing cLBP is to empower patients to exercise rienced as challenging and self-manage their pain and functional problems valuate barriers to the use of practice PT experience feelings of tension between the advice and treatment they mmendations, aimed at preventing back pain disability, with GPs, Ots feel is best for the patient and the patient’s own beliefs and attitudes PTs and identify areas of convergence PT clinical practice was determined by the complexity of the patient. divergence between health essions Several factors (pain history, body structure, body function, activity, participation, mental function, health-related behaviour, workplace Kingdom. environment, personal factors) interplayed to determine the complexity of the patients and subsequent intervention. Easy case: clinical practice decisions based on structure, pain location and joint/muscle function Complex case: decisions on clinical practice mainly based on combinations of aspects related to movement and mental function Very complex case: described as having a high degree of psychosocial problems and troublesome life situations and required several intervention components, therefore collaboration with other professionals PTs talk about choices of intervention as a problem solving process, including questions on four main themes: health responsibility: patients responsibility and their ability for own health and PT role in patient’s health normalization: back pain as an ordinary medical condition and normal feature of ordinary life, normal for patient to want a ‘quick fix change process: need for patient to change their whole life or routine individualisation: PT adapt intervention to specific patient preferences and one’s own professional skills The process has implications on the intervention the individual patient will be offered and has consequences on outcome. PTs’ biomedical approach to LBP limits the uptake of guidelines PTs thought they were not adequately trained to manage psychosocial factors PTs felt guidelines would have limited impact on their clinical practice because of the lack of intervention at the biomedical/pathophysiological aspect of LBP Divergence amongst PTs on how the guidelines would have impact on early referral for yellow flags and return to activity PT belief that most patients expected to be managed using a biomedical and not a biopsychosocial approach PTs believed guidelines less appropriate for patients financing treatment privately 139
Table 6 Themes, subthemes and number of contributing statements and studies with examples of supporting statements from Theme Subtheme Statem Treatment orientation (n cLBP was approached with a strong biomedical model and clinical practice was aimed at addressing biomedical factors 2 PTs classify patients according to a biomedical approach and 6 treat accordingly Patient factors PTs lacked confidence in treating with a biopsychosocial 9 model in clinical practice 1 PTs disliked treating difficult patients and had poor self- 6 efficacy and outcome expectancies regarding their treatment 1 of these patients 1 PTs thought assessment of psychosocial factors was not their 2 role Treatment choice was influenced by patient beliefs and treatment expectations Patient characteristics and consideration of the therapist- patient relationship influenced the therapist’s choice of intervention PTs were likely to make clinical decisions based on their classification of the patient according to the perceived ‘passivity of patient’. cLBP = chronic low back pain, GP = general practitioner, OT = occupational therapist, PT = physiotherapis.
m qualitative studies. 140 Gardner et al: Physiotherapists’ attitudes in chronic low back pain ments Studies Examples of supporting statements with n) (n) citation number of contributing study 23 5 The x-ray identifies L3-4 as being visibly osteo-arthritic, I feel that he does have some degenerative change within his back . . . indication would be to treat, to try 63 and resolve the particular problems that present at the moment, which are the stiffness that I felt below the active level, that’s painful, and then by loosening that 9 3 up, hopefully reduce the discomfort at the over active level- the 3-4 level, and then 18 2 get him on a home program to maintain flexibility of the lower lumbar vertebrae11$DI_21[F]T I would probably explain to her that it was most likely postural strain . . . There 6 2 could be an underlying facet joint degenerative problem evident. I would then go 17 4 on to explaining how her work or habits, hobbies and posture may be exacerbating the problem.14 10 4 Josephson et al32 describe three levels of complexity that merged in their 25 4 analysis: easy case, complex case and very complex case, with each level influencing the decision about intervention. Easy case: An uncomplicated back that feels well and allows someone to lead a rewarding life while still experiencing back pain is easy to treat.32 Complex case: They have so much pain that they lie in bed and say ‘I can’t get out of bed’; they are just lying in bed and are very scared of every little move they have to make and then I think it’s something that has to be.32 Very complex case: When it’s time for pain rehabilitation its very complex; then it is not only the back pain anymore, it’s very much influenced by long service leaves with everything that means to their self esteem, when they get there its very complex. 32 Asking physiotherapists whether they felt equipped to help patients with associated psychological factors . . . the responses varied from ‘it depends on the patients’ to ‘a professional should deal with those issues’.11 Difficult patients contributed to ‘bad days’ at work . . . you . . . switch off a little bit . . . I think you become less sympathetic . . . write them off quickly.11 You can treat until you’re blue in the face, but you’ll take two steps forwards and the patient will go away, do whatever they want to and take two steps back . . . and this is when you get frustrating, unresolved cases.11 I don’t know how successful I’m going to be . . . I might not get that far with her.11 A professional should deal with those issues.11 Difficult patients presented with unrealistic expectations, you can’t get across to them that you haven’t got a magic wand.11 Whether they’re motivated to actually do something for themselves or they just want you to . . . sort of . . . click your fingers; wave your magic wand, and the pain’ll be gone.14 If it’s someone I feel I don’t have good contact with, I feel that the things I do, the things I say, just bounce back; then I complete the intervention fairly fast, while I can go considerably further with someone I have the kind of collaboration with.32 I struggle with people who . . . I’ve explained to them several times what’s wrong with them, what they need to do about it, and they’re still not ‘buying into it’.14 You can’t do it for them, and they’re the ones who you really struggled with, and you had to really explain to them that if they didn’t start taking . . . the responsibility for themselves, then there was little you could do, really.14 You choose an intervention based on patients ability and experiences.32
Research 141 quantitative studies10,30,31 and four qualitative studies8,14,32,33 that structural or biomechanical factors often does not show good have not previously been included in a combined systematic effect, and the therapist is then left with judging the patient as review design such as this one. Chronic low back pain is a complex difficult or passive. Therapists’ poor misinterpretation of patient presentation and it is well known that the interaction of the behaviour may reflect a lack of awareness that these behaviours therapist and patient will have an influence on the outcome.38 If may be indicative of underlying cognitive, psychological and social only quantitative measures were used, this dimension of patient factors, and may contribute to these aspects not being addressed. factors and patient-therapist interaction would be missed. Furthermore, the perception of stigmatisation of persons experiencing chronic back pain may hinder the patient-therapist The current review found that treatment orientation and fear relationship, which further compromises a positive effect of the avoidance beliefs of the physiotherapist had an influence on intervention.21 Our findings correlate well with a recent review clinical practice and advice given to patients. A therapist with investigating physiotherapists’ perceptions about identifying and higher biomedical orientation and fear avoidance beliefs towards managing the cognitive, psychological and social factors in chronic chronic low back pain was associated with advice to restrict return low back pain, which reported a lack of confidence in physiother- to work duties and restrict return to activity, a higher perception of apist skills in identifying and addressing psychosocial aspects of risk associated with work or activity, and increased certification of chronic low back pain.21 Physiotherapists should consider whether sick leave. Healthcare professionals’ beliefs about chronic low back some characteristics, such as poor motivation, or dependence on pain have been shown to have an influence on patient beliefs.11,39,40 passive therapies, may indicate the presence of other factors such High levels of fear avoidance beliefs in healthcare professionals as depression, anxiety or poor self-efficacy, which require greater have been shown to be associated with high levels of fear consideration.21 avoidance beliefs in their patients.41,42 Reinforcement of a cautionary and passive approach from treating physiotherapists It is important to identify that the patient’s role is integral to may lead to long-term passivity, unhelpful beliefs about activity, clinical care, and this review was able to capture this influence. To and disengagement from a patient-focused self-management date, investigations into attitudes and beliefs in chronic low back approach. The qualitative studies included in this review also pain have for the most part given attention to the patient or showed the strong biomedical bias of physiotherapists in chronic clinician in isolation from each other. A patient-centred approach, low back pain. These studies suggested that physiotherapists have where the patient and therapist work collaboratively, and beliefs a strong focus on a biomedical approach to chronic low back pain, and attitudes of both are addressed, may be more effective for placing importance on the severity of tissue damage, classifying facilitating self-management, patient satisfaction and improve patients accordingly and choosing intervention aligned with the outcomes.25,44,45 biomedical model rather than embracing the model that pain and function loss may be influenced by psychological and social factors Studies of chronic low back pain guideline implementation in addition to biomechanical factors. have shown low or modest effects at changing clinical prac- tice.46,47,48,49 The majority of these interventions focus on therapist The findings of the qualitative studies provided an extra knowledge and skills in isolation from the patient. Clinical practice dimension to what influences clinical practice, by exploring the is affected by therapist attitudes and beliefs, which are influenced factors associated with the patient. Patients with low back pain by patient factors such as patient expectations, belief systems expect a clear diagnosis, pain relief and manual therapy as part of and the therapeutic relationship developed in a clinical interac- their care, which may reflect the patient’s biomedical beliefs tion. When considering the design of interventions to improve regarding their back pain.43 It has also been shown that a good guideline adherence, a better approach may be addressing both therapist-patient relationship has a positive effect on patients’ the therapistD4$[T’]F_I s and patient’s contribution to the clinical interven- outcomes.38 Guidelines in line with a biopsychosocial approach tion (Box 2). The clinical intervention should be considered as recommend that physiotherapists need to consider the patient and a dynamic relationship, where both therapist and patient are their expectations in order to facilitate a good therapist-patient involved in an interchange, rather than two separate silos in relationship. This may leave the physiotherapist in conflict isolation from one another, and perhaps training in chronic low between what clinical guidelines recommend and what the back pain intervention needs to reflect this. patient wants. To reduce the tension between the two approaches, therapists may choose to give advice and treatment more closely There were some limitations in regard to the studies included in aligned to the patient’s biomedical understanding and expectation, this review. Direct measurement of clinical behaviour is difficult. in order to avoid conflict and facilitate a more helpful therapist- Clinical practice measures were limited to advice on work, exercise patient relationship. and exercise prescription in the workplace. It is questionable whether the measures used in the included studies captured all An important step in improving skills and confidence in that is practised in the clinical setting.9T_DF5$[I]2 Measurement of clinical addressing the complexity of chronic low back pain is training behaviour was collected by self-report questionnaires or patient physiotherapists in the identification and management strategies vignettes. Responses provided on a questionnaire may reflect a of psychosocial issues. The current review revealed a preference for therapist’s knowledge of guidelines rather than their actual physiotherapists to treat biomechanical issues, a perception that behaviour. This tendency towards desirable answers is a well- they lacked skills to address psychosocial issues, and a tendency to known bias in self-report measurement.31 Patient vignettes are stigmatise those behaviours that may suggest a psychological or easy to manipulate, and there is a reduced impact of social social aspect to low back pain. Treatment only addressing desirability and observer bias; however, they may elicit attitudes Box 2. Factors influencing clinical practice and suggested strategies to improve clinical guideline adherence. Therapist factors Suggested interventions to improve Biomedical versus biopsychosocial approach clinical guideline adherence Lack of confidence in addressing biopsychosocial Training in biopsychosocial approach and management skills of aspects psychosocial factors for chronic pain in $uT]D_F31[I ndergraduate and postgraduate levels Patient factors Patient education of chronic pain model and evidenceF-I_]D$T[14 based practice Patient expectations and beliefs strategies Patient-therapist relationship Patient-led intervention Patient ‘passivity’
142 Gardner et al: Physiotherapists’ attitudes in chronic low back pain and opinions rather than actual behaviour in real situations.50,51 It 15. Corbett M, Foster N, Ong BN. GP attitudes and self-reported behaviour in primary has also been demonstrated that physiotherapy management of care consultations for low back pain. Fam Pract. 2009;26:359–364. back pain can be composed of numerous interventions, which vary during the episode of care,52 a dynamic which is difficult to capture 16. Askew R, Kibelstis C, Overbaugh S, Walker S, Nixon-Cave K, Shepard KF. Physical with case scenarios. Measurement of clinical behaviour would be therapists’ perception of patients’ pain and its effect on management. Physiother best attained by direct observation and audit of clinical behaviour Res Int. 1998;3:37–57. with blinded participants. 17. Rainville J, Babnall D, Phalen L. Health care providers’ attitudes and beliefs about The beliefs and attitudes of physiotherapists as well as functional impairments and chronic back pain. Clin J Pain. 1995;11:287–295. therapist-patient factors have an influence on clinical practice in chronic low back pain. This may impact the uptake of current 18. Ostelo RWJG, Stomp-van den Bergw SGM, Vlaeyenz JWS, Woltersy PMJC, de Vet clinical guidelines and new treatment models of care. Future HCW. Health care provider’s attitudes and beliefs towards chronic low back pain: research is needed to investigate the most effective approach when the development of a questionnaire. Man Ther. 2003;8:214–222. developing training and implementation tools for clinical guide- lines that considers both the therapist and patient factors as 19. Bishop A. Pain attitudes and beliefs scale (PABS). J Physiother. 2010;56:279. mutual influences on clinical practice. 20. Darlow B, Fullen BM, Dean S, Hurlwy DA, Baxter GD, Dowell A. The association What is already known on this topic: Clinical practice between health care professional attitudes and beliefs and the attitudes and guidelines recommend evaluation of biopsychosocial factors beliefs, clinical management and outcomes of patients with low back pain: a in people with chronic low back pain, but many physiothera- systematic review. Eur J Pain. 2012;3–17. pists do not assess and treat these factors. 21. Synnott A, O’Keeffe M, Bunzli S, Dankearts W, O’Sullivan P, O’Sullivan K. Phy- What this study adds: Quantitative and qualitative studies siotherapists may stigmatise or feel unprepared to treat people with low back pain confirm a relationship between treatment orientation and and psychosocial factors that influence recovery: a systematic review. J Physiother. clinical practice. Both beliefs and attitudes regarding treatment 2015;61:67–68. orientation of physiotherapists as well therapist-patient factors 22. Kent P, Keating J. Do primary-care clinicians think that nonspecific low back pain is need to be considered when introducing new clinical practice one condition? Spine. 2010;29:1022–1031. models so that the adoption of new clinical practice is max- 23. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred imised. Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA State- ment. PLoS Med. 2009;6:e1000097. eAddenda: Appendix 1 can be found online at: http://dx.doi. 24. Pinto RZ, Ferreira M, Oliviera VC, Franco M, Adams R, Maher CG, et al. Patient- org/10.1016/j.jphys.2017.05.017 centred communication is associated with positive therapeutic alliance: a system- atic review. J Physiother. 2012;58:77–87. Ethics approval: Nil. 25. Fullen BM, Baxter GD, O’Donovan BGG, Doody C, Daly L, Hurley DA. Doctors’ Competing interests: Nil. attitudes and beliefs regarding acute low back pain management: a systematic Source of support: Nil. review. Pain. 2008;136:388–396. Acknowledgements: Nil. 26. Hannes K. Chapter 4: Critical appraisal of qualitative research. In: Noyes J, Booth A, Provenance: Not invited. Peer reviewed. Hannes K, Harden A, Harris J, Lewin S, Lockwood C (editors). Supplementary Guidance Correspondence: Tania Gardner, Faculty of Pharmacy, Sydney for Inclusion of Qualitative Research in Cochrane Systematic Reviews of University, Australia. Email: [email protected] Interventions. Version 1 (updated August 2011). Cochrane Collaboration Qualitative Methods Group, 2011. http://cqrmg.cochrane.org/supplemental-handbook-guidance References 27. Sandelowski M, Barroso J. Handbook for Synthesizing Qualitative Research. New York: Springer; 2007. 1. Koes BW, van Tulder MW, Lin CW, Macedo LG, McAuley J, Maher C. An updated 28. Linton SJ, Vlaeyen J, Ostelo R. The back pain beliefs of health care providers: are we overview of clinical guidelines for the management of non-specific low back pain in fear-avoidant? J Occup Rehabil. 2002;12:223–232. primary care. Eur Spine J. 2010;19:2075–2094. 29. Houben RMA, Ostelo RWJG, Vlaeyen JWS, Wolters PMJC, Peters M, Stomp-van den Berg SGM. Health care providers’ orientations towards common low back pain 2. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. predict perceived harmfulness of physical activities and recommendations regard- 2006;332:1430–1434. ing return to normal activity. Eur J Pain. 2005;9:173–183. 30. Pincus T, Greenwood L, McHarg E. Advising people with back pain to take time off 3. Bekkering GE, Hendriks HJM, Koes BW, Oostendorp RA, Ostelo RW, Thomassen JM, work: a survey examining the role of private musculoskeletal practitioners in the et al. Dutch physiotherapy guidelines for low back pain. Physiotherapy. UK. Pain. 2011;152:2813–2818. 2003;89:82–96. 31. Simmonds MJ, Derghazarian MJ, Vlaeyen JWS. Physiotherapists’ knowledge, atti- tudes, and intolerance of uncertainty influence decision making in low back pain. 4. Glattacker M, Heyduck K, Meffert C. Illness beliefs, treatment beliefs and informa- Clin J Pain. 2012;28:467–474. tion needs as starting points for patient information—Evaluation of an intervention 32. Josephson I, Bülow P, Hedberg B. Physiotherapists’ clinical reasoning about patients for patients with chronic back pain. Patient Educ Couns. 2012;86:378–389. with non-specific low back pain, as described by the International Classification of Functioning, Disability and Health. Disabil Rehabil. 2011;33:2217–2228. 5. Keefe FJ, Rumble ME, Scipio CD, Giordano LA, Perri LM. Psychological aspects of 33. Josephson I, Hedberg B, Bülow P. Problem-solving in physiotherapy – physiothera- persistent pain: current state of the science. J Pain. 2004;5:195–211. pists’ talk about encounters with patients with non-specific low back pain. Disabil Rehabil. 2013;35:668–677. 6. Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RWJG, Guzman J, et al. 34. Pincus T, Vogel S, Santos R, Breen A, Foster N, Underwood M. The attitudes to back Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. pain scale in musculoskeletal practitioners (ABS-mp): the development and testing Cochrane Datab Syst Rev. 2014;9:CD000963. of a new questionnaire. Clin J Pain. 2006;22:378–386. 35. Tomlin G, Borgetto B. Research pyramid: a new evidence based practice model for 7. Hanney WJ, Masaracchio M, Liu X, Kolber MJ. The influence of physical therapy occupational therapy. Am J Occup Ther. 2011;65:189–196. guideline adherence on healthcare utilization and costs among patients with low 36. Jones R. Strength of evidence in qualitative research. J Clin Epidemiol. 2007;60: back pain: a systematic review of the literature. PLoS ONE. 2016;11:e0156799. 321–323. 37. Slade SC, Kent P, Bucknall T, Molloy E, Patel S, Buchbinder R. Barriers to primary care 8. Poitras S, Durand MJ, Côté AM, Tousignant M. Guidelines on low back pain clinician adherence to clinical guidelines for the management of low back pain: disability: interprofessional comparison of use between general practitioners, protocol of a systematic review and meta-synthesis of qualitative studies. BMJ occupational therapists, and physiotherapists. Spine. 2012;37:1252–1259. Open. 2015;5e:00726. 38. Hall AM, Ferreiria PH, Maher CG, Latimer J, Ferriera ML. The influence of the 9. Swinkels ICS, van den Ende CHM, van den Bosch W, Dekker J, Raymond H, therapist-patient relationship on treatment outcome in physical rehabilitation: a Wimmers RH. Physiotherapy management of low back pain: Does practice match systematic review. Phys Ther. 2010;90:1099–1110. the Dutch guidelines? Aust J Physiother. 2005;51:35–51. 39. Dean SG, Smith JA, Payne S, Weinman J. Managing time: an interpretative phenomenological analysis of patients’ and physiotherapists’ perceptions of 10. Derghazarian T, Simmonds MJ. Management of low back pain by physical therapists adherence to therapeutic exercise for low back pain. Disabil Rehabil. 2005;27: in Quebec: How are we doing? Physiother Can. 2011;63:464–473. 625–636. 40. Werner EL, Ihlebaek C, Skouen JS, Laerum E. Beliefs about low back pain in the 11. Daykin AR, Richardson B. Physiotherapists’ pain beliefs and their influence on the Norwegian general population: are they related to pain experiences and health management of patients with chronic low back pain. Spine. 2004;29:783–795. professionals? Spine. 2005;30:1770–1776. 41. Poiraudeau S, Rannou F, Baron G, Henanff AL, Coudeyre E, Rozenberg S, et al. Fear 12. Foster NE, Delitto A. Embedding psychosocial perspectives within clinical man- avoidance beliefs about back pain in patients with subacute low back pain. Pain. agement of low back pain: integration of psychosocially informed management 2006;124:305–311. principles into physical therapist practice—challenges and opportunities. Phys Ther. 42. Coudeyre E, Rannou F, Tubach F, Baron G, Coriat F, Brin S, et al. General practi- 2011;91:790–803. tioners’ fear-avoidance beliefs influence their management of patients with low back pain. Pain. 2006;124:330–337. 13. Ajzen I. Nature and operation of attitudes. Ann Rev Psychol. 2001;52:27–58. 43. Verbeek J, Sengers MJ, Riemens L, Haafkens J. Patient expectations of treatment for 14. Jeffrey JE, Foster NE. A qualitative investigation of physical therapists’ experiences back pain, a systematic review of qualitative and quantitative studies. Spine. 2004;29:2309–2318. and feelings of managing patients with nonspecific low back pain. Phys Ther. 44. Gardner T, Refshauge K, McAuley J, Goodall S, Hübscher M, Smith L. Patient led goal 2012;92:266–278. setting in chronic low back pain—What goals are important to the patient and are they aligned to what we measure? Pat Educ Couns. 2015;98:1035–1038. 45. Gardner T, Refshauge K, McAuley J, Goodall S, Hübscher M, Smith L. Patient led goal setting – a pilot study investigating a promising approach for the management of chronic low back pain. Spine. 2016;41:1405–1413.
Research 143 46. Bekkering GE, Hendriks HJM, van Tulder MW, Knol DL, Hoeijenbos M, Oostendorp 51. Morrell DC, Roland MO. Analysis of referral behaviour: responses to simulated RAB. Effect on the process of care of an active strategy to implement clinical case histories may not reflect real clinical behaviour. Brit J Gen Pract. 1990;4: guidelines on physiotherapy for low back pain: a cluster randomised controlled 182–185. trial. Qual Saf Health Care. 2005;14:107–112. 52. Poitras S, Blais R, Swaine B, Rossignol M. Practice patterns of physiotherapists in the 47. Grimshaw J, Eccles M, Tetroe J. Implementing clinical guidelines: current evidence treatment of work-related back pain. J Eval Clin Pract. 2007;13:412–421. and future implications. J Contin Educ Health Prof. 2004;24:S31–S37. 53. Sanderson S, Tatt ID, Higgins JP. Tools for assessing quality and susceptibility to bias 48. Grol R. Successes and failures in the implementation of evidence-based guidelines in observational studies in epidemiology: a systematic review and annotated for clinical practice. Med Care. 2001;39(8 Suppl 2):46–54. bibliography. Int J Epidemiol. 2007;36:666–676. 49. Engers AJ, Wensing M, van Tulder MW, Timmermans A, Ostendorp RAB, Koes BW, 54. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The et al. Implementation of the Dutch low back pain guideline for general practi- Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tioners: a cluster randomized controlled trial. Spine. 2005;30:595–600. statement: guidelines for reporting observational studies. Epidemiology. 2007;18: 800–804. 50. Bishop A, Foster NE. Do physical therapists in the United Kingdom recognize psychosocial factors in patients with acute low back pain? Spine. 2005;30:1316–1322.
Journal of Physiotherapy 63 (2017) 183 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Placebo pills provided without deception may help to reduce pain and disability in people with chronic low back pain Synopsis Summary of: Carvalho C, Caetano JM, Cunha L, Rebouta P, Kaptchuk Morris Disability Questionnaire (0 to 24) and bothersomeness, assessed TJ, Kirsch I. Open-label placebo treatment in chronic low back pain: on a 0-to-10 numeric rating scale. Results: A total of 83 participants a randomized controlled trial. Pain. 2016;157:2766-2772. (86%) completed the 3-week follow-up. The mean difference in the total composite pain score at 3 weeks was 1.3 units (95% CI 0.5 to 2.0) in Question: In people with chronic low back pain, will placebo treatment favour of the open-label placebo group. The mean difference in disabil- provided without deception reduce pain and disability? Design: Ran- ity was 2.8 units (95% CI 1.2 to 4.5) in favour of the open-label placebo domised, controlled trial with concealed allocation. Setting: Outpatient group. There were no between-group differences for bothersomeness. pain unit of a general hospital in Portugal. Participants: Both men and After transfer to the open-label placebo group after 3 weeks, the women were included if: aged 18 years and with persistent lower treatment-as-usual group demonstrated significant within-group back pain for > 3 months duration. Participants were excluded if they reductions in both pain (MD 1.5 units, 95% CI 0.8 to 2.3) and disability had used opioid medications in the previous 6 months, or had a history (MD units 3.4, 95% CI 2.2 to 4.5). Conclusion: An open-label placebo of conditions such as cancer, fractures, infections, prior lower back intervention, provided in addition to treatment as usual, for patients surgery, psychiatric diagnoses, severe fibromyalgia, rheumatoid arthri- with chronic low back pain showed a significantly greater reduction in tis, or disc degeneration due to ageing or trauma. Of the 239 people who self-reported pain and disability than usual treatment alone. responded to a recruitment advertisement, 97 participants were ran- domly allocated to the open-label placebo group or the treatment-as- [MD and 95% CI calculated by the CAP Editor] usual group. Interventions: All participants received an explanation and viewed a brief video clip about the placebo effect. Participants allocated Provenance: Invited. Not peer reviewed. to the open-label placebo group were given a medicine bottle of placebo pills with a label clearly marked ‘placebo pills’ and were instructed to Margreth Grotlea and Kåre Birger Hagenb take two pills twice a day for 3 weeks. Participants in the treatment as aOslo and Akershus University College of Applied Sciences, usual group were given the opportunity to receive placebo pills after 3 weeks. Outcome measures: The primary outcome was a composite Department of Physiotherapy, Oslo, Norway pain severity score assessed on three 0-to-10 numeric rating scales bNational Advisory Unit on Rehabilitation in Rheumatology, (maximum, minimum and usual pain) at baseline and 3 weeks. Sec- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway ondary outcomes were disability, assessed with the Roland- http://dx.doi.org/10.1016/j.jphys.2017.05.002 © 2017 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/). Commentary Using placebo interventions in randomised trials is powerful for between-group analyses were underpowered, which resulted in challenging accepted practice; and changing inappropriate practice imprecise estimates of treatment effect. In addition, there appeared when no difference between the active and placebo interventions to be some between-group differences in pain scores at baseline. It is observed. Arguably, the placebo effect of an intervention is may be important in future research to demonstrate that the use of associated with factors other than the active ingredient of that open-label placebos improve objective outcomes in addition to self- intervention, including patient-clinician interactions, expectation report outcomes, as reported in this study. of improvement with management, and rituals involved in the treatment approach. A substantial advantage of introducing the This is the first study to show a potential benefit of placebo placebo intervention in the randomised trial design is to ensure interventions for chronic low back pain and it highlights the blinding of assessors and patients. This is particularly important for impact of a positive treatment rationale and patient-clinician self-reported outcome measures, such as pain and disability, as rapport in the management process. Although the study presents lack of blinding has been associated with significant overestima- and acknowledges some methodological limitations, it provides tion of treatment benefits for self-reported measures.1 The authors important information on the power of placebo without deception. of this study emphasised, however, that recent research has established the effect of open-label placebo prescription in other Provenance: Invited. Not peer reviewed. fields, possibly via the presentation of a positive rationale, rather Manuela L Ferreira than deception, for the use of placebo. Institute of Bone and Joint Research, The Kolling Institute, Sydney This study was powered to detect a between-group difference Medical School, The University of Sydney, Australia in pain intensity of 1 point (0 to 10-point scale) with a sample size of 96 participants. This sample size, however, did not Reference account for the observed attrition rates (22%); it is likely that the 1. Feys F, et al. Syst Rev. 2014;3:14. http://dx.doi.org/10.1016/j.jphys.2017.05.001 1836-9553/© 2017 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 63 (2017) 183 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Placebo pills provided without deception may help to reduce pain and disability in people with chronic low back pain Synopsis Summary of: Carvalho C, Caetano JM, Cunha L, Rebouta P, Kaptchuk Morris Disability Questionnaire (0 to 24) and bothersomeness, assessed TJ, Kirsch I. Open-label placebo treatment in chronic low back pain: on a 0-to-10 numeric rating scale. Results: A total of 83 participants a randomized controlled trial. Pain. 2016;157:2766-2772. (86%) completed the 3-week follow-up. The mean difference in the total composite pain score at 3 weeks was 1.3 units (95% CI 0.5 to 2.0) in Question: In people with chronic low back pain, will placebo treatment favour of the open-label placebo group. The mean difference in disabil- provided without deception reduce pain and disability? Design: Ran- ity was 2.8 units (95% CI 1.2 to 4.5) in favour of the open-label placebo domised, controlled trial with concealed allocation. Setting: Outpatient group. There were no between-group differences for bothersomeness. pain unit of a general hospital in Portugal. Participants: Both men and After transfer to the open-label placebo group after 3 weeks, the women were included if: aged 18 years and with persistent lower treatment-as-usual group demonstrated significant within-group back pain for > 3 months duration. Participants were excluded if they reductions in both pain (MD 1.5 units, 95% CI 0.8 to 2.3) and disability had used opioid medications in the previous 6 months, or had a history (MD units 3.4, 95% CI 2.2 to 4.5). Conclusion: An open-label placebo of conditions such as cancer, fractures, infections, prior lower back intervention, provided in addition to treatment as usual, for patients surgery, psychiatric diagnoses, severe fibromyalgia, rheumatoid arthri- with chronic low back pain showed a significantly greater reduction in tis, or disc degeneration due to ageing or trauma. Of the 239 people who self-reported pain and disability than usual treatment alone. responded to a recruitment advertisement, 97 participants were ran- domly allocated to the open-label placebo group or the treatment-as- [MD and 95% CI calculated by the CAP Editor] usual group. Interventions: All participants received an explanation and viewed a brief video clip about the placebo effect. Participants allocated Provenance: Invited. Not peer reviewed. to the open-label placebo group were given a medicine bottle of placebo pills with a label clearly marked ‘placebo pills’ and were instructed to Margreth Grotlea and Kåre Birger Hagenb take two pills twice a day for 3 weeks. Participants in the treatment as aOslo and Akershus University College of Applied Sciences, usual group were given the opportunity to receive placebo pills after 3 weeks. Outcome measures: The primary outcome was a composite Department of Physiotherapy, Oslo, Norway pain severity score assessed on three 0-to-10 numeric rating scales bNational Advisory Unit on Rehabilitation in Rheumatology, (maximum, minimum and usual pain) at baseline and 3 weeks. Sec- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway ondary outcomes were disability, assessed with the Roland- http://dx.doi.org/10.1016/j.jphys.2017.05.002 © 2017 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/). Commentary Using placebo interventions in randomised trials is powerful for between-group analyses were underpowered, which resulted in challenging accepted practice; and changing inappropriate practice imprecise estimates of treatment effect. In addition, there appeared when no difference between the active and placebo interventions to be some between-group differences in pain scores at baseline. It is observed. Arguably, the placebo effect of an intervention is may be important in future research to demonstrate that the use of associated with factors other than the active ingredient of that open-label placebos improve objective outcomes in addition to self- intervention, including patient-clinician interactions, expectation report outcomes, as reported in this study. of improvement with management, and rituals involved in the treatment approach. A substantial advantage of introducing the This is the first study to show a potential benefit of placebo placebo intervention in the randomised trial design is to ensure interventions for chronic low back pain and it highlights the blinding of assessors and patients. This is particularly important for impact of a positive treatment rationale and patient-clinician self-reported outcome measures, such as pain and disability, as rapport in the management process. Although the study presents lack of blinding has been associated with significant overestima- and acknowledges some methodological limitations, it provides tion of treatment benefits for self-reported measures.1 The authors important information on the power of placebo without deception. of this study emphasised, however, that recent research has established the effect of open-label placebo prescription in other Provenance: Invited. Not peer reviewed. fields, possibly via the presentation of a positive rationale, rather Manuela L Ferreira than deception, for the use of placebo. Institute of Bone and Joint Research, The Kolling Institute, Sydney This study was powered to detect a between-group difference Medical School, The University of Sydney, Australia in pain intensity of 1 point (0 to 10-point scale) with a sample size of 96 participants. This sample size, however, did not Reference account for the observed attrition rates (22%); it is likely that the 1. Feys F, et al. Syst Rev. 2014;3:14. http://dx.doi.org/10.1016/j.jphys.2017.05.001 1836-9553/© 2017 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 63 (2017) 129–130 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Editorial Publishing code: an initiative to enhance transparency of data analyses reported in Journal of Physiotherapy Rob Herbert a,b, Mark Elkins c,d a Editorial Board Member, Journal of Physiotherapy; b Neuroscience Research Australia (NeuRA), Sydney; c Editor, Journal of Physiotherapy; d Sydney Local Health District, Sydney, Australia In a recent interview,1 Professor Michael Gazzaniga, one of the Journal Editors (ICMJE) has recently mandated that, for clinical founders of cognitive neuroscience, provided a wonderful insight trials reported in ICMJE member journals, a data sharing plan must into how good science works: ‘You know, when you’re giving a be provided at the time the trial is registered and submitted with scientific presentation, everybody in the audience is sitting there the trial report.8 saying what’s another explanation for this?’ That’s exactly how it should be. External scrutiny is a key feature of the scientific Now the Journal of Physiotherapy is taking the next step. process. Sometimes scientists get it wrong, and when they do it is Henceforth the authors of accepted reports of quantitative research the responsibility of other scientists to find the mistakes. So, will be strongly encouraged to publish the statistical analysis plan ideally, all research findings are perpetually open to scrutiny. Then and code used to analyse their data. The policy applies to primary differing interpretations of the data can compete for acceptance. quantitative research (not to secondary research such as systematic The hope is that eventually the best interpretation wins. reviews of summary data). The mechanism will be much the same as that used for publishing raw data. The statistical analysis plan and However, scrutiny is only possible when there is transparency. code will be provided as supplementary files on the journal’s Readers of a research report must be able, if they wish, to look website and linked to the primary research report. deeply into how the research was conducted to decide if the authors’ conclusions are or are not supported by the data. Some readers may wonder what we mean when we refer to the ‘statistical analysis plan’ and ‘code’ used to analyse the data, so we Many readers are prepared to trust the published results of explain those terms below. research without scrutinising the data, perhaps because they trust the peer review process. However, even when there has been A statistical analysis plan is a detailed description of intentions rigorous peer review, published manuscripts may still contain about how the investigators intend to analyse the data. Impor- errors: there may be errors in the analysis of data, errors in tantly, the statistical analysis plan is written before the data are typesetting, or (hopefully rarely) deliberate misrepresentation of available for analysis, and is dated and ratified by the investigators. the data. Transparency of analysis procedures allows enthusiastic The plan may be made publicly available as part of the registered readers to detect errors in analyses. For this reason Munafò and protocol, as in these examples,9,10 or as part of a published protocol, colleagues have claimed that ‘transparency is superior to trust’.2 as in this example.11,12 Some statistical analysis plans, particularly for large and complex studies, are published as stand-alone papers, The Editorial Board has tried to maximise the transparency of as in these examples.13,14 The value of a statistical analysis plan is research reports published in the Journal of Physiotherapy. That is that it provides a public declaration of the investigators’ intentions why, for example, the Journal of Physiotherapy was amongst the for the analysis. This makes it clear, for both the investigators and first physiotherapy journals to mandate prospective registration of the readers of the resulting research report, which of the analyses clinical trials3 and encourage prospective registration of systematic were decided upon a priori and which were decided upon after reviews,4,5 and why authors are encouraged to conform to looking at the data. Analyses that were pre-specified in a statistical reporting guidelines such as those generated and made freely analysis plan are more credible than analyses that were not pre- available online by the Equator Network.6 specified. Analyses that were only conceived after looking at the data should be considered exploratory (‘hypothesis generating’) In 2008, the Journal of Physiotherapy led the way in an initiative rather than confirmatory. designed to improve research transparency. The Editorial Board resolved that authors of research reports accepted for publication Almost all analysis of quantitative research published in the in the Journal of Physiotherapy would be strongly encouraged to Journal of Physiotherapy (and, these days, of some qualitative publish raw data (eg, data from individual participants in a research too) involves statistical analyses conducted using randomised trial) on the web alongside the primary research programs such as SPSS, Stata, and SAS. Most programs allow the report. Publication of raw data enables scrutiny, and even re- user to conduct the analysis interactively by pulling down menus, analysis of the data, and makes it possible for other researchers to specifying variables, and selecting various options. The program incorporate the data in conventional or individual-patient-data then processes those instructions, runs the appropriate analyses, meta-analyses.7 This initiative has been tremendously successful: and displays the output on a screen or writes the output to a file. A since 2008, 92% of primary reports of randomised trials published problem with this approach is that the output might not provide a in the Journal of Physiotherapy have provided raw data as a web- complete or permanent record of exactly how the analysis was based supplement to the primary research report. Nearly a decade conducted. later, other clinical journals have begun to implement policies promoting data sharing. The International Committee of Medical Fortunately, most high-end software has the facility to automatically generate a permanent record of exactly how the 1836-9553/© 2017 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/).
130 Editorial analysis was conducted. In SPSS this is done with ‘syntax’ files, in Ethics approval: N/A. Stata it is done with ‘do’ files, and in SAS it is done with ‘SAS Competing interests: The authors declare that they have no program’ files. This is what we refer to as ‘code’. Other programs competing interests. may store code in other formats. The code provides a record of Source of support: Nil. exactly how the data were analysed. It is these files that authors Acknowledgements: Nil. will be encouraged to make publicly available as supplementary Provenance: Invited. Not peer reviewed. files on the Journal of Physiotherapy website. Correspondence: Mark Elkins, Centre for Education & Work- force Development, Sydney Local Health District, Australia. Email: Providing public access to individual participant data, the [email protected] statistical analysis plan and code make it possible for other researchers to examine and reproduce the analyses exactly as they References were originally conducted. Obviously, this increases transparency; but the potential benefits of making the code publicly available 1. Campbell V. Interview with Dr Michael Gazzaniga, author of tales from both sides of extend beyond enhancing transparency. Another advantage of the brain: A life in neuroscience. Brain Science Podcast 2015. http:// making the code public is the potential for education by allowing brainsciencepodcast.com [Accessed 5th May 2017]. inexperienced researchers to see rigorous ways to analyse data. 2. Munafò MR, et al. Nat Hum Behav. 2017;1:0021. Two members of the Editorial Board are each publishing an 3. Askie L, et al. Aust J Physiother. 2006;52:237–239. original research paper in the current issue.15,16 These Editorial 4. Elkins M. J Physiother. 2011;57:67–68. Board members and their respective co-authors have kindly agreed 5. Elkins M, Ada L. J Physiother. 2010;56:69. to lead the way with this new initiative by providing the data file, 6. Elkins M. J Physiother. 2015;61:103–105. the code used to analyse the data, and the protocol showing the 7. Herbert RD. Aust J Physiother. 2008;54:3. original statistical analysis plan. All these files are freely available 8. Taichman DB, et al. New Engl J Med. 2017;376:2277–2279. as electronic appendices to the published papers.15,16 9. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx? While the Editor and the Editorial Board of the Journal of id=364402&isReview=true. Physiotherapy are committed to this new policy, we understand 10. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx? that some researchers will not have followed pre-specified statistical analysis plans or may not have coded their analyses, id=370896&isReview=true. and therefore may not be able to comply with requests to supply 11. Harvey LA, et al. J Physiother. 2016;62:88–95. the statistical analysis plan and code. For now, the absence of a 12. Harvey LA, et al. Trials. 2011;12:14. statistical analysis plan and code will not preclude publication in 13. Williams CM, et al. Trials. 2013;14:248. the Journal of Physiotherapy. However, provision of a statistical 14. Mathieson S, et al. Trials. 2016;17:53. analysis plan and code at the time a manuscript is submitted will 15. Lambert T, et al. J Physiother. 2017;63:161–167. strengthen the prospects of publication. Authors are strongly 16. Oosterhuis T, et al. J Physiother. 2017;63:144–153. encouraged to provide statistical analysis plans and code when they submit their papers to the Journal of Physiotherapy. Websites www.equator-network.org http://dx.doi.org/10.1016/j.jphys.2017.05.011 Readers’ Choice Award The Editorial Board is pleased to announce the annual Readers’ Choice Award, which recognises the paper published in Journal of Physiotherapy that generates the most interest by readers of the journal. The winning paper is chosen based on the number of times that each paper published in a given year is downloaded in the six months after its day of publication. The winning paper from among those published in 2016 is ‘Physiotherapy rehabilitation for people with spinal cord injuries’ by Professor Lisa Harvey from the University of Sydney.1 The winning paper is one of the journal’s new Invited Topical Reviews. It deftly summarises the results of a large amount of research into the assessment and rehabilitation management of people with spinal cord injury. The section on assessment includes clear and concise guidance on how to convert the assessment into goal setting for individual patients. The physiotherapy interventions considered by the paper include interventions to increase strength, interventions to improve the performance of motor tasks, and interventions to prevent and treat contracture. The paper also calls for spinal cord injury to be the topic of further high-quality clinical studies, several of which have subsequently been published in Journal of Physiotherapy.2–4 The only other Invited Topical Review5 published in the same year was the second ranked paper, indicating the popularity of this relatively new category of paper in the journal. The Editorial Board of Journal of Physiotherapy congratulates Professor Harvey on her success. References 1. Harvey LA. Physiotherapy rehabilitation for people with spinal cord injuries. J Physiother. 2016;62:4–11. 2. Nooijen CFJ, et al. A behavioural intervention increases physical activity in people with subacute spinal cord injury: a randomised trial. J Physiother. 2016;62:4–11. 3. Harvey LA, et al. Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury (‘Hands On’): a randomised trial. J Physiother. 2016;62:88–95. 4. Jørgensen V, et al. Falls and fear of falling predict future falls and related injuries in ambulatory individuals with spinal cord injury: a longitudinal observational study. J Physiother. 2016;63:108–113. 5. Granger C. Physiotherapy management of lung cancer. J Physiother. 2016;62:60–67. http://dx.doi.org/10.1016/j.jphys.2017.05.012
130 Editorial analysis was conducted. In SPSS this is done with ‘syntax’ files, in Ethics approval: N/A. Stata it is done with ‘do’ files, and in SAS it is done with ‘SAS Competing interests: The authors declare that they have no program’ files. This is what we refer to as ‘code’. Other programs competing interests. may store code in other formats. The code provides a record of Source of support: Nil. exactly how the data were analysed. It is these files that authors Acknowledgements: Nil. will be encouraged to make publicly available as supplementary Provenance: Invited. Not peer reviewed. files on the Journal of Physiotherapy website. Correspondence: Mark Elkins, Centre for Education & Work- force Development, Sydney Local Health District, Australia. Email: Providing public access to individual participant data, the [email protected] statistical analysis plan and code make it possible for other researchers to examine and reproduce the analyses exactly as they References were originally conducted. Obviously, this increases transparency; but the potential benefits of making the code publicly available 1. Campbell V. Interview with Dr Michael Gazzaniga, author of tales from both sides of extend beyond enhancing transparency. Another advantage of the brain: A life in neuroscience. Brain Science Podcast 2015. http:// making the code public is the potential for education by allowing brainsciencepodcast.com [Accessed 5th May 2017]. inexperienced researchers to see rigorous ways to analyse data. 2. Munafò MR, et al. Nat Hum Behav. 2017;1:0021. Two members of the Editorial Board are each publishing an 3. Askie L, et al. Aust J Physiother. 2006;52:237–239. original research paper in the current issue.15,16 These Editorial 4. Elkins M. J Physiother. 2011;57:67–68. Board members and their respective co-authors have kindly agreed 5. Elkins M, Ada L. J Physiother. 2010;56:69. to lead the way with this new initiative by providing the data file, 6. Elkins M. J Physiother. 2015;61:103–105. the code used to analyse the data, and the protocol showing the 7. Herbert RD. Aust J Physiother. 2008;54:3. original statistical analysis plan. All these files are freely available 8. Taichman DB, et al. New Engl J Med. 2017;376:2277–2279. as electronic appendices to the published papers.15,16 9. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx? While the Editor and the Editorial Board of the Journal of id=364402&isReview=true. Physiotherapy are committed to this new policy, we understand 10. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx? that some researchers will not have followed pre-specified statistical analysis plans or may not have coded their analyses, id=370896&isReview=true. and therefore may not be able to comply with requests to supply 11. Harvey LA, et al. J Physiother. 2016;62:88–95. the statistical analysis plan and code. For now, the absence of a 12. Harvey LA, et al. Trials. 2011;12:14. statistical analysis plan and code will not preclude publication in 13. Williams CM, et al. Trials. 2013;14:248. the Journal of Physiotherapy. However, provision of a statistical 14. Mathieson S, et al. Trials. 2016;17:53. analysis plan and code at the time a manuscript is submitted will 15. Lambert T, et al. J Physiother. 2017;63:161–167. strengthen the prospects of publication. Authors are strongly 16. Oosterhuis T, et al. J Physiother. 2017;63:144–153. encouraged to provide statistical analysis plans and code when they submit their papers to the Journal of Physiotherapy. Websites www.equator-network.org http://dx.doi.org/10.1016/j.jphys.2017.05.011 Readers’ Choice Award The Editorial Board is pleased to announce the annual Readers’ Choice Award, which recognises the paper published in Journal of Physiotherapy that generates the most interest by readers of the journal. The winning paper is chosen based on the number of times that each paper published in a given year is downloaded in the six months after its day of publication. The winning paper from among those published in 2016 is ‘Physiotherapy rehabilitation for people with spinal cord injuries’ by Professor Lisa Harvey from the University of Sydney.1 The winning paper is one of the journal’s new Invited Topical Reviews. It deftly summarises the results of a large amount of research into the assessment and rehabilitation management of people with spinal cord injury. The section on assessment includes clear and concise guidance on how to convert the assessment into goal setting for individual patients. The physiotherapy interventions considered by the paper include interventions to increase strength, interventions to improve the performance of motor tasks, and interventions to prevent and treat contracture. The paper also calls for spinal cord injury to be the topic of further high-quality clinical studies, several of which have subsequently been published in Journal of Physiotherapy.2–4 The only other Invited Topical Review5 published in the same year was the second ranked paper, indicating the popularity of this relatively new category of paper in the journal. The Editorial Board of Journal of Physiotherapy congratulates Professor Harvey on her success. References 1. Harvey LA. Physiotherapy rehabilitation for people with spinal cord injuries. J Physiother. 2016;62:4–11. 2. Nooijen CFJ, et al. A behavioural intervention increases physical activity in people with subacute spinal cord injury: a randomised trial. J Physiother. 2016;62:4–11. 3. Harvey LA, et al. Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury (‘Hands On’): a randomised trial. J Physiother. 2016;62:88–95. 4. Jørgensen V, et al. Falls and fear of falling predict future falls and related injuries in ambulatory individuals with spinal cord injury: a longitudinal observational study. J Physiother. 2016;63:108–113. 5. Granger C. Physiotherapy management of lung cancer. J Physiother. 2016;62:60–67. http://dx.doi.org/10.1016/j.jphys.2017.05.012
Journal of Physiotherapy 63 (2017) 189–190 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Correspondence Critical appraisal leaves our upper limb therapy intervention trial misrepresented We have recently come across a critical appraisal and in addition to our open access published paper we have produced a commentary1,2 published in the Journal of Physiotherapy regarding lay summary http://www.scope.org.uk/Support/Professional/ our published trial3 comparing action observation and repeated Medical/Play, which clearly states the trial findings, and a website practice with repeated practice alone in children age 3 to 10 years https://research.ncl.ac.uk/hemiplegiaresearch- fungames/ provid- with unilateral cerebral palsy. We were disappointed to find that ing free access to materials for parents to use and therapists to our trial was misrepresented. The title of the synopsis should suggest as supplementary to formal therapy sessions. convey our message that home-based, parent-delivered therapy comprising action observation and repeated practice does not We applaud the provision of open access summaries of research improve upper limb function more than repeated practice alone. findings in the Journal of Physiotherapy. On this occasion, key Instead, the title of the synopsis implies that parent-delivered aspects of the research have been misrepresented in the critical therapy does not lead to improved upper limb function in this appraisal and we request that this is addressed. group compared with repeated practice alone. It is not possible to make conclusions from our trial about the benefits of adding Acknowledgements: Funding: Dr Basu is funded through an parent-delivered therapy to repeated practice alone, as in our trial NIHR Career Development Fellowship. The views expressed in this both groups of children were receiving parent-delivered therapy. publication are those of the authors and not necessarily those of Furthermore, the synopsis title omits the word ‘unilateral’; we the NHS, the National Institute for Health Research, or the studied a specific group of children with unilateral cerebral palsy, Department of Health. not cerebral palsy in general. The comment regarding difference in adherence between the two groups does not acknowledge the fact Anna Purna Basua,b, Emma Victoria Kirkpatrickc and that the difference observed was not statistically significant. With Janice Pearsed reference to the comment that children with more severely affected hand function might not be able to perform the prescribed aInstitute of Neuroscience, Newcastle University, Newcastle upon Tyne tasks, we tailored activities to the interests and abilities of bDepartment of Paediatric Neurology, Newcastle upon Tyne Hospitals participants. NHS Foundation Trust, Newcastle In contrast to the suggestion from the published synopsis title, we cClinical Trials Unit, Southampton University, Southampton found that both parent-delivered home-based approaches that were dTherapy Services, Newcastle upon Tyne Hospitals NHS Foundation used led to small but significant improvements in hand function in children aged 3 to 10 years with unilateral cerebral palsy. These Trust, Newcastle upon Tyne, UK improvements were seen in all of the three outcome measures that were used. The very reason for embarking on this trial was our References awareness of a need to supplement therapist input with parent- delivered home-based approaches in an attempt to increase the 1. Shields N. J Physiother. 2016;62:224. overall therapy dose. We were successful in achieving this. Therefore, 2. Johnston LM. J Physiother. 2016;62:224. 3. Kirkpatrick E, et al. Dev Med Child Neurol. 2016;58:1049–1056. http://dx.doi.org/10.1016/j.jphys.2017.05.008 Reply to Basu et al We are happy to respond to the comments made in the above approaches used led to small but significant improvements in hand letter about the Journal of Physiotherapy’s appraisal1 of the trial by function in children aged 3 to 10 years with unilateral cerebral palsy’. Kirkpatrick et al.2 A misconception that underlies the authors’ comments is that The approach taken in the Critically Appraised Papers section of the within-group improvements observed in both groups in the the Journal of Physiotherapy for reporting results of randomised, trial should be interpreted as evidence that both interventions are controlled trials is to focus on between-group differences. As effective. In point of fact, analyses of within-group data against stated by the eminent statisticians, Bland and Altman: baseline, although often used, can be highly misleading.4 Inter- preting data in this way may be invalid because any improvement The essential feature of a randomised trial is the comparison could be due to something other than the interventions, such as between groups. Within group analyses do not address a becoming more familiar with the test procedures. The only way to meaningful question: the question is not whether there is a determine whether any improvement was due to the interventions change from baseline, but whether any change is greater in one is by using a third ‘no intervention’ group for comparison, which group than the other.3 this trial did not have. We stand by this approach. This makes it impossible to agree with The letter also indicates that the title of the synopsis was the authors’ claim that both ‘parent-delivered home-based misleading and lacked important details. Because of the amount of 1836-9553/© 2017 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/).
190 Appraisal Correspondence text in the Synopsis and Commentary, we enforced the editorial or introduction of Lycra sleeves/suits). In this context, the trial guideline 5FDtI]$[_T hat specifies a space limit of two lines for the title of ][61Fa_ID$T recommendations can be considered for children with active grasp Critically Appraised Paper. As the published version shows, almost and good cognition who do not require medical, surgical or other all of the space allowed was used. We acknowledge that there was interventions for hand function. Further research is required to room to add the word unilateral or that the intervention received understand any potential effect for children who were excluded by the experimental group could have been described as parent- from the trial and who might be described as having more delivered action observation therapy instead of parent-delivered impaired hand function. therapy, but not both. However, readers need only read the first sentence of the synopsis to understand that the participants in the Finally, we would like to emphasise that our goal is to help trial were diagnosed with unilateral cerebral palsy and that the dissemination of clinically relevant research to a broader reader- added intervention was parent-delivered action observation therapy. ship and only high-quality trials such as Kirkpatrick et al2D]$TI_F4[ are selected for inclusion in the Critically Appraised Papers section of The synopsis reports adherence rates for the two groups based the Journal of Physiotherapy. on the mean number of play sessions reported for the trial. The authors’ comment that the difference between the groups was Nora Shieldsa, Leanne Johnstonb, Nicholas Taylorc and statistically significant is new information that was not reported in Mark Elkinsd the original publication. We acknowledge that we could have reported the mean difference in the number of play sessions aSchool of Allied Health, La Trobe University between the groups as 6.6 sessions (95% CI –3.5 to 16.7). However, bSchool of Health & Rehabilitation Sciences, The University of a decision was made to report the rate of adherence, as this is a more easily interpretable concept for readers, although it was not Queensland possible to calculate a difference in the rate of adherence between cSection Editor groups without additional data. dEditor We acknowledge the intervention activities were tailored to the interests and abilities of participants, which is important in References providing meaningful therapy. However, the trial excluded children who: were registered as vision impaired; were unable 1. Shields N. J Physiother. 2016;62:224. or unwilling to understand or attempt the tasks; had no active 2. Kirkpatrick E, et al. Dev Med Child Neurol. 2016;58:1049–1056. grasp in the affected hand; were expecting another intervention; 3. Bland JM, Altman DG. BMJ. 2011;342:d561. or who had undergone an intervention in the preceding 3 months 4. Bland JM, Altman DG. Trials. 2011;12:264. (eg, upper limb botulinum toxin injections, surgical intervention, http://dx.doi.org/10.1016/j.jphys.2017.05.009
Journal of Physiotherapy 63 (2017) 187 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinimetrics The Gross Motor Function Measure (GMFM) Summary Description and administration: The Gross Motor Function Measure GMFM-88 is valid for use with children with Down syndrome and (GMFM) is a tool that has been developed to assess change in gross acquired brain injury.5 motor function in children with cerebral palsy aged 5 months to 16 years of age.1 The GMFM measures ‘activity’ as defined within the Interna- Shortened versions of GMFM-66 have been developed more recently. tional Classification of Functioning, Disability and Health.2 To administer The GMFM-66 Items Sets (IS)6 uses a scoring algorithm, whereby a the GMFM, a trained therapist observes the child completing a number number of decision items guide the therapist toward a predetermined of gross motor tasks in a standardised environment, and the child’s best set of items relevant to a child functioning at that level, and the child is ability is measured. The tool measures capacity (what a person can do in then tested on that ‘item set’. The GMFM- 66 Basal and Ceiling (B&C)7 a standardised, controlled environment) rather than performance (what approach establishes the ‘basal’ score of three successes in a row as the a person actually does do in his/her daily environment).3 The assessment start of the test and testing ends when the ‘ceiling’ is reached, which typically takes 45 to 60 minutes to complete and only requires ‘usual is indicated by scoring three zeros in a row. However, if the primary therapy equipment’. goal of assessment is to measure change, the full GMFM-66 should be used.8 The original GMFM version has 88 items each scored on a 4-point ordinal scale of 0 to 3, where 0 indicates that the child does not initiate The GMFM user’s manual for all versions can be purchased from Wiley the task; 1 indicates that the child initiates the task (completes < 10% of Blackwell Publishing5 and the GMFM score sheets are freely available for the activity); 2 indicates that the child partially completes the task personal and non-commercial use. In addition, the Gross Motor Ability (completes from 10 to 99% of the activity); 3 indicates that the child Estimator (GMAE-2) Scoring Software for the GMFM-66 can be down- completes the task (100%); and NT indicates that the child was not loaded from the CanChild website (https://www.canchild.ca/).9 tested. The 88 items are grouped into five dimensions: 1) lying and rolling, 2) sitting, 3) crawling and kneeling, 4) standing, and 5) walking, Reliability, validity and responsiveness to change: Studies have reported running and jumping. A maximum of three trials is allowed for each excellent interrater and test-retest reliability and internal consistency in item and the best trial is recorded. Scores for each dimension are children with cerebral palsy and Down syndrome,10 as well as supporting expressed as a percentage of the maximum score for that dimension content, concurrent, construct, and discriminative validity in the same and the total score is obtained by averaging the percentage scores across populations.10,11 Responsiveness to change has been tested using various the five dimensions.4 statistical methods, including comparison of parental and clinician responses, investigating minimum clinically important difference, effect Rasch analysis was applied to the GMFM-88 in order to improve its size, receiver operating curves and standardised response means.10,11 The interpretability and clinical usefulness, which resulted in a unidimen- minimum clinically important difference is 0.8 to 1.6 for medium effect sional interval-measure hierarchical scale – the GMFM-66 – consisting size and 1.3 to 2.6 for larger effect size.12Different versions of the GMFM are of 66 items from the original 88.4 The GMFM-66 is only valid for use with responsive in children with cerebral palsy, Down syndrome and traumatic children with cerebral palsy, while there is some evidence that the brain injury.10 Commentary The GMFM is a reliable, valid and responsive measure of gross motor Provenance: Invited. Not peer reviewed. function for children with cerebral palsy. It is frequently utilised in clinical and research practice to measure change over time or following Adrienne R Harvey interventions. With a reasonably lengthy administration time, the tool is Developmental Disability and Rehabilitation Research, best suited for yearly or half yearly longitudinal clinical assessments or for research studies. It is strongly recommended that testers be familiar Murdoch Children’s Research Institute, Australia with use before administering the tool. References Limitations of the GMFM include: it is not well suited for children with higher functioning gross motor ability13 because of ceiling effects; it 1. Russell DJ, et al. Dev Med Child Neurol. 1989;31:341–352. measures capacity and therefore does not consider the environmental 2. World Health Organisation. WHO; 2001. influence on the child’s functioning in their everyday activities; and the 3. Holsbeeke L, et al. Arch Phys Med Rehabil. 2009;90:849–855. GMFM-66 version requires access to a computer and software. 4. Russell DJ, et al. Phys Ther. 2000;80:873–885. 5. Russell DJ, et al. Mac Keith Press; 2013. In summary, the GMFM is a psychometrically sound measure for children 6. Russell DJ, et al. Dev Med Child Neurol. 2010;52:e48–e54. with cerebral palsy. It measures one aspect of activity only and therefore 7. Brunton LK, Bartlett DJ. Phys Ther. 2011;91:577–588. should be used where the clinical or research outcome of interest is gross 8. Avery LM, et al. Devl Med Child Neurol. 2013;55:534–538. motor ability. For a comprehensive assessment of a child with cerebral 9. Gross Motor Ability Estimator (GMAE-2) Scoring Software for the GMFM-66; palsy, the GMFM should be part of a suite of measures with other psychometrically sound tools to ensure that all aspects of the International 2012. Viewed 28 December 2016 from https://www.canchild.ca/. Classification of Functioning, Disability and Health are covered. 10. Adair B, et al. Dev Med Child Neurol. 2012;54:596–605. 11. Harvey A, et al. Devl Med Child Neurol. 2008;50:190–198. 12. Oeffinger D, et al. Dev Med Child Neurol. 2008;50:918–925. 13. Vos-Vromans. et al. Disab Rehabil. 2005;27:1245–1252. http://dx.doi.org/10.1016/j.jphys.2017.05.007 1836-9553/© 2017 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 63 (2017) 191 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Media There’s an app for that! iOrtho+ Special Tests and Manual Techniques is a useful resource for students and recently graduated physiotherapists https://itunes.apple.com/us/app/iortho-special-tests-and-manual- rules such as the Ottawa Knee and Ankle Rules or the Canadian C-Spine _T7[D$IF] techniques/id433505647?mt=8 Rule, enabling the clinician to quickly access this information and ensure that they are applying the rule correctly. iOrtho+ Special Tests and Manual Techniques is an app that is available for use on Apple and Android phones and tablets. It is packed full of ortho- The app can be downloaded as a free trial with limited access, or the full paedic special tests and manual techniques, and is a great practical clinical version is available to purchase for AUD14.99. This is a small cost compared resource in the musculoskeletal setting, especially for students or recently with a comparable orthopaedic text, and has the added advantage of graduated physiotherapists. More-experienced clinicians are also likely to regular updates for no extra cost, as well as the added utility of being a find it useful as a reference for special tests or manual treatment techniques device-based resource. It is possible to download all of the data on your for conditions that they may not routinely manage, or for other purposes device so that you do not have to rely on internet access to use the app in such as a teaching aid when supervising students. the clinic. Another option is to store data in the cloud and access with WiFi. The app has over 350 special tests and over 100 different manual techni- In my work as a clinical educator of physiotherapy in graduate entry ques. Each test or technique has high-resolution photos and/or videos of programs in Australia, I spend a lot of time mentoring students and helping the procedures, and concise descriptions of purpose, technique and inter- them with the challenges that they face while on clinical placements in pretation or use of each skill, as well as information about specificity, both public and private settings. Students are continually challenged in all sensitivity, and likelihood ratios for the orthopaedic tests. manner of ways when learning how to apply their university education to clinical practice. One common challenge for students, especially working in The app is neatly organised with a home page showing a skeleton, over which private practice, is realising just how much more knowledge there is for major regions of the body are highlighted (Figure 1A). Simply clicking on an them to learn with regard to manual therapy techniques and special tests, area brings up a menu, which lists the special tests, manual techniques or beyond the fundamentals that are covered early in their entry level screening procedures relevant to that region (Figure 1B). Special tests are then curriculum. For example, students may observe more experienced clin- further grouped by type, such as neural provocation tests (Figure 1C), stability icians performing tests or techniques that they have not yet been exposed tests, labral tests or functional tests. Favourite tests can be highlighted for to or learnt about. For some students this can cause an overload of quick reference. information, often detracting from their clinical education learning expe- rience. Once a test is selected, a photo of the test appears (eg, Figure 1C). The majority of tests also include a useful short video (by swiping right), which An easily accessible reference guide such as the iOrtho+ app gives students demonstrates how the test is performed by a clinician on the patient. Below the ability to quickly look up tests for a variety of conditions, revise this there is a description of the purpose of the test, the technique and techniques through the video and photo demonstrations, practise inter- clinical interpretation. References to the original evidence are provided preting test results, learn the value of clustering techniques and access with most tests or techniques, sometimes with links to the full paper. Given related literature if required. that papers published in 2015 are referenced in the app, it appears that much of the evidence is reasonably up to date. Finally, another section For a clinical educator of students or mentor of recently graduated phy- provides useful information about the accuracy of the test, including siotherapists, this app has plenty of features to guide and enhance teaching, sensitivity, specificity, and likelihood ratios, often grouping these with whether for formal in-service tutorials or for more spontaneous learning. For more experienced musculoskeletal therapists, the app is still extremely c[(Figure_1)TD$IG] lusters of other tests. The app also includes established clinical prediction useful, as there is a wide variety of clinical tests and techniques that can be easily accessed as a useful resource. The data about diagnostic test accuracy (eg, likelihood ratios) also assists clinicians to apply evidence to clinical practice, evaluate the outcomes and continually improve $DTI_F1[]8their clinical reasoning. There are a few limitations of the iOrtho+ app that should be mentioned. First, when using the app on a small screen, such as an iPhone 5, some of the longer titles of tests or techniques cannot be read in full, potentially causing some confusion or frustration. Therefore, use on a larger smart phone or iPad may be preferable. Second, although most tests have data regarding diagnostic accuracy, not all do, and some references may not be up to date. It is incumbent on the app designers to keep this information up to date and based on current evidence. Provenance: Invited. Not peer reviewed. Figure 1. A. Home screen of iOrtho+ Special Tests and Manual Techniques app. B. Tim Foulcher Example of menu of special tests of a selected body region (Wrist & Hand). C. Macquarie University, Australia Example of a special test (Median Nerve Test), which is flagged as a favourite test by the heart symbol. http://dx.doi.org/10.1016/j.jphys.2017.05.013 1836-9553/© 2017 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 63 (2017) 188 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinical Practice Guidelines Too Fit To Fracture Exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture Date of latest update: March 2014. Date of next update: by Osteoporosis Canada, the National Osteoporosis Foundation, and Unknown. Osteoporosis Australia’s Medical and Scientific Advisory Committee. Location: Osteoporosis International (Vol 25, No. 3, March 2014, pp. Patient group: Older adults with osteoporosis and no history 821-835); http://doi.org/10.1007/s00198-013-2523-2 of fracture; and older adults with a history of an osteoporotic vertebral fracture. Intended audience: Primary care clinicians, rheumatologists, Description: These recommendations were published as a physiotherapists, physical therapists and personal trainers. Additional 15-page journal article. They provide a consensus about exercise versions: Version one. Expert working group: An expert panel of recommendations for two target groups: older adults with osteoporosis researchers and clinicians was selected by the following criteria: and no history of fracture; and older adults with a history of an previous experience of guideline development; prior experience in osteoporotic vertebral fracture. An international expert panel used the conducting clinical trials in exercise and in people with osteoporosis or Grading of Recommendation Assessment, Development, and Evalua- vertebral fracture; or having clinical or anatomy/biomechanics tion (GRADE) approach to evaluate the quality of existing evidence and expertise related to exercise. Members of the panel were from generate recommendations. A number of reviews, meta-analyses, Australia, Canada, Finland and the United States, and included observational studies and systematic reviews from peer-reviewed stakeholders from Osteoporosis Canada. The expert panel had a wide journals were used to inform this project. A clear summary of the range of expertise, including: biomechanics, endocrinology, geriatrics, exercise recommendations is provided for the two target groups. The gerontology, internal medicine, kinesiology and physical therapy. Four recommendations are followed by a short summary of the evidence and patient advocates were chosen from the Canadian Osteoporosis Patient the rationale underlying it. The recommendations have most direct Network to inform outcomes on patient preference. Funded by: The relevance to physicians who prescribe exercise or professionals who University of Waterloo, Osteoporosis Canada, the Ontario Osteoporosis design exercise programs. Table 4 provides a comprehensive summary Strategy and Schlegel-University of Waterloo Research Institute for of the key recommendations. Tables 5 and 6 provide details of exercises Aging supported the project. Consultation with: Stakeholders from the used in clinical trials and exercise prescription details, respectively. Osteoporosis Canada Clinical Practice Guidelines committee, Canadian Osteoporosis Patient Network, National Osteoporosis Foundation Provenance: Invited. Not peer reviewed. Exercise and Rehabilitation Advisory Council, International Osteopo- rosis Foundation, Finnish Osteoporosis Association, Osteoporosis Isabel Rodrigues and Joy MacDermid Australia, and Canadian Physiotherapy Association were consulted McMaster University, Ontario, Canada for input about utility and clarity of the report. Approved by: Endorsed http://dx.doi.org/10.1016/j.jphys.2017.04.003 Knee osteoarthritis Surgical Management of Knee Osteoarthritis Evidence-Based Clinical Practice Guideline Date of latest update: December 2015. American Association of Hip and Knee Surgeons. Location: http:// www.orthoguidelines.org/topic?id=1019. Description: This guideline Patient group: Adult patients with suspected or confirmed osteoar- is intended to enhance musculoskeletal care for adult patients under- thritis of the knee. Intended audience: Primarily orthopaedic surgeons going surgical management of knee osteoarthritis. The guideline pro- and secondarily a variety of healthcare professionals, including phy- vides evidence-based recommendations that address 42 questions siotherapists. Additional versions: This is an updated version of a generated by the working group to define risk factors, types of anaes- previous guideline. The full 661-page version, including all summary thesia, surgical approaches, postoperative mobilisation/supervised tables and brief summaries of the key recommendations, is available. exercises that affect outcomes, including pain and complication rates. Expert working group: The group was chaired by an assistant clinical For physiotherapists, the most relevant points are recommendations professor of medicine and consisted of 13 members representing suggesting strong evidence for that rehabilitation initiated on the day of additional professional societies, including: four from the American arthroplasty reduces length of hospital stay, and that postoperative Academy of Orthopaedic Surgeons; three from the American Associa- continuous passive motion does not improve outcomes. This guideline tion of Hip and Knee Surgeons; and one from each of the Arthroscopy for surgical management of knee osteoarthritis is the most recent Association of North America, American Orthopaedic Society for Sports among a number of guidelines related to orthopaedic conditions that Medicine, Society of Military Orthopaedic Surgeons, American Physical have been funded by the American Academy of Orthopaedic Surgeons. Therapy Association, Society of Hospital Medicine, and American Soci- All of which are freely available at http://www.aaos.org/guidelines/? ety of Anesthesiologists. Funded by: The American Academy of Ortho- ssopc=1. paedic Surgeons. Consultation with: The professional associations represented and within the American Academy of Orthopaedic Sur- Provenance: Invited. Not peer reviewed. geons organisation. Approved by: The American Academy of Ortho- paedic Surgeons. Endorsed by: Arthroscopy Association of North Goris Nazari America, American College of Radiology, Society of Military Orthopae- Western University, Canada dic Surgeons, The Knee Society, American Geriatric Society, and http://dx.doi.org/10.1016/j.jphys.2017.04.004 1836-9553/© 2017 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/).
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