Journal of Physiotherapy 65 (2019) 186–188 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Editorial An international perspective on integrating physiotherapists in oncology care Martijn M Stuiver a,b, Nicole L Stout c, Amy M Dennett d,e, Caroline M Speksnijder f,g,h, Kristin L Campbell i a Center for Quality of Life, Netherlands Cancer Institute; b ACHIEVE Center of Expertise, Amsterdam University of Applied Sciences, Amsterdam, Netherlands; c Rehabilitation Medicine Department, National Institutes of Health, Bethesda, USA; d Allied Health Clinical Research Office, Eastern Health; e La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Australia; f Department of Head and Neck Surgical Oncology; g Department of Oral and Maxillofacial Surgery and Special Dental Care; h Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands; i Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada Introduction interactive Audience Response Systema. Clear themes and relative agreement became apparent regarding the current state of affairs, Cancer and its treatments can result in impairments, which can challenges, and future directions for physiotherapy in oncology. affect multiple body systems. These impairments restrict physical functioning and participation in activities of daily living and life roles The current status of physiotherapists in oncology of many patients, consequently limiting their quality of life. Many such impairments are amenable to physiotherapy interventions. Participants agreed that education for entry level to practise Numerous studies have shown beneficial effects of physiotherapy already enables physiotherapists to play a role in the detection and interventions – including exercise programs – on joint pain and range management of many cancer-related impairments (eg, pain and of motion, physical functioning, physical fitness, fatigue, and health- reduced range of motion or physical fitness) that may preclude related quality of life.1 However, the integration of physiotherapy patients from engaging in activities of daily functioning and services into cancer care continues to languish.2,3 participating in life roles. Most physiotherapists can manage these impairments and help patients adapt to functional loss or chronic Recently, the Clinical Oncology Society of Australia acknowledged symptom burden by teaching coping strategies, maximising the importance of exercise in the cancer continuum by issuing a compensation capacity, and improving ergonomics of (alternative) guideline recommending that exercise prescription be embedded as movement strategies. Yet, more specialised knowledge about part of standard practice in cancer care, with patients referred to cancer treatments and their side effects, as well as advanced skills, exercise professionals with experience in cancer care, including are desirable to support individuals with cancer in their specific physiotherapists.4 Additionally, the National Cancer Policy Forum in needs throughout the cancer care continuum. This includes, but is the United States published recommendations for better integration not limited to, the management of lymphoedema,6,7 peripheral of rehabilitation services into cancer care, including physiotherapy, neuropathy,8 and cancer-related fatigue.9 The panel representa- ideally starting at the point of cancer diagnosis, in order to reduce tives identified existing, and the ongoing development of, post- long-term, treatment-related adverse effects and disability.5 graduate educational programs and Master programs to advance oncology-specific knowledge and skills. This includes board spe- Clearly, physiotherapy has an important role to play in cancer care. cialty examinations and accompanying credentialing. In addition, Are we up to this task, or do we need to step up our game? This the national physiotherapy associations of several countries – manuscript provides international perspectives on these questions; including Australia, Canada, Chile, Denmark, Netherlands, and they were obtained using an interactive plenary discussion at the first USA – have established dedicated oncology sections. There was International Conference on Physiotherapy in Oncology. also strong agreement that the growing evidence base for the effectiveness of physiotherapy interventions in the oncology pop- International Conference on Physiotherapy in Oncology 2018 ulation has helped to improve integration of rehabilitation services into cancer care.1 The first International Conference on Physiotherapy in Oncology (an open congress) took place in Amsterdam, June 2018. There were Challenges for broader implementation and further advancement 280 physiotherapists representing 30 countries from African, Asian, of oncology physiotherapy European, and North and South American regions. The objective was to present scientific and professional developments in the field of During the panel discussion, it became clear that there are three oncology physiotherapy and enable international collaboration and major challenges to successful implementation of physiotherapy in idea exchange. The conference program included an interactive, cancer care, which were shared and generally agreed upon among plenary panel discussion with subject matter experts, representing representatives from all 30 countries. These were: costs associated Australia, Canada, Chile, Denmark, the Netherlands, Spain, and the with access to physiotherapy care; insufficient awareness of benefits United States. Panellists were queried for input on their nation’s ex- of and lack of referral pathways to physiotherapy services for periences and asked to identify successes and challenges in the field of oncology rehabilitation. The audience participated via an https://doi.org/10.1016/j.jphys.2019.07.004 1836-9553/© 2019 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/).
Editorial 187 individuals with cancer; and the need for capacity building of the will occur due to the disease or its treatment. Functional gains and physiotherapy workforce - including specialisation. losses necessitate ongoing surveillance and guidance to manage im- pairments that arise, as well as to accommodate exercise prescription. Costs This will only be achieved by incorporating physiotherapy as a standard part of the work flow of a cancer centre, and having dedi- In many countries, access to physiotherapy services in cancer care cated physiotherapy staff who can provide consultative assessment is inadequate or even absent. Services provided within public and triage to the appropriate setting of care. The physiotherapist healthcare systems are limited (ie, Canada, UK, and USA) or there is provides a unique role that complements the cancer team by little third-party insurance coverage for services in other private providing insights on functional movement. healthcare systems. Legislative efforts have yielded marginal success, usually targeting one specific population or disease type (eg, the USA Capacity building and specialisation Women’s Health and Cancer Rights Act) but fail to address the needs of the greater population, especially as they move beyond active Panellists and the audience agreed that in order to provide safe medical disease treatment. Moreover, legislation does not always and effective interventions, physiotherapists working with in- keep up with the rapid changes in the field of cancer care. For dividuals with cancer need to have an understanding of the mecha- example, in the Netherlands, basic insurance partially covers nisms of anti-cancer therapy and how these effect physiological physiotherapy-supervised exercise during adjuvant chemotherapy, systems involved in human movement.18 In addition, since the ma- based on the preceding hospital admission. However, since neo- jority of individuals with cancer also have one or more comorbidities, adjuvant therapy has become the standard treatment for some can- a high level of clinical reasoning is required.19 A cancer diagnosis cers (eg, breast cancer), patients can no longer apply for often comes with a high psychosocial and existential burden, and reimbursement for the same intervention, as they have not yet been many patients have anxiety or depressive symptoms, which need to hospitalised. be recognised and accounted for during physiotherapy treatment. Managing these issues requires high-level communication skills. While the evidence base underpinning the effectiveness of phys- Therefore, additional education in oncology is a prerequisite for iotherapy interventions for individuals with cancer is growing, cost- physiotherapists who want to be fully capable of providing high- effectiveness data are currently limited to a few studies.10–12 Cost quality care to people with cancer. This supposition is supported by containment is foremost among governments, regulators, and the US Institute of Medicine report Delivering High-Quality Cancer healthcare insurers. Physiotherapy interventions have great potential Care, which identifies the need for the healthcare workforce to have for cost mitigation through prospective rehabilitation services, and advanced education and training in oncology in order to optimise the through mitigation of functional decline during and after cancer quality of care for this population.20 treatments. However, in the absence of evidence that demonstrates this economic benefit, payers have limited incentive to improve In physiotherapy practice, specialisation commonly has several reimbursement for physiotherapy in cancer care. levels. High-level specialists or the most advanced practice-trained individuals may primarily practise within a specialised cancer care Awareness and referral setting, but also act as consultants to physiotherapists with lower levels of specialisation who see cancer patients in a more general in- The lack of referral pathways that engage physiotherapists in patient medical or outpatient setting. These physiotherapists, who cancer care is likely a result of limited awareness of the benefits that are capable of treating the majority of health problems associated physiotherapy can offer individuals with cancer, and of the impor- with cancer, can consult or refer to the specialists in specific, complex tance of the timing of physiotherapy interventions. The limited time cases. In the Netherlands, there are accredited Master-level post- available in an oncology consultation may push the dialogue on graduate programs in oncology to advance the clinical specialty skills rehabilitation or supportive care to the background, in favour of needed for this complex population, as well as entry-level and discussing the likelihood of survival, medical treatment planning, and intermediate-level postgraduate courses. Several other countries (ie, pharmaceutical symptom control. Panellists asserted and participants the USA) are currently developing such programs. agreed that embedding physiotherapists in cancer care clinical pathways allows easy and timely referral to physiotherapy services. Recommendations for action Participants at the conference from a variety of countries (Qatar, USA, Iran, etc) provided examples of this model of care being implemented The discussions at the International Conference on Physiotherapy with great success. In addition to increasing referrals, this approach in Oncology demonstrated that the challenges for physiotherapy in encourages a move from reactive to more proactive physiotherapy. In oncology care are quite similar across international boundaries. Also, a traditional model of supportive care, referral or self-referral to a they provided a starting point for improving the quality and avail- physiotherapist is at the discretion of the physician or the patient, and ability of physiotherapy services for individuals with cancer. First, it is happens only once an impairment has been identified and often important to develop professional practice guidelines and standards when it has already led to a disabling state. Adopting a more proac- for physiotherapy in oncology. Such an effort would improve tive approach has the potential to improve supportive cancer care.13 awareness among physiotherapists and other healthcare providers Impairments – in particular declines in exercise capacity – and regarding optimal care standards, and will improve consistency in symptoms such as fatigue or pain can be prevented or minimised by care delivery and reduce unwanted practice variation. Second, phys- timely interventions. Several studies have shown that supervised iotherapy associations should engage in advocacy to highlight ineq- exercise during active cancer treatment can reduce negative side ef- uity in healthcare services and to encourage payment schemes that fects, and may even improve medical treatment fidelity and sur- support physiotherapy for individuals with cancer throughout the vival.14,15 Prehabilitation and prospective surveillance are a promising disease and treatment continuum. Third, addressing oncology-related area for physiotherapy, where early physiotherapeutic intervention – problems explicitly in entry level physiotherapy education, and including exercise and routine monitoring of impairments – may lead showing physiotherapy students how the basic principles of physio- to improved functional status and health service benefits, including therapy apply to issues in oncology, would create a strong foundation reductions in length of stay and health-related expenditure1,16 This for advanced clinical practice and catalyse interest towards post- may be particularly valuable for individuals at risk of a poor func- graduate pursuit of specialty practice in oncology. The panel further tional outcome due to poor baseline health status, and those with low recommended that physiotherapy researchers should consider ap- self-efficacy, the elderly, and those who lack social support or have proaches to health services research that can study cost and health- low health-literacy.17 care utilisation mitigation through physiotherapy interventions. Engaging physiotherapists throughout the trajectory of cancer On the levels of research and practice, enhanced international care enables ongoing assessment of changes in physical function that collaboration and communication between physiotherapists working
188 Editorial in oncology are desirable. This could be facilitated by the continuation PT, CLT (Australia); Karol Ramirez Parada PT, PhD (Chile); G. Ste- of the International Conference on Physiotherapy in Oncology as well phen Morris, PT, PhD (USA); Morten Quist, PT, PhD (Denmark); as through the World Confederation for Physical Therapy (WCPT) Theo Ruitenbeek, PT, PhD (The Netherlands); Anna Campbell, PhD international subgroup IPT-HOPEb. At a national level, physiotherapy (United Kingdom); Christopher Barnes, DPT (USA); Paul LaStayo, PT, associations need to make an effort to increase awareness of the PhD (USA); and Manuel Arroyo-Morales, PT, PhD (Spain). potential of physiotherapy among other healthcare professionals in oncology, and develop and implement care models that are suited to Correspondence: Martijn M Stuiver, Center for Quality of Life, their individual in-country system constraints. The World Health Netherlands Cancer Institute, the Netherlands. Email: [email protected] Organization’s Vision 2030 also offers an opportunity for interna- tional collaboration to coalesce around goals that target reducing References cancer-related disability in an equitable and sustainable way. 1. Stout NL, et al. PM R. 2017;9:S347–S384. In conclusion, physiotherapists have strong foundational knowl- 2. Cheville AL, et al. Am J Phys Med Rehabil. 2011;90:S27–S37. edge and skills in oncology and they are playing an increasingly 3. Pergolotti M, et al. J Geriatr Oncol. 2015;6:194–201. important role in the management of individuals with cancer. As this 4. Cormie P, et al. Med J Aust. https://doi.org/10.5694/mja18.00199 [E-pub ahead of print]. field grows and matures, international collaborations towards shared 5. National Academies of Sciences, Engineering, and Medicine, Division HAM, Ser- goals in clinical practice, education, and research could significantly enhance the integration of physiotherapy services in the cancer care vices BOHC, National Cancer Policy Forum. Long-Term Survivorship Care After Cancer continuum and ultimately improve functional outcomes and quality Treatment. National Academies Press; 2018. https://doi.org/10.17226/25043. of life for cancer survivors. 6. Paramanandam VS, Roberts D. J Physiother. 2014;60:136–143. 7. Ezzo J, et al. Cochrane Database Syst Rev. 2015;5:CD003475. Footnotes: aAudience Response System, Mentimeter, Sweden; 8. Duregon F, et al. Crit Rev Oncol Hematol. 2018;121:90–100. bPhysiotherapy in HIV/AIDS, Oncology, Hospice and Palliative Care. 9. Dennett AM, et al. J Physiother. 2016;62:68–82. 10. Waart H, et al. Eur J Health Econ. 2017:1–12. Ethics approval: Nil. 11. Kampshoff CS, et al. J Cancer Surviv. 2018;12:417–429. Competing interests: Nil. 12. May AM, et al. BMJ Open. 2017;7:e012187. Source(s) of support: Nil. 13. Cheville AL, et al. Phys Med Rehabil Clin N Am. 2017;28:1–17. Acknowledgements: The authors would like to thank the 14. Hayes SC, et al. Breast Cancer Res Treat. 2017;167:505–514. following persons for their intellectual input for this editorial 15. Courneya KS, et al. Med Sci Sports Exerc. 2014;46:1744–1751. during the panel discussion and during a discussion meeting 16. Stout NL, et al. Cancer. 2012;118:2191–2200. adjacent to International Conference on Physiotherapy in 17. van Waart H, et al. Psychooncology. 2015;25:964–970. Oncology: Margaret McNeely, PT, PhD (Canada) Leonie Naumann 18. Maltser S, et al. PM R. 2017;9:S415–S428. 19. van der Leeden M, et al. Disabil Rehabil. 2018;40:486–496. 20. Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population, Board on Health Care Services, Institute of Medicine, et al. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Levit L, Balogh E, Nass S, Ganz PA, eds. 2013. doi: 10.17226/18359.
Journal of Physiotherapy 65 (2019) 242 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Appraisal of Clinical Practice Guideline: NICE Guidance on Spondyloarthritis in over 16s: diagnosis and management [NG65] Date of latest update: June 2017. Date of next update: 2022. Patient Key recommendations: Health professionals should suspect axial group: People aged 16 years with back pain or buttock pain onset spondyloarthritis (axSpA) and refer to rheumatology if a person pre- before 45 years of age and lasting . 3 months, or with dactylitis or sents with back pain . 3 months, with onset before 45 years of age, persistent or multisite tendon or joint pain or swelling, and people and if four or more additional features are present: onset before 35 diagnosed with spondyloarthritis. Intended audience: Health pro- years of age; woken during second half of night by symptoms; im- fessionals, healthcare providers, commissioners, people with sus- proves with movement; buttock pain; improves with nonsteroidal pected or diagnosed spondyloarthritis, and families. Expert working anti-inflammatories (often within 48 hours); close relative (parent, group: Multidisciplinary guideline development group of specialist sibling, child) with spondyloarthritis; current/past psoriasis; family health professionals in rheumatology (rheumatologists, radiologists, history of psoriasis; and inflammatory arthritis, enthesitis, tendon or specialist physiotherapist, specialist nurse, general practitioners and joint pain/swelling not due to injury. Other risk factors include a occupational therapist), people with spondyloarthritis, technical an- history of uveitis, inflammatory bowel disease and HLA-B27 positivity. alysts, co-opted specialists from dermatology, ophthalmology, Importantly, people can have axSpA with normal inflammatory gastroenterology and podiatry, and patient representatives. Funded markers and be HLA-B27 negative; axSpA occurs equally in women by: National Institute for Health and Care Excellence (NICE). and men. If clinical suspicion remains but insufficient features are Consultation with: Final draft was informed by stakeholder consulta- present to support referral, advise the person to seek reassessment if tion and comments, including Chartered Society of Physiotherapy, new signs or symptoms develop. Magnetic resonance imaging for British Society of Rheumatology and British Society of Spondyloar- suspected axSpA differs from that for standard lumbar spine imaging thritis. Approved by: NICE. Location: The NICE website has the sum- and needs imaging of the sacroiliac joints and whole spine. The mary of recommendations and full guideline available at: https://www. guidelines recommend referral to rheumatology for suspected pe- nice.org.uk/guidance/ng65. There is an interactive flowchart https:// ripheral spondyloarthritis if dactylitis (whole swollen ‘sausage’ finger pathways.nice.org.uk/pathways/spondyloarthritis and endorsed or toe) is present. Also suspect peripheral spondyloarthritis in people clinical guide leaflet for clinicians available at: https://www.esht.nhs. with persistent or multiple-site enthesitis (inflammation where uk/wp-content/uploads/2018/07/Msk-Think-SpA-NICE-guidance-on- tendon attaches to bone), and if there are other features, including: recognition-and-referral-of-Spondyloarthritis.pdf. Description: The back pain without apparent mechanical cause; psoriasis or family guideline covers recognition, diagnosis and management of spondy- history of psoriasis; inflammatory bowel disease; uveitis; close rela- loarthritis, which encompasses a group of inflammatory diseases tive with spondyloarthritis; or symptom onset following gastrointes- associated with extra-articular inflammatory conditions including tinal or genitourinary infection. The guideline recommends that psoriasis, inflammatory bowel disease (Crohn’s disease/ulcerative coli- people diagnosed with axSpA should be referred to specialist phys- tis) and uveitis. This guideline links with NICE Guidance on low back iotherapy for an individualised, structured exercise program and pain and sciatica [NG59] and outlines features that raise suspicion of consider aquatic physiotherapy. spondyloarthritis, dispel common misunderstandings and give advice on when to refer to rheumatology. Recommendations on investigations, Provenance: Invited. Not peer reviewed. diagnosis, long-term complications and management are also provided. This includes pharmacological and non-pharmacological strategies and, Carol McCruma,b in rare circumstances, surgery. Recommendations most relevant to aEast Sussex Healthcare NHS Trust, physiotherapists include when to suspect axial or peripheral spondy- loarthritis, referral criteria, investigations, and awareness of complica- Eastbourne, UK tions such as osteoporosis and non-pharmacological management. bUniversity of Brighton, Eastbourne, UK https://doi.org/10.1016/j.jphys.2019.07.001 1836-9553/Crown Copyright © 2019 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/).
Journal of Physiotherapy 65 (2019) 230–236 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Research Australian adults expect physiotherapists to provide physical activity advice: a survey Breanne Kunstler a, Rachel Fuller b, Simon Pervan b, Mark Merolli c a BehaviourWorks Australia, Monash University; b Department of Entrepreneurship, Innovation and Marketing, La Trobe University; c Health and Biomedical Informatics Centre, Melbourne Medical School, The University of Melbourne, Melbourne, Australia KEY WORDS ABSTRACT Expectations Questions: Do Australian adults think that physiotherapists are likely to provide physical activity (PA) advice, Exercise general health advice, and physical interventions? Do Australian adults think it is important for physio- Physical therapy modalities therapists to provide each of these services? What factors are associated with adults’ expectations of Physical activity receiving these services from physiotherapists? Design: Online nationwide cross-sectional survey. Physical therapy Participants: Australian adults aged , 18 years who have or have not had a physiotherapy appointment before. Outcome measures: The survey instrument included questions asking respondents if it was both important and likely that a physiotherapist would provide services pertaining to PA and general health- related advice as well as physical interventions. Responses were measured on a 6-point Likert scale. Results: Full responses were obtained from 587 respondents. Most respondents reported that it is likely (40%) or extremely likely (29%) and important (47%) or extremely important (29%) that a physiotherapist provides advice to help them increase their PA levels. This was similar to the percentage of respondents reporting that it is likely (46%) or extremely likely (19%) and important (43%) or extremely important (24%) that a physiotherapist provides advice to help them improve their general health. A similar number of re- spondents also reported that it is likely (37%) or extremely likely (29%) and important (42%) or extremely important (26%) that a physiotherapist provides massage. The odds of respondents expecting physiothera- pists to provide PA advice were higher for those who were older (OR 1.2, 95% CI 1.1 to 1.5), chose to see a physiotherapist to feel better and receive a home exercise program (OR 2.0, 95% CI 1.0 to 3.9), and felt that physiotherapists met their expectations (OR 4.5, 95% CI 2.2 to 9.3). Conclusion: Australian adults believe it is likely and important that physiotherapists provide PA and general health advice in addition to specific physical interventions. [Kunstler B, Fuller R, Pervan S, Merolli M (2019) Australian adults expect physiotherapists to provide physical activity advice: a survey. Journal of Physiotherapy 65:230–236] © 2019 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/). Introduction Physiotherapists are qualified and sufficiently skilled to improve patient PA levels.6,7 Physiotherapists can employ PA to prevent and Current evidence-based recommendations for physical activity (PA) suggest that adults should participate in at least 150 minutes of treat several conditions, such as common musculoskeletal conditions moderate-intensity activity (eg, cycling or swimming) or at least 75 (ie, osteoarthritis),8,9 and to improve aspects of general health.6 minutes of vigorous-intensity activity (eg, running) weekly.1,2 To meet global recommendations, adults should also participate in muscle Physiotherapists are perceived to be capable of promoting other strengthening for all major muscle groups twice weekly.1,2 health behaviours too, such as a healthy diet, smoking cessation and However, 23% of adults and 81% of adolescents globally are not safe alcohol consumption.10 However, the role of the physiotherapist meeting PA recommendations, prompting the World Health Organi- in the provision of this advice is less established than for PA.11 This is zation to produce their Global Action Plan on Physical Activity 2018 to 2030.3 In 2014 to 2015, 45% of Australian adults did not achieve the despite there being a strong push by the research and broader public minimum recommended PA levels, being either insufficiently active (30%) or inactive (15%).4 Complications associated with not meeting health communities for physiotherapists to become more involved in PA recommendations are both expensive and deadly. The cost asso- supporting patients to change behaviours such as these.10,12 ciated with global inactivity-related deaths and disability reached international $ (INT$) 67.5 billion in 2013 alone; in Australia, the cost Australian physiotherapists consider the provision of PA advice to of inactivity was INT$805 million.5 patients to be part of their role, but they can find it difficult to do.13 A qualitative exploration of Australian physiotherapists found that they perceive patients as expecting passive therapies or physical in- terventions, like hands-on or manual therapy, before advice to participate in more active therapies such as increasing their PA levels.13 International research supports this finding, suggesting that https://doi.org/10.1016/j.jphys.2019.08.002 1836-9553/© 2019 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/).
Research 231 patients expect hands-on therapies from physiotherapists.14 It is Table 1 important for physiotherapists to pay attention to patient expecta- Characteristics of survey respondents. tions because they influence satisfaction and repeat patronage.15 However, this perception suggests that physiotherapists might pri- Characteristics Respondents oritise services expected by the patient ahead of providing PA advice. (n = 671) This might ultimately result in physiotherapists providing PA advice Age (yr), n (%) a less often, despite it being clinically indicated.16 18 to 24 68 (10) 25 to 34 150 (23) Given that limited evidence exists about patients’ expectations for 35 to 44 80 (12) PA advice from physiotherapists, it is important to establish whether 45 to 54 physiotherapists’ perceptions about this issue are accurate. This study 55 to 64 57 (9) will build on related work17 and establish whether Australian adults 65 to 74 100 (15) expect PA advice from physiotherapists. The study will also establish 75 to 84 164 (25) whether adults expect other types of health advice and services, such 85 as physical interventions and advice on general health, from 47 (7) physiotherapists. Gender, n (%) b 2 (, 1) female Therefore, the research questions for this cross-sectional survey male 330 (50) were: non-binary 317 (48) 1. Do Australian adults think that physiotherapists are likely to pro- Location, n (%) c 12 (2) vide physical activity advice, general health advice, and physical Victoria interventions? New South Wales and Australian Capital Territory 197 (29) Queensland 159 (24) 2. Do Australian adults think that it is important for physiotherapists Western Australia 158 (24) to provide each of these services? South Australia 66 (10) Tasmania 3. What factors are associated with adults’ expectations of receiving Northern Territory 61 (9) these services from physiotherapists? 17 (3) Education level, n (%) c 3 (, 1) Method Primary school Secondary school 27 (4) Design Certificate/technical apprenticeship 217 (33) Diploma (certificate, graduate) 98 (15) A nationwide cross-sectional survey was administered by a com- Advanced diploma 104 (16) mercial market research companya, who advertised the survey Bachelor’s degree Australia-wide using various online methods (eg, blogs, social media Post-graduate degree (Master’s, PhD) 33 (5) and email) throughout October and November 2018, to obtain a 125 (19) general sample reflective of the Australian adult population. Physical activity level, n (%) c inactive d 57 (9) Participants insufficiently active e active f 328 (50) Responses from adults residing in Australia, aged . 18 years who 187 (28) were able to read and respond in English were included. Present or Private health insurance: ‘extras’ cover, n (%) c 146 (22) past use of physiotherapy services was not an eligibility criterion. No no additional exclusion criteria were applied, to ensure that the yes 331 (50) responding cohort was as representative of the Australian adult don’t know 295 (45) population as possible. Perceived health compared to friends, n (%) c 35 (5) Outcome measure much healthier healthier 61 (9) The survey instrument employed was designed and refined by the same 181 (27) clinical physiotherapy and marketing experts. Data were collected more injured or ill 295 (45) using online survey softwareb. The instrument was informed by other much more injured or ill 94 (14) valid instruments that have explored patient expectations and satis- faction with physiotherapy services and outcomes but neglected to Exposure to physiotherapy, n (%) g 30 (5) measure expectations of services.17–24 currently seeing a physiotherapist not seeing a physiotherapist but have in the past 83 (13) The instrument (Appendix 1, available on the eAddenda) included never seen a physiotherapist 319 (49) sections specific to respondent demographics, general health and PA would not choose to see a physiotherapist 249 (38) levels, as well as experience seeing a physiotherapist. The remainder of the instrument explored the perceived likelihood of receiving 7 (1) particular physiotherapy services and the level of importance re- spondents placed on physiotherapists providing said services. Most Some percentages do not sum to 100 due to the effects of rounding. questions were multiple choice, some with the ability to provide a 3 missing. further qualitative information, or matrix-style and measured on a 6- b 12 missing. point Likert scale (eg, 1 = extremely unimportant, to 5 = extremely c 10 missing. important, with an ‘I do not know what this [service] is’ option). d Not participating in any weekly cardiovascular or strength-based activities. e Participating in some cardiovascular or strength-based activity, but not enough to Data analysis meet the guidelines. As of July 2018, there were 19,786,363 people aged 15 to 84 years f Participating in enough physical activity to meet the guidelines. in Australia.25 Using this value, a confidence level of 0.95 and a g 13 missing. margin of error of 5%, an estimated desired sample size of 385 was calculated a priori. Data were exported from the online survey software and imported into statistical softwarec for analysis. Incomplete responses were included. Data were cleaned with missing data removed pairwise. Negatively/inversely worded questions were reverse coded prior to analysis. Descriptive statistics (frequencies and percentages) were used to present responses to all questions measuring likelihood and importance. For the purposes of multivariable analysis, variables reflecting expectations of respondents were created by merging var- iables measuring likelihood and importance, as expectations are informed by both perceived likelihood and importance of receiving a certain service.26 This allowed for the identification of factors influ- encing adults’ expectations for particular services.26 Non-parametric multivariable analyses (binary logistic regression) were used to
232 Kunstler et al: Expectations of physiotherapy by Australian adults How likely is it that a physiotherapist would: Percentage of participants 0% 20% 40% 60% 80% 100% Services related to physical activity help me to increase my physical activity levels help me to increase my fitness levels tell me that I need to exercise more to improve my overall fitness Services related to physical interventions provide massage provide manipulation/cracking provide hot and cold therapy provide acupuncture provide cupping tape/strap my joints or areas that are painful Services related to general health tell me what I should do to improve my general health advise me on ways to improve my sleep help me to prevent future illness tell me that I need to lose weight advise me to quit smoking advise me to avoid unsafe alcohol consumption advise me to eat a healthy diet help me to improve my sexual function Extremely likely Likely Not likely or unlikely Unlikely Extremely unlikely I don't know what this is Figure 1. Frequency of responses to questions related to the likelihood of physiotherapists providing specific services (n = 583). Numerical data are presented in Appendix 2 on the eAddenda. identify odds ratios (OR), and 95% confidence intervals (CIs) were perceived as likely or extremely likely by most respondents (n = 379, reported to demonstrate strength of associations.27 65%) (Figure 1). Results A similar number reported that it was likely or extremely likely that a physiotherapist would provide massage (n = 383, 66%) and Characteristics of the participants taping/strapping (n = 375, 64%). However, this was not representative of all physical interventions, with fewer respondents reporting that it A total of 671 responses, comprising 587 full responses, were would be likely or extremely likely for a physiotherapist to provide received. Most respondents were female (n = 330, 50%), from Victoria manipulation/cracking (n = 244, 42%) and acupuncture (n = 189, 32%) (n = 197, 30%), aged 18 to 64 years (n = 455, 68%), had higher edu- (Figure 1). cation beyond secondary schooling (n = 417, 62%), considered them- selves just as healthy as their friends (n = 295, 45%), and were Fewer respondents reported that specific general health advice physically inactive or insufficiently active (n = 515, 77%). Furthermore, was likely or extremely likely to be provided by physiotherapists most respondents had seen a physiotherapist in the past or were compared to PA advice, including advice on: weight loss (n = 302, currently seeing one (n = 402, 60%) and did not have ‘extras cover’ to 52%), smoking cessation (n = 241, 41%), avoiding unsafe alcohol fund physiotherapy services (n = 331, 50%) (Table 1). consumption (n = 236, 40%), and healthy eating (n = 320, 55%) (Figure 1). Do Australian adults think that physiotherapists are likely to provide physical activity advice, general health advice, and Do Australian adults think it is important for physiotherapists to physical interventions? provide physical activity advice, general health advice, and physical interventions? Most respondents agreed that it is likely or extremely likely that a physiotherapist would provide advice to help them increase their PA Most respondents agreed that it is important or extremely (n = 401, 69%) and fitness levels (n = 399, 68%), and suggest that they important for a physiotherapist to provide advice to help them in- need to exercise more to improve their fitness (n = 389, 67%). Pro- crease their PA (n = 444, 76%) and fitness levels (n = 427, 73%), and vision of advice on how to improve their general health was also suggest that they need to exercise more to improve their fitness (n = 392, 67%). Providing advice on how to improve their general health was also perceived as important or extremely important by most respondents (n = 388, 67%) (Figure 2).
Research 233 How important is it to you that a physiotherapist would: Percentage of participants 100% Services related to physical activity 0% 20% 40% 60% 80% help me to increase my physical activity levels help me to increase my fitness levels tell me that I need to exercise more to improve my overall fitness Services related to physical interventions provide massage provide manipulation/cracking provide hot and cold therapy provide acupuncture provide cupping tape/strap my joints or areas that are painful Services related to general health tell me what I should do to improve my general health advise me on ways to improve my sleep help me to prevent future illness tell me that I need to lose weight advise me to quit smoking advise me to avoid unsafe alcohol consumption advise me to eat a healthy diet help me to improve my sexual function Extremely important Important Not important or unimportant Not important Extremely important I don't know what this is Figure 2. Frequency of responses to questions related to the importance of physiotherapists providing specific services (n = 583). Numerical data are presented in Appendix 3 on the eAddenda. A similar percentage of respondents reported that it was impor- expectations (OR 2.9, 95% CI 1.4 to 5.8; OR 3.6, 95% CI 1.8 to 7.2; and tant or extremely important that a physiotherapist provides massage OR 2.6, 95% CI 1.3 to 5.2, respectively) (Table 2). (n = 391, 67%) and taping/strapping (n = 396, 68%). Again, this was not representative of all physical interventions, with fewer respondents There were some notable differences in the likelihood of expect- reporting that it is important or extremely important for a physio- ing that a physiotherapist would provide PA advice compared to therapist to provide manipulation/cracking (n = 256, 44%) and general health advice. The likelihood of expecting that a physiother- acupuncture (n = 224, 38%) (Figure 2). apist would provide PA advice was higher for respondents attending physiotherapy to feel better and receive a home exercise program Fewer respondents reported that receiving specific general health (HEP) (OR 2.0, 95% CI 1.0 to 3.9), whereas the likelihood of expecting advice from physiotherapists was important or extremely important general health advice was only higher when respondents attended compared to PA advice, including advice on: weight loss (n = 285, physiotherapy to feel better without receiving a HEP (OR 2.1, 95% CI 1.1 49%), smoking cessation (n = 205, 35%), avoiding unsafe alcohol to 4.1) (Table 2). consumption (n = 216, 37%), and healthy eating (n = 309, 53%) (Figure 2). For physical interventions, the likelihood that respondents ex- pected a physiotherapist to provide massage was lower if they chose What factors are associated with adults’ expectations of receiving to see a physiotherapist for injury prevention purposes (OR 0.45, 95% specific services from physiotherapists? CI 0.23 to 0.86) and higher if they attended physiotherapy to feel better without receiving a HEP (OR 2.3, 95% CI 1.1 to 4.5). The likeli- The results of logistic regression analyses demonstrated that the hood that respondents expected a physiotherapist to provide mas- likelihood of expecting PA advice was higher for those who were sage was also higher for those who felt physiotherapists met their older (OR 1.2, 95% CI 1.1 to 1.5) and felt that physiotherapists met expectations (OR 4.5, 95% CI 2.2 to 9.3) (Table 2). their expectations (OR 4.5, 95% CI 2.2 to 9.3) (Table 2). Discussion The likelihood of expecting a physiotherapist to provide general health advice, help to increase their fitness levels and advice on using This study identified services that Australian adults perceived to exercise to do so, was also higher for those who were older (OR 1.1, be important and likely to be provided by a physiotherapist, while 95% CI 1.0 to 1.3; OR 1.2, 95% CI 1.0 to 1.4; and OR 1.2, 95% CI 1.1 to 1.4, also identifying some factors that are associated with expectations of respectively) and for those who felt that physiotherapists met their receiving these services. More respondents felt that receiving advice pertaining to improving PA, fitness levels and general health,
234 Kunstler et al: Expectations of physiotherapy by Australian adults Table 2 The factors associated with Australian adults’ expectations of services provided by physiotherapists. Dependent Independent variable OR 95% CI variable 1.247 1.072 to 1.450 Expect physical activity advice Age 1.446 0.851 to 2.457 from physiotherapists Gender 1.068 0.923 to 1.235 Education 1.162 0.849 to 1.591 Satisfaction level with physiotherapy 4.545 2.225 to 9.286 Physiotherapist meets their expectations a 2.012 1.039 to 3.894 Chose to see a physiotherapist to feel better and receive a HEP 1.505 0.735 to 3.082 Chose to see a physiotherapist to feel better without receiving a HEP 0.592 0.307 to 1.143 Chose to see a physiotherapist to have a greater level of health 1.159 0.581 to 2.309 Chose to see a physiotherapist to prevent illness or injury 1.148 1.004 to 1.312 Expect general health advice Age 1.360 0.847 to 2.186 from physiotherapists Gender 0.980 0.860 to 1.116 Education 1.095 0.821 to 1.460 Satisfaction level with physiotherapy 2.887 1.443 to 5.779 Physiotherapist meets their expectations a 1.205 0.696 to 2.086 Chose to see a physiotherapist to feel better and receive a HEP 2.116 1.102 to 4.063 Chose to see a physiotherapist to feel better without receiving a HEP 0.971 0.531 to 1.775 Chose to see a physiotherapist to have a greater level of health 0.803 0.433 to 1.492 Chose to see a physiotherapist to prevent illness or injury 1.202 1.038 to 1.392 Expect physiotherapists to help Age 1.536 0.913 to 2.582 increase fitness levels Gender 1.077 0.934 to 1.242 Education 1.224 0.899 to 1.668 Satisfaction level with physiotherapy 3.594 1.785 to 7.236 Physiotherapist meets their expectations a 1.531 0.819 to 2.859 Chose to see a physiotherapist to feel better and receive a HEP 1.496 0.737 to 3.035 Chose to see a physiotherapist to feel better without receiving a HEP 1.067 0.552 to 2.064 Chose to see a physiotherapist to have a greater level of health 0.999 0.508 to 1.963 Chose to see a physiotherapist to prevent illness or injury 1.232 1.072 to 1.416 Expect physiotherapists to advise Age 1.142 0.702 to 1.857 them to exercise more to increase Gender 0.954 0.835 to 1.091 fitness levels Education 1.104 0.822 to 1.482 Satisfaction level with physiotherapy 2.579 1.286 to 5.172 Physiotherapist meets their expectations a 1.704 0.957 to 3.036 Chose to see a physiotherapist to feel better and receive a HEP 2.026 1.035 to 3.968 Chose to see a physiotherapist to feel better without receiving a HEP 1.007 0.539 to 1.883 Chose to see a physiotherapist to have a greater level of health 0.878 0.464 to 1.662 Chose to see a physiotherapist to prevent illness or injury 1.137 0.990 to 1.307 Expect physiotherapists Age 1.378 0.840 to 2.261 to provide massage Gender 1.055 0.921 to 1.208 Education 1.280 0.949 to 1.727 Satisfaction level with physiotherapy 4.536 2.210 to 9.313 Physiotherapist meets their expectations a 1.276 0.716 to 2.276 Chose to see a physiotherapist to feel better and receive a HEP 2.266 1.134 to 4.525 Chose to see a physiotherapist to feel better without receiving a HEP 0.936 0.502 to 1.746 Chose to see a physiotherapist to have a greater level of health 0.445 0.229 to 0.864 Chose to see a physiotherapist to prevent illness or injury HEP = Home exercise program. a Answered only by respondents who had experience seeing a physiotherapist. followed by massage and taping services, was likely and important evidence-based alternative interventions should also be provided compared with receiving manipulation, acupuncture and more spe- where the expected service is not appropriate.30 cific general health advice on weight loss, healthy eating, sleep, safe alcohol consumption and smoking cessation. Adults were more likely Physiotherapists might not have an accurate understanding of to expect advice on PA and general health from physiotherapists if exactly what patients expect from them.14 To date, research has they were older and reported that physiotherapists met their ex- suggested that Australian physiotherapists are hesitant to provide PA pectations. These findings suggest that Australian adults expect physiotherapists to provide PA and general health-related advice, advice because they perceive that patients do not expect PA advice possibly more so than physical interventions and advice on specific from them, instead preferring physical interventions.13 This makes chronic disease risk factors such as smoking. physiotherapists hesitant to provide PA advice to avoid damaging It is important for physiotherapists to pay attention to patient rapport.13 However, based on the findings of this study, Australian expectations because not meeting them might lead to poor patient adults expect both PA advice and physical interventions from phys- satisfaction. Previous experience with physiotherapy can inform pa- iotherapists, with slightly more respondents reporting PA advice as tient expectations for certain outcomes at future visits.28 Fulfilling or not fulfilling these expectations can influence patient satisfaction15 important and likely to be provided rather than massage. This finding and, potentially, the desire of the patient to return to the physio- is supported by other studies that have found that patients expect therapist in the future. Patient satisfaction with physiotherapy for self-management strategies30 as well as hands-on treatment.14 This musculoskeletal conditions in Australia has been reported as high.29 implies that expectations are not just limited to activities that are To maintain high satisfaction levels, Australian physiotherapists must be familiar with patient expectations and provide the expected simply ‘done to’ patients, but are broader to include those that are services. Considering the findings from this study, this means ‘done with’ them. providing both passive and active interventions, as appropriate, and Two explanations for the disconnect between what physiothera- pists think patients expect and what patients actually expect could arise from the credence-based nature of the physiotherapy service. Credence-based services are difficult for patients to evaluate, during or after the exchange, so they rely heavily on the expertise of the
Research 235 provider to guide them in knowing whether they have received assume that patients expect passive before active therapies, and appropriate treatment.31,32 If some physiotherapists are not offering should not hesitate to provide PA advice to their patients, as this PA advice, it is possible that patients will not demand it even if they advice is likely to be welcomed. consider it important, preferring instead to receive guidance from the expert as to what they need, leading physiotherapists to believe that What was already known on this topic: Many adults do not patients do not expect or want PA advice. Another explanation is that achieve recommended physical activity levels. Physiotherapists patients are seen by physiotherapists to have preconceived ideas can advise patients about physical activity and other health be- around the condition they have and the treatments they will haviours to prevent and treat several conditions. Past research receive.14 Thus, there may be a disconnect between what physio- suggests that patients expect physical interventions more than therapists might interpret as patients not expecting PA advice and a advice about physical activity and health behaviours, and that reluctance to act on said advice outside of the clinic. Further research physiotherapists perceive these expectations in their patients. is needed to explore a possible point of tension or dissatisfaction for a What this study adds: Most Australian adults think that it is patient from receiving PA advice and the personal involvement likely and important that a physiotherapist would provide advice needed to act on the advice. about physical activity and general health behaviours. This was similar or greater than their expectations about specific physical Expecting PA advice from physiotherapists was more likely among interventions. Physiotherapists should anticipate that patients respondents who were older, chose to see a physiotherapist to receive expect to receive advice about physical activity and other health a HEP and felt that physiotherapists met their expectations. Living a behaviours. physically active lifestyle has been promoted strongly in Australia, for example through government-funded campaigns such as ‘Life. Be in Footnotes: a Cint, Sydney, Australia. b Qualtrics, Provo, USA. c SPSS, It’33 and, more recently, ‘Move it Aus – Find your 30’.34 Thus, IBM Corporation, New York, USA. Australian adults are likely to have been exposed to accumulating PA messaging as they age, making them aware that they should be eAddenda: Appendices 1, 2 and 3 can be found online at https:// physically active and expect that physiotherapists will encourage doi.org/10.1016/j.jphys.2019.08.002. them to do so. Furthermore, physiotherapists are promoted as ‘ex- ercise experts’35 and can visually appear as fit themselves, thus their Ethics approval: The La Trobe University Human Ethics Commit- appearance and the profession’s relationship with exercise might also tee (HEC18370) approved this study. Consent was implied upon make people inclined to expect PA advice from physiotherapists.36 voluntary commencement of the survey. Although these findings appear valid, the lower limit of the confi- dence intervals for these associations was close to one. Thus, the Competing interests: Nil. observed relationships may or may not be substantial enough to Source(s) of support: Nil. inform physiotherapy practice. Acknowledgements: Nil. Provenance: Not invited. Peer reviewed. There are strengths and limitations to this study. Previous Correspondence: Breanne Kunstler, BehaviourWorks Australia, Mon- research has commonly focused on patient expectations for outcome ash University, Melbourne, Australia. Email: [email protected] (eg, complete pain resolution),28,37 rather than for certain treatments (eg, massage) and other service provisions such as PA and general References health advice.14,17 Thus, this study fills an important gap in the literature pertaining to expectations of physiotherapy as the profes- 1. World Health Organization. Global Recommendations on Physical Activity for sion enters an era focused on health promotion. Health; 2010. http://apps.who.int/iris/bitstream/10665/44399/1/9789241599979_ eng.pdf. Accessed 9 July, 2019. All Australian adults who had or had not seen a physiotherapist previously were eligible to participate in the survey, in an attempt 2. World Health Organization. Physical Activity and Adults; 2019. https://www.who. to gain a representation of the general adult population. In doing int/dietphysicalactivity/factsheet_adults/en/. Accessed 9 July, 2019. so, over one third of respondents had not seen a physiotherapist previously. 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Journal of Physiotherapy 65 (2019) 240 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Clinimetrics: Indirect calorimetry Summary Description: Indirect calorimetry is a technology that measures The range of available open circuit system configurations ensures that energy expenditure by quantifying oxygen consumption (VO2) and indirect calorimetry measurements can be completed in spontaneously carbon dioxide production (VCO2). It is considered to be the gold breathing or ventilated patients1 across the healthcare continuum (acute, standard device for measuring resting energy expenditure in the clin- ical setting.1 There are several indirect calorimetry systems, with the subacute and rehabilitation settings). Canopy and ventilated hood con- most well-known being the total collection system (eg, Douglas bag) and the modern open circuit system, which are currently used (eg, figurations provide the most accurate measure of energy expenditure, as Deltatrac II, Quark RMR).1,2 Open circuit systems range from desktop they are less likely to interfere with breathing patterns and gas mea- devices with facemasks or mouthpieces/nose clips in spontaneously breathing patients to arrangements that include a canopy or ventilated surement readings, and should be considered for clinical and research hood.3,4 The reliability and validity vary between indirect calorimetry purposes.3 Facemask or mouthpiece/nose clip configurations provide systems and configurations. All of this needs to be carefully considered useful information on physical activity-related changes in energy expen- along with the purpose of use prior to purchasing devices, as costs vary between AUD10 000 to 60 000 per unit. diture, but unfamiliarity and constriction can interfere with the stability of gas exchange measurement.3,4 Psychometric properties between systems and configurations: The Douglas bag total collection system is considered to be the most Psychometric properties when completing measurements: Speci- accurate and reference standard for the measurement of gas exchange, but is seldomly used due to limitations in the size of the collection bag, alised training is required for the accurate use and interpretation of indi- expensive analyser equipment and need for technical expertise.1,2 There are several modern open circuit devices that have inbuilt mixing rect calorimetry measurements. Several elements can be assessed to chambers and gas analysers available in Australia. The Deltatrac II, which is no longer produced, was considered to be the most accurate confirm test reliability. The respiratory quotient, a ratio of VCO2 produced open circuit system due to its precision with the Douglas bag.2 Vali- to VO2 consumed, provides an indication of unreliable tests when readings dation studies between currently available open circuit systems and are outside the normal physiological range of 0.67 to 1.3.1,5 The stability of reference methods should be considered prior to purchasing or using devices. measurements can also be assessed by determining if a test reaches a ‘steady state’, commonly defined as a variation in VO2 and VCO2 of , 10% for five consecutive minutes.5,6 A steady state period is considered to reflect total daily energy expenditure and has been shown to provide reliable measurements of total daily energy expenditure.5,6 For measure- ments that do not reach a steady state, a 30-minute or longer indirect calorimetry measurement is generally considered a valid and reliable measure of energy expenditure in most populations.6 Therefore, test duration varies and is heavily influenced by test stability. Commentary Indirect calorimetry is currently underutilised in clinical and calorimetry to guide nutrition therapy, coupled with repeat physio- therapy, presents a unique research opportunity to determine if this research settings and is not widely recommended for use outside of the combination may assist in preserving muscle mass during hospital- intensive care unit. This is due to many factors, including cost, lack of isation and the associated impact on functional recovery. expertise, technical limitations in certain populations (eg, patients Provenance: Invited. Not peer reviewed. with high ventilatory needs), requirement for specialised training, Oana Alina Tatucu-Babeta and Emma Jean Ridleya,b need for completion under stringent conditions and lack of definitive aAustralian and New Zealand Intensive Care Research Centre, School of evidence on the benefit of use.1,2,5 Predictive equations, which estimate energy expenditure using a mathematical equation and are quick and Public Health and Preventative Medicine, Monash University; easy to apply at the bedside, remain the most common method used in bNutrition Department, Alfred Health, Melbourne, Victoria, Australia standard care.7 Nonetheless, accuracy issues surrounding the use of predictive equations are well documented, with the use of these References equations resulting in clinically significant underestimation and over- 1. Haugen HA, et al. Nutr Clin Pract. 2007;22:377–388. estimation of energy expenditure in several populations.7–9 2. Mtaweh H, et al. Front Pediatr. 2018;6:257. 3. Roffey DM, et al. J Parenter Enteral Nutr. 2006;30:426–432. Despite the limitations raised, with appropriate training and 4. Forse RA. J Parenter Enteral Nutr. 1993;17:388–391. knowledge of the appropriate application, indirect calorimetry pro- 5. Gupta RD, et al. Indian J Endocrinol Metab. 2017;21:594–599. vides a reliable measure of energy expenditure.1 This tool has the 6. McClave SA, et al. J Parenter Enteral Nutr. 2003;27:16–20. potential to be used more in both clinical and research settings to 7. Frankenfield D, et al. J Am Diet Assoc. 2005;105:775–789. 8. Tatucu-Babet OA, et al. J Parenter Enteral Nutr. 2016;40:212–225. enhance understanding of resting energy expenditure and inform 9. Ullah S, et al. Ann R Coll Surg Engl. 2012;94:129–132. nutrition delivery.1 Indirect calorimetry can also be used to provide 10. Hickmann CE, et al. Intensive Care Med. 2014;40:548–555. information on active energy expenditure, including the impact of increased physiotherapy on metabolism. Although it is acknowledged that increases in physical activity increase energy expenditure, clinicians often do not adjust for this in practice.10 The use of indirect https://doi.org/10.1016/j.jphys.2019.07.002 1836-9553/© 2019 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 65 (2019) 241 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Clinimetrics: The Neurological Fatigue Index for Multiple Sclerosis Summary Description: Fatigue is common in multiple sclerosis (MS). (SEMagreement as % of scale range 8.3 to 9.2) were found on all sub- However, a broadly accepted definition of fatigue is lacking and, with scales of the Dutch version.3 Moreover, using the Bland and Altman that, the determination of its many dimensions.1 Usually, fatigue in MS is quantified by means of self-report questionnaires assessing the method, a negligible systematic difference (–0.07; limits of agree- perceived level or impact of fatigue. ment –6.91/6.77) for the summary scale of the NFI-MS was found.3 For the English version,2 test-retest reliability was good (Spearman The Neurological Fatigue Index MS (NFI-MS)a is a self-report questionnaire that was specifically developed to measure fatigue r 0.79 to 0.86). In addition, there were no significant differences in severity and factors influencing fatigue in patients with MS. Using Rasch analysis, the initial 57 potential items were reduced to 23 items the median scores for two time points separated by 2 to 4 weeks (p . in the final questionnaire.2 The 23 items are subdivided over four 0.05).3 different unidimensional subscales: physical (eight items), cognitive (four items), relief by diurnal sleep or rest (six items) and abnormal Construct validity of the Dutch NFI-MS3 was confirmed by high nocturnal sleep and sleepiness (five items). Participants rate their agreement with each item on a 4-point Likert scale: 0 = ‘strongly correlations with commonly used self-report fatigue questionnaires disagree’, 1 = ‘disagree’, 2 = ‘agree’ and 3 = ‘strongly agree’. For each of Fatigue Severity Scale (FSS)4 and Modified Fatigue Impact Scale the subscales, a total score can be calculated, with higher scores (MFIS)5 and moderate correlations between non-similar constructs corresponding to more fatigue. In addition, a summary NFI-MS score (eg, NFI-MS physical and MFIS cognitive5 (r = 0.30 to 0.59). Construct can be calculated (range summary score 0 to 30) and contains 10 validity of the English version2 was confirmed by moderate correla- items (seven and three items from the subscales physical and cognitive, respectively). There is a single-sentence instruction asking tions (r = 0.4 to 0.7) between the NFI-MS and comparative measures respondents to consider their experience over the previous 2 weeks. in the MFIS physical subscale,5 MFIS cognitive subscale,5 FSS-56 and a Assessment of the psychometric properties of the NFI-MS has Visual Analogue Scale score (‘lively and alert’ (0, left) to ‘absolutely no been performed for the English2 and Dutch3 versions. Sufficient test- retest reliability (ICC 0.75 to 0.83) and small measurement errors energy to do anything at all’ (10, right)). The minimum clinically important difference (MCID) was deter- mined for the English version. Using the interval level NFI-MS scores, the largest MCID equated to 2.49 points on the Summary scale, 2.36 points on the Physical scale, 0.84 points on the Cognitive scale, 0.97 on the Diurnal Sleep scale and 1.95 on the Nocturnal Sleep scale.7 The NFI-MS thus has desirably smaller MCIDs and is therefore responsive. Commentary The NFI-MS is a valid, reliable and responsive self-reported mea- outcome measures that are used for research purposes at a group surement of fatigue. The 5- to 10-minute completion time is very level. acceptable, improving the clinical utility of the NFI-MS. In addition, on-line administration allows for automatic calculation of sub scores, Provenance: Invited. Not peer reviewed. increasing feasibility if the clinician or patient has limited time to conduct the assessment. Marc B Rietberg and Erwin EH van Wegen Amsterdam UMC, Vrije Universiteit Amsterdam, Rehabilitation Medicine, Limitations: The absence of a widely accepted definition of fatigue poses significant challenges for adequately assessing cri- Amsterdam Movement Sciences, MS Center Amsterdam, terion validity of fatigue questionnaires.8 The clinician or Amsterdam, Netherlands researcher has to consider that each self-report fatigue question- naire is characterised by its own underlying construct, measure- References ment properties and practical feasibility. Most importantly, clinicians who use self-report questionnaires to monitor changes 1. Chaudhuri A, et al. Lancet. 2004;363(9413):978–988. in fatigue perception should be aware of the methodological 2. Mills RJ, et al. Health Qual Life Outcomes. 2010;12:8–22. properties and limitations of these instruments. Outcome mea- 3. Derksen A, et al. Qual Life Res. 2013;22:2435–2441. sures that are used to evaluate treatment effects in clinical prac- 4. Krupp LB, et al. Arch Neur. 1989;46:1121–1122. tice should be able to reliably identify clinically relevant changes 5. Kos D, et al. Mult Scler. 2005;11:76–80. at an individual level. This suggests that the demands with regard 6. Mills R, et al. Mult Scler. 2009;15:81–87. to reliability and responsiveness are high, in comparison with 7. Mills RJ, et al. Mult Scler. 2013;19:502–505. 8. Rietberg MB, et al. Disabil Rehabil. 2010;32:1870–1876. a The NFI-MS is free for use in Public Health and non-for-profit agencies, and can be obtained from the University of Leeds by a simple registration (http://www.leeds. ac.uk/medicine/rehabmed/psychometric/Scales1.htm). https://doi.org/10.1016/j.jphys.2019.07.003 1836-9553/© 2019 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 65 (2019) 239 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: Supplemental oxygen during exercise training provides no benefit over medical air for people with chronic obstructive pulmonary disease who are normoxaemic at rest but who desaturate during exercise Synopsis Summary of: Alison JA, McKeough ZJ, Leung RWM, Holland AE, Hill K, walking and stationary cycling performed three times per week. During the Morris NR, et al. Oxygen compared to air during exercise training in COPD training program, the intervention group received intranasal oxygen at 5 l/ with exercise-induced desaturation. Eur Respir J 2019 Mar 17 https://doi. minute from an oxygen concentrator and the control group received intra- org/10.1183/13993003.02429-2018. [Epub ahead of print]. nasal air at 5 l/minute from an oxygen concentrator modified to deliver air. Outcome measures: The primary outcomes were endurance exercise ca- Question: In people with chronic obstructive pulmonary disease who are pacity measured by the endurance shuttle walk test, and health-related normoxaemic at rest and desaturate during exercise, does the provision of quality of life measured by the total score of the Chronic Respiratory Dis- supplemental oxygen during exercise training when compared with room air ease Questionnaire. Results: A total of 97 participants completed the study optimise the gains in exercise capacity and health-related quality of life? (52 in the intervention group and 45 in the control group). At completion of Design: Randomised controlled trial with concealed allocation and blinded the exercise program there was no difference between the intervention and participants, therapists and outcome assessors. Setting: Seven tertiary hos- control groups for endurance exercise capacity (MD 15 seconds, 95% CI 2106 pitals across Australia. Participants: Inclusion criteria were people: with to 136) or health-related quality of life (MD 0.0, 95% CI 20.3 to 0.3). chronic obstructive pulmonary disease with nadir oxygen saturations , 90% Conclusion: In people with chronic obstructive pulmonary disease who are on the better of two 6-minute walk tests performed on room air; with a more normoxaemic at rest but who desaturate during exercise, providing sup- than 10 pack-year smoking history; and who were medically stable (at least plemental oxygen during exercise training does not offer additional benefit 4 weeks after an exacerbation). Exclusion criteria were people: receiving over room air in the magnitude of training-related gains in endurance ex- long-term oxygen therapy; with a resting partial pressure of arterial oxygen ercise capacity or health-related quality of life. on room air of , 55 mmHg or a partial pressure of arterial carbon dioxide of . 50 mmHg; who had participated in any supervised exercise training in the Provenance: Invited. Not peer reviewed. last 12 months; and/or who had severe cardiovascular, neurological or musculoskeletal conditions that were likely to adversely affect performance Vinicius Cavalheri during assessments or exercise training. Randomisation of 111 participants School of Physiotherapy and Exercise Science, Curtin University, Australia allocated 58 to an intervention group and 53 to a control group. Interventions: Both groups underwent 8 weeks of supervised treadmill https://doi.org/10.1016/j.jphys.2019.07.009 1836-9553/© 2019 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/). Commentary About 30 to 40% of people with chronic obstructive pulmonary disease have at the level of ‘moderate-to-somewhat severe’ dyspnoea or rate of perceived exercise-induced oxygen desaturation.1 These people improve their 6-minute exertion (a score of 3 to 4 on the modified 0 to 10 scales). walk distance when receiving supplemental oxygen.2 Therefore, it seems reasonable to provide supplemental oxygen during exercise training to those To conclude, life without oxygen is impossible; but exercise training who have exercise-induced oxygen desaturation. This would allow an increase without supplemental oxygen is possible in people with chronic obstructive in the actual training intensity and, in turn, result in greater improvement in pulmonary disease who have exercise-induced oxygen desaturation. endurance shuttle walk time compared with exercise training on room air.3 Provenance: Invited. Not peer reviewed. In a well-designed, multicentre, randomised controlled trial, Alison and Martijn A Spruit colleagues showed that endurance shuttle walk time and health status improved significantly following 8 weeks of exercise training in people with Department of Research and Development, CIRO, Horn, The Netherlands chronic obstructive pulmonary disease that presented exercise-induced oxy- Department of Respiratory Medicine, MUMC1; NUTRIM School of gen desaturation. No greater benefit was found from training with supple- Nutrition and Translational Research in Metabolism, Maastricht, mental oxygen compared with medical air. These findings were The Netherlands unanticipated.4 Does the exercise training stimulus overpower the small-to- moderate physiological benefit of supplemental oxygen? The answer re- REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research mains unknown. However, participants in the ‘oxygen group’ did not achieve Institute, Faculty of Rehabilitation Sciences, Hasselt University, higher training loads. Indeed, both groups increased the training dose per Diepenbeek, Belgium treadmill session, and there was no between-group difference in mean training dose over the 24 training sessions. Interestingly, participants in the https://doi.org/10.1016/j.jphys.2019.07.010 ‘oxygen group’ had significantly higher mean oxygen saturation in the last 5 minutes of the 20-minute treadmill training session compared with the ‘air References group’, and significantly lower dyspnoea and rate of perceived exertion scores. This may, at least in part, be due to the fact that the training intensity was fixed 1. Andrianopoulos V, et al. Respir Med. 2016;119:87–95. 2. Jarosch I, et al. Chest. 2017;151:795–803. 3. Alison JA, et al. BMC Pulm Med. 2016;16:25. 4. Walsh JA, et al. Eur Respir J. 2019;53. 1836-9553/© 2019 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/).
Journal of Physiotherapy 65 (2019) 239 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: Supplemental oxygen during exercise training provides no benefit over medical air for people with chronic obstructive pulmonary disease who are normoxaemic at rest but who desaturate during exercise Synopsis Summary of: Alison JA, McKeough ZJ, Leung RWM, Holland AE, Hill K, walking and stationary cycling performed three times per week. During the Morris NR, et al. Oxygen compared to air during exercise training in COPD training program, the intervention group received intranasal oxygen at 5 l/ with exercise-induced desaturation. Eur Respir J 2019 Mar 17 https://doi. minute from an oxygen concentrator and the control group received intra- org/10.1183/13993003.02429-2018. [Epub ahead of print]. nasal air at 5 l/minute from an oxygen concentrator modified to deliver air. Outcome measures: The primary outcomes were endurance exercise ca- Question: In people with chronic obstructive pulmonary disease who are pacity measured by the endurance shuttle walk test, and health-related normoxaemic at rest and desaturate during exercise, does the provision of quality of life measured by the total score of the Chronic Respiratory Dis- supplemental oxygen during exercise training when compared with room air ease Questionnaire. Results: A total of 97 participants completed the study optimise the gains in exercise capacity and health-related quality of life? (52 in the intervention group and 45 in the control group). At completion of Design: Randomised controlled trial with concealed allocation and blinded the exercise program there was no difference between the intervention and participants, therapists and outcome assessors. Setting: Seven tertiary hos- control groups for endurance exercise capacity (MD 15 seconds, 95% CI 2106 pitals across Australia. Participants: Inclusion criteria were people: with to 136) or health-related quality of life (MD 0.0, 95% CI 20.3 to 0.3). chronic obstructive pulmonary disease with nadir oxygen saturations , 90% Conclusion: In people with chronic obstructive pulmonary disease who are on the better of two 6-minute walk tests performed on room air; with a more normoxaemic at rest but who desaturate during exercise, providing sup- than 10 pack-year smoking history; and who were medically stable (at least plemental oxygen during exercise training does not offer additional benefit 4 weeks after an exacerbation). Exclusion criteria were people: receiving over room air in the magnitude of training-related gains in endurance ex- long-term oxygen therapy; with a resting partial pressure of arterial oxygen ercise capacity or health-related quality of life. on room air of , 55 mmHg or a partial pressure of arterial carbon dioxide of . 50 mmHg; who had participated in any supervised exercise training in the Provenance: Invited. Not peer reviewed. last 12 months; and/or who had severe cardiovascular, neurological or musculoskeletal conditions that were likely to adversely affect performance Vinicius Cavalheri during assessments or exercise training. Randomisation of 111 participants School of Physiotherapy and Exercise Science, Curtin University, Australia allocated 58 to an intervention group and 53 to a control group. Interventions: Both groups underwent 8 weeks of supervised treadmill https://doi.org/10.1016/j.jphys.2019.07.009 1836-9553/© 2019 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/). Commentary About 30 to 40% of people with chronic obstructive pulmonary disease have at the level of ‘moderate-to-somewhat severe’ dyspnoea or rate of perceived exercise-induced oxygen desaturation.1 These people improve their 6-minute exertion (a score of 3 to 4 on the modified 0 to 10 scales). walk distance when receiving supplemental oxygen.2 Therefore, it seems reasonable to provide supplemental oxygen during exercise training to those To conclude, life without oxygen is impossible; but exercise training who have exercise-induced oxygen desaturation. This would allow an increase without supplemental oxygen is possible in people with chronic obstructive in the actual training intensity and, in turn, result in greater improvement in pulmonary disease who have exercise-induced oxygen desaturation. endurance shuttle walk time compared with exercise training on room air.3 Provenance: Invited. Not peer reviewed. In a well-designed, multicentre, randomised controlled trial, Alison and Martijn A Spruit colleagues showed that endurance shuttle walk time and health status improved significantly following 8 weeks of exercise training in people with Department of Research and Development, CIRO, Horn, The Netherlands chronic obstructive pulmonary disease that presented exercise-induced oxy- Department of Respiratory Medicine, MUMC1; NUTRIM School of gen desaturation. No greater benefit was found from training with supple- Nutrition and Translational Research in Metabolism, Maastricht, mental oxygen compared with medical air. These findings were The Netherlands unanticipated.4 Does the exercise training stimulus overpower the small-to- moderate physiological benefit of supplemental oxygen? The answer re- REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research mains unknown. However, participants in the ‘oxygen group’ did not achieve Institute, Faculty of Rehabilitation Sciences, Hasselt University, higher training loads. Indeed, both groups increased the training dose per Diepenbeek, Belgium treadmill session, and there was no between-group difference in mean training dose over the 24 training sessions. Interestingly, participants in the https://doi.org/10.1016/j.jphys.2019.07.010 ‘oxygen group’ had significantly higher mean oxygen saturation in the last 5 minutes of the 20-minute treadmill training session compared with the ‘air References group’, and significantly lower dyspnoea and rate of perceived exertion scores. This may, at least in part, be due to the fact that the training intensity was fixed 1. Andrianopoulos V, et al. Respir Med. 2016;119:87–95. 2. Jarosch I, et al. Chest. 2017;151:795–803. 3. Alison JA, et al. BMC Pulm Med. 2016;16:25. 4. Walsh JA, et al. Eur Respir J. 2019;53. 1836-9553/© 2019 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/).
Journal of Physiotherapy 65 (2019) 238 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: Three months of high-intensity aerobic exercise and strength training reduce disease activity in axial spondyloarthritis Synopsis Summary of: Sveaas SH, Bilberg A, Berg IJ, Provan SA, Rollefstad S, followed by supervised muscle strengthening (20 minutes), Semb AG, et al. High intensity exercise for 3 months reduces disease comprising six exercises for major muscle groups (two to three sets activity in axial spondyloarthritis (axSpA): a multicentre randomised with eight to ten repetitions). One unsupervised home cardiorespi- trial of 100 patients. Br J Sports Med. 2019;0:1–7. https://doi.org/ ratory session comprised at least 40 minutes of walking/running/ 10.1136/bjsports-2018-099943 cycling exercise ( 70% of HRmax). Outcome measures: Primary outcomes were disease activity assessed by Ankylosing Spondylitis Question: Does high-intensity exercise improve disease activity, Disease Activity Scale and Bath Ankylosing Spondylitis Disease Ac- compared with standard care, in people with axial spondyloarthritis? tivity Index at 3 months. Secondary outcomes were inflammatory Design: Multicentre, two-armed, randomised controlled trial. Setting: markers, physical function, spinal mobility, body composition and Three outpatient rheumatology departments in Norway and one in cardiovascular health. Results: Ninety-seven participants completed Sweden. Participants: Participants had to fulfil the Assessment of the study. At 3 months, there was a mean between-group difference in SpondyloArthritis International Society criteria for axial spondyloar- Ankylosing Spondylitis Disease Activity Scale score of –0.6 units (95% thritis; be aged 18 to 70 years; have had no change in tumour necrosis CI –0.8 to –0.3), and in Bath Ankylosing Spondylitis Disease Activity factor-alpha inhibitor use during the last 3 months; have moderate to Index score of –1.2 units (–1.8 to –0.7) favouring the intervention. high disease activity at pre-screening; and not have performed regular Significant treatment effects were also found for physical function, aerobic or strength exercises (last 6 months). Main exclusion criteria spinal mobility and estimated peak oxygen uptake in favour of the were cardiovascular disease; comorbidity limiting exercise capacity; exercise group. Conclusion: High-intensity aerobic interval training in and/or pregnancy. Randomisation of 100 participants allocated 50 to combination with strength training was effective for reducing disease the intervention group and 50 to the control group. Interventions: activity in participants with axial spondyloarthritis. Exercise was conducted three times per week (two supervised ses- sions by trained physiotherapists and one unsupervised session) for Provenance: Invited. Not peer reviewed. 12 weeks. Two supervised high-intensity cardiovascular sessions consisted of 38 minutes walking/running on a treadmill or cycle Britt Elin Øiestad ergometer, with warm up at 70% of maximal heart rate (HRmax), then Department of Physiotherapy, Oslo Metropolitan University, Norway 4 x 4 minute intervals at 90 to 95% of HRmax, with 3-minute rest periods in between, and a cool down at 70% of HRmax. This was https://doi.org/10.1016/j.jphys.2019.07.007 Commentary high-intensity and isocaloric moderate-intensity exercise. It is possible that any exercise intervention may be significantly better than no exercise, High-intensity training has been shown to be effective in increasing and the beneficial effects observed in this study may be due to partici- cardiovascular fitness and muscle strength in healthy people and pation in any exercise program rather than high-intensity training per se. different patient groups.1 Less evidence about high-intensity training exists for people with rheumatological diseases. In particular, an This study is an important step forward in determining best absence of randomised controlled trials in people with axial spondy- practice treatment in this group of patients. Future studies could loarthritis hampers physiotherapy clinical practice with these patients. focus on defining prognostic factors, including the role of self-efficacy, This randomised controlled trial found clinically relevant benefits from as well as exploring barriers to implementing such an exercise pro- a high-intensity exercise program compared with standard care after 3 gram into routine physiotherapy clinical practice. months in patients with axial spondyloarthritis, suggesting that high- intensity exercises might reduce disease symptoms. Provenance: Invited. Not peer-reviewed. Håvard Østerås There is a lack of consensus regarding what types and doses of exer- cises are optimal for long-term clinical benefit in patients with axial Department of Health Sciences, spondyloarthritis. In this study, the participants performed two to three Norwegian University of Science and Technology, Trondheim, Norway exercise sessions weekly for 12 weeks. However, adherence to and effects of high-intensity training beyond 3 months are unknown. In addition, is https://doi.org/10.1016/j.jphys.2019.07.008 this program feasible for most physiotherapists to implement in clinical practice? These aspects are particularly important in patients with axial References spondyloarthritis because long-term adherence to exercise is a desired physiotherapy treatment goal. Further trials should also investigate the 1. Alansare A, et al. Int J Environ Res Public Health. 2018;15:1508. potential dose-response relationship in this patient group by comparing 1836-9553/© 2019 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 65 (2019) 238 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: Three months of high-intensity aerobic exercise and strength training reduce disease activity in axial spondyloarthritis Synopsis Summary of: Sveaas SH, Bilberg A, Berg IJ, Provan SA, Rollefstad S, followed by supervised muscle strengthening (20 minutes), Semb AG, et al. High intensity exercise for 3 months reduces disease comprising six exercises for major muscle groups (two to three sets activity in axial spondyloarthritis (axSpA): a multicentre randomised with eight to ten repetitions). One unsupervised home cardiorespi- trial of 100 patients. Br J Sports Med. 2019;0:1–7. https://doi.org/ ratory session comprised at least 40 minutes of walking/running/ 10.1136/bjsports-2018-099943 cycling exercise ( 70% of HRmax). Outcome measures: Primary outcomes were disease activity assessed by Ankylosing Spondylitis Question: Does high-intensity exercise improve disease activity, Disease Activity Scale and Bath Ankylosing Spondylitis Disease Ac- compared with standard care, in people with axial spondyloarthritis? tivity Index at 3 months. Secondary outcomes were inflammatory Design: Multicentre, two-armed, randomised controlled trial. Setting: markers, physical function, spinal mobility, body composition and Three outpatient rheumatology departments in Norway and one in cardiovascular health. Results: Ninety-seven participants completed Sweden. Participants: Participants had to fulfil the Assessment of the study. At 3 months, there was a mean between-group difference in SpondyloArthritis International Society criteria for axial spondyloar- Ankylosing Spondylitis Disease Activity Scale score of –0.6 units (95% thritis; be aged 18 to 70 years; have had no change in tumour necrosis CI –0.8 to –0.3), and in Bath Ankylosing Spondylitis Disease Activity factor-alpha inhibitor use during the last 3 months; have moderate to Index score of –1.2 units (–1.8 to –0.7) favouring the intervention. high disease activity at pre-screening; and not have performed regular Significant treatment effects were also found for physical function, aerobic or strength exercises (last 6 months). Main exclusion criteria spinal mobility and estimated peak oxygen uptake in favour of the were cardiovascular disease; comorbidity limiting exercise capacity; exercise group. Conclusion: High-intensity aerobic interval training in and/or pregnancy. Randomisation of 100 participants allocated 50 to combination with strength training was effective for reducing disease the intervention group and 50 to the control group. Interventions: activity in participants with axial spondyloarthritis. Exercise was conducted three times per week (two supervised ses- sions by trained physiotherapists and one unsupervised session) for Provenance: Invited. Not peer reviewed. 12 weeks. Two supervised high-intensity cardiovascular sessions consisted of 38 minutes walking/running on a treadmill or cycle Britt Elin Øiestad ergometer, with warm up at 70% of maximal heart rate (HRmax), then Department of Physiotherapy, Oslo Metropolitan University, Norway 4 x 4 minute intervals at 90 to 95% of HRmax, with 3-minute rest periods in between, and a cool down at 70% of HRmax. This was https://doi.org/10.1016/j.jphys.2019.07.007 Commentary high-intensity and isocaloric moderate-intensity exercise. It is possible that any exercise intervention may be significantly better than no exercise, High-intensity training has been shown to be effective in increasing and the beneficial effects observed in this study may be due to partici- cardiovascular fitness and muscle strength in healthy people and pation in any exercise program rather than high-intensity training per se. different patient groups.1 Less evidence about high-intensity training exists for people with rheumatological diseases. In particular, an This study is an important step forward in determining best absence of randomised controlled trials in people with axial spondy- practice treatment in this group of patients. Future studies could loarthritis hampers physiotherapy clinical practice with these patients. focus on defining prognostic factors, including the role of self-efficacy, This randomised controlled trial found clinically relevant benefits from as well as exploring barriers to implementing such an exercise pro- a high-intensity exercise program compared with standard care after 3 gram into routine physiotherapy clinical practice. months in patients with axial spondyloarthritis, suggesting that high- intensity exercises might reduce disease symptoms. Provenance: Invited. Not peer-reviewed. Håvard Østerås There is a lack of consensus regarding what types and doses of exer- cises are optimal for long-term clinical benefit in patients with axial Department of Health Sciences, spondyloarthritis. In this study, the participants performed two to three Norwegian University of Science and Technology, Trondheim, Norway exercise sessions weekly for 12 weeks. However, adherence to and effects of high-intensity training beyond 3 months are unknown. In addition, is https://doi.org/10.1016/j.jphys.2019.07.008 this program feasible for most physiotherapists to implement in clinical practice? These aspects are particularly important in patients with axial References spondyloarthritis because long-term adherence to exercise is a desired physiotherapy treatment goal. Further trials should also investigate the 1. Alansare A, et al. Int J Environ Res Public Health. 2018;15:1508. potential dose-response relationship in this patient group by comparing 1836-9553/© 2019 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 65 (2019) 237 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: Unilateral neglect impairs functional recovery but evidence for upper limb interventions in patients with neglect is lacking Synopsis Summary of: Doron N, Rand D. Is unilateral spatial neglect associated neglect and upper limb recovery such that the presence of neglect was with motor recovery of the affected upper extremity poststroke? A associated with poorer functional outcome. This finding was consistent systematic review. Neurorehabil Neural Repair. 2019;33:170–187. in both acute and chronic stroke. Differences in the measures used to assess unilateral spatial neglect and upper limb function, as well as Objective: To review the evidence as to whether there is a relationship variations in severity of upper limb impairment and severity and type of between unilateral spatial neglect and motor or functional recovery of unilateral neglect may have contributed to inconsistencies across the upper limb after stroke, and to examine if sensorimotor in- studies and prevented pooling of data. In the single experimental study, terventions improve upper limb function in people with unilateral which examined the effects of a task-specific upper extremity inter- spatial neglect after stroke. Data sources: MEDLINE, EMBASE, CINAHL, vention on functional performance in patients with unilateral spatial and Cochrane CENTRAL searched up to February 2018. Study selection: neglect more than 6 months after stroke, there was a significant but Observational or experimental studies of adults with stroke that small improvement in upper limb function. Conclusion: Although there included at least one outcome measure each for unilateral spatial is evidence that unilateral spatial neglect is associated with poorer neglect and upper limb function, and were available in English. Case functional recovery of the hemiparetic upper limb after stroke, there is studies and intervention studies that targeted unilateral spatial neglect currently very little experimental research evaluating the efficacy of without measuring upper limb function were excluded. Data extrac- upper limb interventions in people with unilateral spatial neglect. tion: Two reviewers extracted the data. Methodological quality was Further research is required to guide upper limb rehabilitation for pa- assessed using a modified Quality Index checklist. Data synthesis: Of tients with neglect after stroke. 850 studies initially identified by the search, 14 studies with a total of 1074 participants met the selection criteria and were included. Thirteen Provenance: Invited. Not peer reviewed. of these studies examined relationships between unilateral spatial neglect and upper limb recovery, and one examined the effect of an Prudence Plummer upper limb intervention in patients with unilateral spatial neglect. Department of Allied Health Sciences, Studies were rated as fair to good quality. Ten of the 13 observational University of North Carolina at Chapel Hill, USA studies found that a relationship existed between unilateral spatial https://doi.org/10.1016/j.jphys.2019.07.005 Commentary system training, respectively.3 Addressing longstanding clinical questions The heterogeneity of stroke challenges clinicians and researchers. related to dosage optimisation and treatment responders versus non- Systematic reviews therefore serve a valuable role in promoting responders across unilateral spatial neglect subtypes and severity levels, evidence-based practice and stimulating innovative research for instance, will prove more valuable than conducting additional low- questions. According to the authors, unilateral spatial neglect is a powered trials. Existing strategies employing repetitive task-orientated ‘well-researched phenomenon’. Indeed, prior neuroimaging work training4 and attention control tasks5 show promise. Might combining identifying key anatomical substrates of neglect1 supports their claim. these treatment strategies boost motor outcomes in unilateral spatial Yet, in their analysis of treatment efficacy in unilateral spatial neglect, neglect? Lastly, formulating conclusive statements on upper limb treat- one out of 850 (0.1%) articles met the criteria. The authors’ ‘unan- ment efficacy in unilateral spatial neglect also depends on elucidating ticipated’ observation underscores current challenges (and opportu- motor and cognitive system interplay during stroke recovery. nities) in stroke rehabilitation research. Provenance: Invited. Not peer reviewed. A lack of transparency in stroke rehabilitation trials is a common Jessica M Cassidy issue. Inconsistent reporting of stroke features, methodology, and treatment parameters ultimately hinders clinical advancement. Ef- Division of Physical Therapy, forts to ameliorate rigor and reproducibility in stroke rehabilitation University of North Carolina at Chapel Hill, USA research are underway, including establishing a universal set of clinical assessments and intervention reporting/monitoring guide- https://doi.org/10.1016/j.jphys.2019.07.006 lines.2 Notably, the primary focus of these efforts is in the sensori- motor domain. To positively impact clinical practice, researchers must References implement similar research practices to other stroke behavioural phenotypes (neglect, aphasia, apraxia) and design intervention 1. Corbetta M, et al. Nat Neurosci. 2005;8:1603–1610. studies concentrating exclusively on these phenotypes. 2. Bernhardt J, et al. Neurorehabil Neural Repair. 2017;31:694–698. 3. Winstein CJ, et al. Stroke. 2016;47:e98–e169. Current treatment approaches in unilateral spatial neglect involve top- 4. Grattan ES, et al. Am J Occup Ther. 2016;70:7004290020p1-7004290020p8. down and bottom-up strategies emphasising compensation and attention 5. Rinne P, et al. Proc Natl Acad Sci. 2018;115:e536–e545. 1836-9553/© 2019 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 65 (2019) 237 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Appraisal Critically appraised paper: Unilateral neglect impairs functional recovery but evidence for upper limb interventions in patients with neglect is lacking Synopsis Summary of: Doron N, Rand D. Is unilateral spatial neglect associated neglect and upper limb recovery such that the presence of neglect was with motor recovery of the affected upper extremity poststroke? A associated with poorer functional outcome. This finding was consistent systematic review. Neurorehabil Neural Repair. 2019;33:170–187. in both acute and chronic stroke. Differences in the measures used to assess unilateral spatial neglect and upper limb function, as well as Objective: To review the evidence as to whether there is a relationship variations in severity of upper limb impairment and severity and type of between unilateral spatial neglect and motor or functional recovery of unilateral neglect may have contributed to inconsistencies across the upper limb after stroke, and to examine if sensorimotor in- studies and prevented pooling of data. In the single experimental study, terventions improve upper limb function in people with unilateral which examined the effects of a task-specific upper extremity inter- spatial neglect after stroke. Data sources: MEDLINE, EMBASE, CINAHL, vention on functional performance in patients with unilateral spatial and Cochrane CENTRAL searched up to February 2018. Study selection: neglect more than 6 months after stroke, there was a significant but Observational or experimental studies of adults with stroke that small improvement in upper limb function. Conclusion: Although there included at least one outcome measure each for unilateral spatial is evidence that unilateral spatial neglect is associated with poorer neglect and upper limb function, and were available in English. Case functional recovery of the hemiparetic upper limb after stroke, there is studies and intervention studies that targeted unilateral spatial neglect currently very little experimental research evaluating the efficacy of without measuring upper limb function were excluded. Data extrac- upper limb interventions in people with unilateral spatial neglect. tion: Two reviewers extracted the data. Methodological quality was Further research is required to guide upper limb rehabilitation for pa- assessed using a modified Quality Index checklist. Data synthesis: Of tients with neglect after stroke. 850 studies initially identified by the search, 14 studies with a total of 1074 participants met the selection criteria and were included. Thirteen Provenance: Invited. Not peer reviewed. of these studies examined relationships between unilateral spatial neglect and upper limb recovery, and one examined the effect of an Prudence Plummer upper limb intervention in patients with unilateral spatial neglect. Department of Allied Health Sciences, Studies were rated as fair to good quality. Ten of the 13 observational University of North Carolina at Chapel Hill, USA studies found that a relationship existed between unilateral spatial https://doi.org/10.1016/j.jphys.2019.07.005 Commentary system training, respectively.3 Addressing longstanding clinical questions The heterogeneity of stroke challenges clinicians and researchers. related to dosage optimisation and treatment responders versus non- Systematic reviews therefore serve a valuable role in promoting responders across unilateral spatial neglect subtypes and severity levels, evidence-based practice and stimulating innovative research for instance, will prove more valuable than conducting additional low- questions. According to the authors, unilateral spatial neglect is a powered trials. Existing strategies employing repetitive task-orientated ‘well-researched phenomenon’. Indeed, prior neuroimaging work training4 and attention control tasks5 show promise. Might combining identifying key anatomical substrates of neglect1 supports their claim. these treatment strategies boost motor outcomes in unilateral spatial Yet, in their analysis of treatment efficacy in unilateral spatial neglect, neglect? Lastly, formulating conclusive statements on upper limb treat- one out of 850 (0.1%) articles met the criteria. The authors’ ‘unan- ment efficacy in unilateral spatial neglect also depends on elucidating ticipated’ observation underscores current challenges (and opportu- motor and cognitive system interplay during stroke recovery. nities) in stroke rehabilitation research. Provenance: Invited. Not peer reviewed. A lack of transparency in stroke rehabilitation trials is a common Jessica M Cassidy issue. Inconsistent reporting of stroke features, methodology, and treatment parameters ultimately hinders clinical advancement. Ef- Division of Physical Therapy, forts to ameliorate rigor and reproducibility in stroke rehabilitation University of North Carolina at Chapel Hill, USA research are underway, including establishing a universal set of clinical assessments and intervention reporting/monitoring guide- https://doi.org/10.1016/j.jphys.2019.07.006 lines.2 Notably, the primary focus of these efforts is in the sensori- motor domain. To positively impact clinical practice, researchers must References implement similar research practices to other stroke behavioural phenotypes (neglect, aphasia, apraxia) and design intervention 1. Corbetta M, et al. Nat Neurosci. 2005;8:1603–1610. studies concentrating exclusively on these phenotypes. 2. Bernhardt J, et al. Neurorehabil Neural Repair. 2017;31:694–698. 3. Winstein CJ, et al. Stroke. 2016;47:e98–e169. Current treatment approaches in unilateral spatial neglect involve top- 4. Grattan ES, et al. Am J Occup Ther. 2016;70:7004290020p1-7004290020p8. down and bottom-up strategies emphasising compensation and attention 5. Rinne P, et al. Proc Natl Acad Sci. 2018;115:e536–e545. 1836-9553/© 2019 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 65 (2019) 189–199 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Research Home-based prescribed exercise improves balance-related activities in people with Parkinson’s disease and has benefits similar to centre-based exercise: a systematic review Allyson Flynn a,b, Natalie E Allen a, Sarah Dennis a,c, Colleen G Canning a, Elisabeth Preston b a Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney; b Discipline of Physiotherapy, Faculty of Health, University of Canberra; c South Western Sydney Local Health District, Australia KEY WORDS ABSTRACT Parkinson disease Questions: In people with Parkinson’s disease, does home-based prescribed exercise improve balance-related Exercise activities and quality of life compared with no intervention? Are the effects of home-based exercise similar to Home based those of equivalent centre-based exercise? Design: Systematic review and meta-analysis of randomised and Systematic review quasi-randomised controlled trials. Participants: Adults diagnosed with idiopathic Parkinson’s disease. Rehabilitation Intervention: Predominantly home-based prescribed exercise (defined as a minimum of two-thirds of the exercise being completed at home). The intervention had to primarily involve physical practice of exercises targeting gait and/or standing balance compared with either control (ie, usual care only, a sham intervention or no physiotherapy) or equivalent predominantly centre-based exercise. Outcome measures: The primary outcome was balance-related activities and the secondary outcomes were gait speed, Berg Balance Scale, Functional Reach test, and quality of life. Results: Sixteen trials met the inclusion criteria and all contributed to the meta-analyses. Twelve trials compared home-based prescribed exercise with control, and four trials compared home-based prescribed exercise with equivalent centre-based exercise. Home-based prescribed exercise improved balance-related activities (SMD 0.21, 95% CI 0.10 to 0.32) and gait speed (SMD 0.30, 95% CI 0.12 to 0.49), but not quality of life (SMD 0.11, 95% CI 20.01 to 0.23) compared with control. Home-based and centre-based exercise had similar effects on balance-related activities (SMD 20.04, 95% CI 20.36 to 0.27) and quality of life (SMD 20.08, 95% CI 20.41 to 0.24). Conclusion: Home-based prescribed exercise improves balance-related activities and gait speed in people with Parkinson’s disease, and these improvements are similar to improvements with equivalent centre-based exercise. Registration: PROSPERO CRD 42018107331. [Flynn A, Allen NE, Dennis S, Canning CG, Preston E (2019) Home-based prescribed exercise improves balance-related activities in people with Parkinson’s disease and has benefits similar to centre-based exercise: a systematic review. Journal of Physiotherapy 65:189–199] © 2019 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/). Introduction across studies.10 The prescribed exercise that has been reported in- cludes: individual centre-based or home-based programs; supervised Parkinson’s disease is a chronic, progressive, neurodegenerative group sessions at a centre; home exercise programs with minimal disorder. It is the fastest growing neurological disorder in the world; supervision; and a combination of supervised centre-based sessions the number of people with Parkinson’s disease is projected to double and home exercise programs.10 Given the progressive nature of Par- from 6 million in 2015 to 12 million in 2040.1 Physiotherapy in- kinson’s disease combined with near-normal life expectancy,11 it is terventions such as balance exercises, treadmill training, cueing and imperative that prescribed exercise programs for people with Par- strength exercise have become an integral part of the management of kinson’s disease are sustainable and effective over a long period of Parkinson’s disease.2 High-quality systematic reviews and rando- time. Home-based prescribed exercise, where the exercise is mised controlled trials have shown that exercise improves mobility completed in the person’s home, is one model of care that has the (gait speed, step length and walking capacity),3–5 balance6,7 and potential to be sustained over a long period of time with minimal quality of life,3 and can reduce falls.8,9 resources. To date, no systematic reviews have specifically investi- gated the effectiveness of home-based prescribed exercise for people Questions remain, however, about the optimal location, amount of with Parkinson’s disease. supervision, mode of delivery (individual, group or both), intensity, duration and type of exercise required to achieve these benefits. A few small randomised controlled trials have aimed to identify if These questions arise due to the wide range of prescribed exercise location impacts on the effectiveness of prescribed exercise, by used in research, with the location and amount of supervision varying comparing home-based and centre-based interventions of similar https://doi.org/10.1016/j.jphys.2019.08.003 1836-9553/© 2019 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 Flynn et al: Home-based exercise for Parkinson’s disease Box 1. Inclusion criteria. Design Randomised or quasi-randomised controlled trials Participants Adults with Parkinson’s disease Intervention Involved predominantly home-based prescribed exercise 4 sessions over 2 weeks Prescribed by a physiotherapist or health professional with a degree-level qualification in exercise prescription Primarily involved physical practice of exercises targeting gait and/or standing balance Outcome measures Balance-related activities Quality of life Comparisons Home-based exercise versus a control group receiving no intervention, usual care, or a placebo intervention Home-based exercise versus centre-based exercise, where the centre-based exercise is equivalent in terms of dose and type of intervention to that of the home-based prescribed exercise type and intensity. These studies suggest that centre-based exercises which provides information on the internal validity of the trial and may be superior.12–15 Two systematic reviews7,16 have presented the appropriate reporting of statistical information. Each trial is subgroup analyses suggesting that location may have an impact on scored out of 10, with a higher rating indicating greater methodo- the effect of prescribed exercise. Shen et al7 reported that compared logical quality. The PEDro score was used to assess and report the with no exercise, centre-based exercise resulted in long-term im- quality of the trials but no trials were excluded from the analysis provements in balance and gait, while home-based exercise did not. based on the PEDro score. Similarly, Klamroth et al16 reported that home-based exercise did not improve balance compared with no exercise. These results need to be Participants interpreted with caution because neither review explicitly searched Trials involving adults diagnosed with Parkinson’s disease were for or operationally defined ‘home-based exercise’ and searches were completed in early 2015.7,16 Therefore, relevant trials (eg, Caglar included, while trials involving those with Parkinsonism or Parkin- et al17) and recently published trials (eg, Chivers Seymour et al18) son’s plus disorders were excluded. were not included. Given that the cost of fully supervised centre- based exercise is unlikely to be sustainable in the context of a Intervention neurodegenerative condition, it is crucial to identify whether home- Trials were included if the intervention was exercise that was based prescribed exercise is effective. predominantly home-based, defined as two-thirds of the exercise Therefore, the research questions for this systematic review were: being conducted at home. To be included, a minimum dose of four sessions over a minimum of 2 weeks, prescribed by a physiotherapist 1. In people with Parkinson’s disease, does home-based prescribed or health professional with a degree-level qualification in exercise exercise improve balance-related activities and quality of life prescription, was required. In addition, the exercise had to primarily compared with no intervention? involve physical practice of exercises targeting gait and/or standing balance. Trials were excluded if the home-based exercise 2. Are the effects of home-based exercise similar to those of was designed as a sham or control with no potential therapeutic equivalent centre-based exercise? benefit. Method Trials were included when the control group received no inter- vention, usual care, placebo or centre-based exercise. Centre-based Identification and selection of trials exercise was defined as two-thirds of the exercise being provided at a centre, such as hospital outpatient department, private practice, A comprehensive search of the Cochrane Central Register of medical centre or community centre. The dose and type of centre- Controlled Trials (CENTRAL), CINAHL, EMBASE, and Physiotherapy based exercise had to be equivalent to that of the home-based exer- Evidence Database (PEDro) databases was conducted in April 2019. cise and be prescribed by a physiotherapist or health professional Search terms included words related to: Parkinson’s disease, phys- with a degree-level qualification in exercise prescription. iotherapy, exercise, home-based therapy, group-based therapy, su- pervision, gait, mobility, balance, quality of life, randomised and Outcomes quasi-randomised (see Appendix 1 on the eAddenda for full search The primary outcome was balance-related activities. Given the strategy). There were no date or language restrictions. Titles and abstracts were screened by two independent reviewers (AF, EP), po- range of mobility and balance outcomes, the analysis involved pool- tential trials identified, and any conflicts resolved by discussion with a ing the most comprehensive balance-related activity measure avail- third reviewer (SD). Full copies of the relevant trials were retrieved able. This was identified prior to performing the analysis using the and reviewed by two independent reviewers (AF, EP) against pre- following priority order: MiniBESTest;20 Functional Gait Assessment21 determined inclusion and exclusion criteria (Box 1), with any conflicts or Dynamic Gait Index;22 Berg Balance Scale;23 Short Physical Per- resolved by discussion with a third reviewer (SD). The reference lists formance Battery;24 Timed Up and Go test;25 gait speed; turning of included trials were also reviewed for potential trials. time; sit to stand time; Functional Reach test;26 single leg stand time; Pull Test27 or Push and Release Test;28 Physical Performance Test;29 Assessment of characteristics of the trials and Sensory Organisation Test.30 This method has been used in pre- vious systematic reviews reporting mobility and balance outcomes in Quality Parkinson’s disease.7,31 Where a trial reported results for more than The quality of the included trials was assessed using the published one of these outcomes, the outcome with the highest priority was included in the analysis. Individual balance-related outcome mea- PEDro score.19 The PEDro score is determined by an 11-item scale, sures reported by three or more trials were analysed independently
Research 191 Titles and abstracts screened (n = 2122) . CENTRAL (n = 898) . CINAHL (n = 406) . EMBASE (n = 678) . PEDro (n = 140) Duplicated removed (n = 726) Papers excluded after screening titles/abstracts (n = 1257) Potentially-relevant papers retrieved for evaluation of full text (n = 139) Papers excluded after evaluation of full text (n = 122)a . study design not (quasi-)randomised trial (n = 7) . intervention not predominantly home-based (n = 102) . intervention not prescribed by physiotherapist or person with a degree-level qualification (n = 19) . intervention did not meet minimum dosage (n = 2) . intervention did not include physical practice of . exercises targeting gait and/or standing balance (n = 12) outcome measures were not balance-related activities or quality of life (n = 11) . location of the intervention was not reported (n = 7) . prescriber of the intervention was not reported (n = 16) . no relevant comparison (n = 40) Papers included in review (n = 17) Trials included in meta-analysis (n = 16) Figure 1. Flow of trials through the review. a Papers may have been excluded for failing to meet more than one eligibility criterion. as secondary outcomes. Quality of life measured using Parkinson’s information was also extracted: outcomes used, timing of mea- disease-specific questionnaires or other valid health-related quality of surements, medication status during measurement (on/off), and life questionnaires was also reported as a secondary outcome measure. result at each time point (mean, standard deviation and number of participants). Data analysis Post-intervention scores and scores beyond the intervention were Data were extracted independently by two reviewers (AF, EP). used for the pooled analysis of the effect of home-based prescribed Authors were contacted where clarification for data extraction was required. To characterise the study participants, data were extrac- exercise. If the results were reported as median, range and/or inter- ted regarding sample size, age, time since diagnosis, measure of quartile range, the mean and standard deviation were determined disease severity (eg, Hoehn and Yahr, Unified Parkinson’s Disease using the formula described by Wan et al.32 If data were only reported Rating Scale (UPDRS), UPDRS motor subsection, and the Movement in a figure, data were extracted using the software program Web- Disorders Society Unified Parkinson’s Disease Rating Scale (MDS- PlotDigitizer.33 King et al compared home-based prescribed exercise UPDRS) Item III) and measures of cognitive ability. Details of the with two centre-based exercise programs: one with individual su- intervention for the home-based prescribed exercise and compar- pervision and one with group supervision.15 To ensure that partici- ison group were extracted, including: dose and type of exercise; pants were not counted twice during the meta-analysis, each medication state during training (on/off); percentage of exercise delivered at home (home-based prescribed sessions/total pre- pairwise comparison was separately included with the sample size of scribed sessions); percentage of sessions supervised by a therapist the home-based prescribed exercise group equally divided. As either in person or via teleconferencing (prescribed supervised sessions/total prescribed sessions); and adherence (the percentage different outcome measures were used for balance-related activities, of sessions undertaken/total prescribed sessions). The following gait speed, and quality of life outcomes, data were pooled using Hedges’ g standardised mean difference with a 95% confidence in- terval. A fixed-effect model was used, and each analysis was tested for statistical heterogeneity (I2 . 50%). If heterogeneity was present, a random-effects model was applied instead of a fixed-effect model. The analyses were performed using RevMan softwarea.
192 Flynn et al: Home-based exercise for Parkinson’s disease Table 1 Characteristics of included studies: home-based prescribed exercise compared with no intervention (n = 12). Study Participantsa Intervention Supervision Adherence Outcomesb (%) Allen n = 48 Exp = Home-based (92%) 12% supervision 70 SPPB 201034 Age (yr) = 67 (9) Balance and strength 1/mth group session Preferred gait speed PD (yr) = 8 (6) 40 to 60 min 3 3/wk 3 26 wk supervised by therapist N/R PDQ 39 Ashburn H & Y = N/R (centre) 100 Timing: 26 wk 200735 UPDRS Motor = 30 (13) Con = Usual care 1 to 2 home visits 78 MMSE = 29 (1) BBS Caglar Exp = Home-based (100%) 14% supervision 72 Functional Reach 200517 n = 140 Balance, ROM, strength and 1/wk session supervised EuroQoL-5D Age (yr) = 72 (9) walking by therapist N/R Timing: 8 wk, 26 wk Canning PD (yr) = 8 (6) 60 mind 3 7/wk 3 6 wk Time taken to walk 201236 H & Y = 3.1 (0.6) 2% supervision 87 10 m Cognitionc Con = Usual care 1 initial session supervised Timing: 9 wk Canning by therapist (centre) 77 20158 n = 30 Exp = Home-based (98%) Preferred gait speed Age (yr) = 66 (9) Balance, everyday activities, ROM, 29% supervision N/R PDQ 39 Chivers PD (yr) = 5 (2) walking 7 sessions at home 100 Timing: 6 wk, 12 wk Seymour H & Y = 2.1 (0.5) 60 min 3 7/wk 3 9 wk supervised by therapist 201918 Cognition = N/R 86 SPPB Con = Usual care 13% supervision Fast gait speed Goodwin n = 20 1/mth group session PDQ 39 201138 Age (yr) = 62 (8) Exp = Home-based (100%) supervised by therapist Timing: 26 wk and PD (yr) = 6 (4) Treadmill walking (centre) Fletcher H & Ye 30 to 40 min 3 4/wk 3 6 wk 2 to 4 home visits MiniBESTest 201237 UPDRS motor = 19 (9) PDQ 39 Khalil MMSE = 30 (0.4) Con = Usual care 7% supervision Timing: 26 wk, 52 wk 201739 12 sessions at home n = 231 Exp = Home-based (92%) supervised by therapist BBS Morris Age (yr) = 71 (9) Balance, cueing and strength TUG 201740 PD (yr) = 8 (6) 40 to 60 min 3 3/wk 3 26 wk 33% supervision EuroQoL-5D H & Y = 2.7 (0.6) 1/wk group session Timing:10 wk, 20 wk Nieuwboer UPDRS motor = 26 (10) Con = Usual care supervised by therapist 200741 MMSE = 29 (1) MiniBESTest Exp = Home-based (100%) 25% supervision Preferred gait speed Song n = 474 Balance, freezing strategies and Wks 1 to 4, 2/wk sessions Timing: 8 wk 201842 Age (yr) = 72 (8) strength supervised by therapist PD (yr) = 8 (6) 30 min 3 7/wk 3 26 wk Wks 5 to 8, 1/wk telephone PDQ39 H & Y = 2.6 (0.9) call from therapist Timing: 6 wk, 52 wk UPDRS motor = 33 (16) Con = Usual care MMSE = 29 (2) 50% supervision TUG Exp = Home-based (67%) 1/wk session supervised Functional Reach n = 130 Balance and strength by therapist (home visit) Preferred gait speed Age (yr) = 71 (8) 60 ming 3 3/wk 3 10 wk PDQ39 PD (yr) = 9 (6) 1/wk centre-based 100% supervision Timing: 3 wk H & Y = 2.5 (0.9) 2/wk home-based 3/wk sessions supervised FGA Cognitionf by therapist (home visit) TUG Con = Usual care Timing: 12 wk n = 30 8% supervision Age (yr) = 60 (14) Exp = Home-based (75%) 2 initial home visits for set up PD (yr) = 8 (5) Balance, everyday activities, 1 home visit at 6 weeks H & Y = 2.3 (0.8) ROM, strength, and walking Telephone call every 2 weeks MDS UPDRS III = 48 (18) 45 minh 3 4/wk 3 8 wk Cognitionf 3/wk exercise sessions 1/wk walking n = 133 Age (yr) = 71 (9) Con = Usual care PD (yr) = N/R H & Y = 2.3 (0.7) Exp = Home-based (100%) MMSE = 28 (2) Cueing and strength 60 min 3 2/wk 3 6 wk n = 153 Age (yr) = 67.5 (61.5 to 73) Con = Placebo: life-skills program PD (yr) = 8 (4 to 11) 60 min 3 2/wk 3 6 wk H & Y = 3 (2.5 to 3) UPDRS motor = 33 (25 to 41) Exp = Home-based (100%) MMSE = 29 (27 to 30) Cueing during everyday activities 30 min 3 3/wk 3 3 wk n = 60 Age (yr) = 67 (7) Con = Usual care PD (yr) = 8 (5) H & Y = N/R Exp = Home-based (100%) MDS UPDRS III = 32 (12) Balance MMSE = 29 (2) 15 min 3 3/wk 3 12 wk Con = Usual care
Research 193 Table 1 (Continued) Participantsa Intervention Supervision Adherence Outcomesb Study (%) Stack n = 47 Exp = Home-based (100%) 100% supervision N/R 180 deg turn test 201243 Age (yr) = 74 (6) Cueing, everyday activities, and 3/wk sessions supervised Functional Reach PD (yr) = 8 (6) strength by therapist (home visit) HRQoL H & Y = 3.1 (0.8) 60 min 3 3/wk 3 4 wk UPDRS motor = 28 (13) Timing: 4 wk, 8 wk, Cognitioni Con = No physiotherapy 12 wk BBS = Berg Balance Scale, FGA = Functional Gait Assessment, HRQoL = Health-related quality of life, H & Y = Hoehn and Yahr, MDS UPDRS III = Movement Disorders Society Unified Parkinson’s Disease Rating Scale motor subsection, MMSE = Mini-Mental State Examination, MoCA = Montreal Cognitive Assessment, N/R = not reported, PDQ39 = Parkinson’s disease Questionnaire 39, ROM = range of motion, SPPB = Short Physical Performance Battery, TUG = Timed Up and Go test, UPDRS motor = Unified Parkinson’s Disease Rating Scale motor subsection. a Data are n, mean (SD), or median (IQR). b Outcomes measure and timing of outcome measures used in data analysis. c Inclusion criterion: no gross cognitive impairment. d Duration of intervention reported for home visits only. e Inclusion criterion: mild Parkinson’s disease (Hoehn and Yahr stages I to II). f Exclusion criteria: severe/marked cognitive deficit. g Duration of intervention reported for centre-based sessions only. h Duration of intervention reported for walking component of intervention only. i Inclusion criterion: 8/12 on the Middlesex Elderly Assessment of Mental State. Subgroup analysis MDS-UPDRS) and one trial36 included participants with mild Par- Subgroup analyses were performed to explore the effect of dose kinson’s disease (Hoehn and Yahr stage I to II). Participants with significant cognitive impairment were excluded in all but one trial, and supervision. With respect to dose, interventions were categorised which did not report a cognitive criterion for eligibility.17 as high dose if they were prescribed for a minimum 150 min/wk for at least 6 weeks. With respect to supervision, the trials that delivered Intervention intervention with full (100%) supervision were compared with trials All included trials primarily involved exercises targeting gait and/ that were not fully supervised. or standing balance. The exercise was prescribed by a physiotherapist Results in all but one12 of the studies, where the exercise was prescribed by an exercise physiologist. In 13 trials8,12–15,17,18,34,35,38–40,43 the exercise Flow of trials through the review program involved multiple components including: balance, cueing, range of movement, strength, walking and everyday activities (eg, sit The search identified 1396 records (excluding duplicates). After to stand, turning and stairs). Three trials prescribed one exercise only: screening the titles and abstracts, the full texts of 139 papers were Canning et al 201236 prescribed walking on a treadmill; Nieubower retrieved. Of these, 17 papers8,12–15,17,18,34–43 met the inclusion et al41 prescribed cue training during everyday activities; and Song criteria. Two papers reported data from the same trial37,38 so 16 trials et al42 prescribed balance training using an exergame that required were included in the meta-analysis. See Figure 1 for the flow of trials stepping in different directions. Five trials reported that the partici- through the review. pants performed the exercise during the ‘on’ phase, where their Parkinson’s disease medication was working optimally,13–15,36,42 with Characteristics of included trials the remainder not reporting medication status during exercise. Twelve trials8,17,18,34–36,38–43 involving 1496 participants compared The dose of the interventions varied between the trials. The length home-based prescribed exercise with usual care or a placebo of the exercise programs ranged from 3 to 26 weeks, which was re- (Table 1). Four trials12–15 involving 204 participants compared home- flected in the total number of prescribed sessions ranging from 9 to based prescribed exercise with centre-based exercise (Table 2). One of 182 (median 30.5). The majority of trials (63%) had an intervention these four trials15 compared home-based prescribed exercise with duration of between 6 to 10 weeks. Participants completed a mini- both centre-based exercise conducted in a group and centre-based mum of 15 minutes and a maximum of 60 minutes of prescribed exercise conducted individually. exercise per session. Nine trials8,12,14,17,18,34,35,38,39 prescribed a higher dose of at least 150 minutes of exercise per week for at least 6 weeks. Quality There was a high adherence rate of 70% (range 70 to 100%) in the The mean PEDro score of the trials was 7 (range 4 to 8) (Table 3). ten8,13,15,17,34,36,38,39,41,42 trials where adherence was reported. All trials reported similar groups at baseline and point estimate The amount of supervision provided for home-based prescribed variability. The majority of trials (88%) reported random allocation, exercise ranged from 0 to 100%. Fifteen trials8,13–15,17,18,34–36,38–43 assessor blinding and a loss to follow-up of , 15%. Concealed allo- (93%) provided the participants with at least one supervised session cation occurred in 75% of the trials. Only 50% of trials reported either at home or a centre prior to commencing the home exercise. intention-to-treat analysis. Due to the nature of the intervention it Types of supervision included individual (one participant and one was not possible to blind the participants or the therapists to the therapist) sessions at home or a centre, or group-based sessions at a intervention. centre. One trial14 studied supervised home-based sessions using teleconferencing (Skype). Two trials12,14 reported caregiver supervi- Participants sion to ensure safety of the participants when completing the home- The mean age of the participants across the trials ranged from 60 based exercise. All centre-based sessions were supervised. to 74 years. The mean time since Parkinson’s disease diagnosis across Outcome measures the trials ranged from 5 to 9 years. Fourteen trials reported disease Fifteen of the trials reported that the outcome measures were severity using the Hoehn and Yahr Scale and two trials34,42 used the motor subsection of the UPDRS or MDS-UPDRS. Eight tri- completed during the participants’ ‘on’ phase.8,12–15,17,34–36,38–43 A als8,18,35,38–41,43 included participants with mild to severe Parkinson’s measure of balance-related activities immediately after the inter- disease (Hoehn and Yahr stage I to IV), seven trials12–15,17,34,42 vention was reported in 14 trials.8,12,14,15,17,18,34–36,38,39,41–43 All 14 included participants with mild to moderate Parkinson’s disease trials reported data for a least one of the comprehensive measures of (Hoehn and Yahr stage I to III and motor subsection of the UPDRS or balance-related activity listed in the priority order determined a priori. For the meta-analysis, the following outcome measures were
194 Flynn et al: Home-based exercise for Parkinson’s disease Table 2 Characteristics of included studies: home-based prescribed exercise compared with centre-based exercise (n = 4). Study Participantsa Intervention Supervision Adherence Outcomesb (%) Atterbury n = 40 Home-based (100%) 0% supervision N/R FGA 201712 Age (yr) = 65 (8) Balance DVD with instructions and Timing: 8 wk PD (yr) = 5 (7) 40 to 60 min 3 3/wk 3 8 wk safety guidelines H & Y = 2.5 (0.5) Assisted by caregiver for safety N/R MDS UPDRS III = 34 (13) Centre-based MoCA = 26 (2) Balance exercises 100% supervision 40 to 60 min 3 3/wk 3 8 wk 3/wk sessions supervised by therapist (group) 4 to 8 people per group Dereli n = 30 Home-based (97%) 3% supervision 100 PDQLQ 201013 Age (yr) = 64 (11) Balance, breathing, relaxation, ROM and 1 3 participant education session Timing: 10 wk PD (yr) = 7 (4) walking 1/wk telephone call from therapist H & Y = 2.1 (0.7) 45 min 3 3/wk 3 10 wk 100 UPDRS motor = 17 (7) 100% supervision MMSE = 27 (2) Centre-based 1 3 participant education session Balance, breathing, relaxation, ROM and 3/wk sessions supervised by a walking therapist (individual) 45 min 3 3/wk 3 10 wk Gandolfi n = 76 Home-based (95%) 100% supervision N/R DGI 201714 Age (yr) = 69 (8) Balance PD (yr) = 7 (4) 50 min 3 3/wk 3 7 wk 1 3 explanation of intervention in centre Fast gait speed H & Y = 2.5 (2.5 to 3.0) UPDRS = 47 (24) Centre-based 3/wk sessions supervised by PDQ8 MMSE = 28 (4) Balance 50 min 3 3/wk 3 7 wk therapist, using Skype Caregiver present to provide Timing: 8 wk, 12 wk safety 100% supervision N/R 3/wk sessions supervised by therapist (individual) King n = 58 Home-based (92%) 8% supervision 85 MiniBESTest 201515 Age (yr) = 64 (7) Balance and walking 1 3 session to receive home PDQ39 PD (yr) = 6 (6) 60 min 3 3/wk 3 4 wk exercise program H & Y = 2.4 (0.5) Timing: 4 wk UPDRS motor = 37 (13) Centre-based individual 100% supervision 97 MoCA = 26 (4) Balance and walking 3/wk sessions supervised by 60 min 3 3/wk 3 4 wk therapist (individual) Centre-based group 100% supervision 95 Balance and walking 3/wk sessions supervised by 60 min 3 3/wk 3 4 wk therapist (group) DGI = Dynamic gait index, FGA = Functional Gait Assessment, H & Y = Hoehn and Yahr, MDS UPDRS III = Movement Disorders Society Unified Parkinson’s Disease Rating Scale motor subsection, MMSE = Mini-Mental State Examination, MoCA = Montreal Cognitive Assessment, N/R = not reported, PDQLQ = Parkinson’s Disease Quality of Life Questionnaire, PDQ8 = Parkinson’s disease questionnaire 8, PDQ39 = Parkinson’s disease Questionnaire 39, ROM = Range of motion, UPDRS = Unified Parkinson’s Disease Rating Scale, UPDRS motor = Unified Parkinson’s Disease Rating Scale motor subsection. a Data are n, mean (SD), or median (IQR). b Outcomes measure and timing of outcome measures used in data analysis. used: MiniBESTest,15,18,39 Functional Gait Assessment,12,42 Dynamic pooling 11 trials totalling 1220 participants, with a mean PEDro score Gait Index,14 Berg Balance Scale,35,38 Short Physical Performance of 7.2 indicating good quality. Overall, there was an SMD of 0.21 (95% Battery,8,34 preferred gait speed,17,36 turning time,43 and Timed Up CI 0.10 to 0.32, I2 = 0%) in favour of home-based prescribed exercise and Go test.41 Gait speed, Functional Reach test and Timed Up and Go (Figure 2a, see also Figure 3a on the eAddenda for detailed forest test were the only balance-related activity outcome measures re- plot). ported in three or more trials with data available at the end of the intervention only. The effect of home-based prescribed exercise on balance-related activities beyond the intervention period was determined by Four trials measured preferred gait speed,34,36,39,41 one trial pooling five trials totalling 541 participants, with a mean PEDro measured fast gait speed8 and one trial measured time taken to walk score of 7.2 indicating good quality. The length of time after the 10 m.17 Three trials reported Functional Reach35,41,43 and three trials exercise intervention ranged from 4 to 26 weeks. One trial re- reported Timed Up and Go test.38,41,42 ported follow-up data at both 4 and 8 weeks beyond the exercise, so the values for the longest follow-up period (8 weeks) were used Quality of life was measured in 12 trials.8,13–15,18,34–36,38,40,41,43 in the meta-analysis. Overall, there was no difference between Some trials used Parkinson’s disease-specific measures: Parkinson’s home-based prescribed exercise and usual care or a placebo disease Questionnaire 39 (PDQ 39),44 Parkinson’s disease question- beyond the intervention, with an SMD of 0.12 (95% CI 20.05 to naire 8 (PDQ8),45 and Parkinson’s Disease Quality of Life Question- 0.29, I2 = 0%) (Figure 2b, see also Figure 3b on the eAddenda for naire (PDQLQ).46 Other trials used generic quality of life measures: detailed forest plot). EuroQoL-5D47 and a generic health-related quality of life measure.48 The effect of home-based prescribed exercise on gait speed Seven trials14,18,35,36,38,40,43 reported measures beyond the inter- immediately after the intervention was determined by pooling six vention period, with the follow-up period ranging from 4 to 46 weeks trials totalling 482 participants, with a mean PEDro score of 7.2 (median 10 weeks). indicating good quality. The overall effect was an SMD of 0.30 (95% CI 0.12 to 0.49, I2 = 3%) in favour of home-based prescribed exercise Effect of home-based prescribed exercise compared with usual (Figure 4, see also Figure 5 on the eAddenda for detailed forest plot). care or a placebo This translates to a mean increase in gait speed of 0.12 m/s (0.01 to 0.20) when results are back converted using the largest, least-biased Balance-related activities and most representative study of those included in the analysis.8 Only The effect of home-based prescribed exercise on balance-related one trial compared the effect of home-based prescribed exercise on activities immediately after the intervention was determined by
Research 195 Table 3 PEDro criteria and scores for included trials (n = 16). Study Random Concealed Groups Participant Therapist Assessor , 15% Intention Between-group Point estimate and Total allocation allocation similar at blinding blinding blinding dropouts -to-treat Difference Variability (0 to 10) baseline N analysis reported reported N N Y Y Y Y 8 Allen Y YY N N Y Y Y Y Y 8 (2010)34 N N N N Y Y Y 4 N N Y Y N Y Y 5 Ashburn Y YY N N Y Y N Y Y 8 (2007)35 N N Y Y Y Y Y 8 N N Y Y Y Y Y 8 Atterbury YNY N N Y Y Y Y Y 5 (2017)12 N N Y Y N Y Y 6 N N N Y N Y Y 7 Caglar NNY N N Y Y Y Y Y 7 (2005)17 N N Y Y N Y Y 7 N N Y Y N Y Y 8 Canning Y YY N N Y Y Y Y Y 7 (2012)36 N N Y Y N Y Y 8 N Y N Y N Y 5 Canning Y YY N (2015)8 Chivers Seymour Y Y Y (2019)18 Dereli NNY (2010)13 Gandolfi YNY (2017)14 Goodwin Y YY (2011)38 Khalil Y YY (2017)39 King Y YY (2015)15 Morris Y YY (2017)40 Nieuwboer Y YY (2007)41 Song Y YY (2018)42 Stack Y YY (2012)43 gait speed beyond the intervention, so a meta-analysis could not be Subgroup analyses performed. Subgroup analyses were conducted for the primary outcome of There was no effect of home-based prescribed exercise on the Functional Reach test when pooling three trials totalling 315 partic- balance-related activities regarding dose and supervision. The effect ipants, with a mean PEDro score of 6.7 indicating good quality (MD 0.66 cm, 95% CI 20.84 to 2.16, I2 = 0%). There was also no effect on the of dose on balance-related activities was determined by pooling data Timed Up and Go test when pooling three trials totalling 330 par- from seven trials8,17,18,34,35,38,39 that delivered a high dose of inter- ticipants, with a mean PEDro score of 7.3 indicating good quality (MD 0.07 seconds, 95% CI 20.65 to 0.79, I2 = 28%). vention, totalling 964 participants, with a mean PEDro score of 7.3 indicating good quality; and by pooling data from four trials36,41–43 Quality of life The effect of home-based prescribed exercise on quality of life that delivered a low dose of intervention, totalling 256 participants, immediately after the intervention was determined by pooling nine with a mean PEDro score of 7.0 indicating good quality. When trials trials with a total of 1119 participants, with a mean PEDro score of 7.4 indicating good quality. Overall, there was a trend for home-based were grouped according to dose, high-dose home-based prescribed prescribed exercise to improve quality of life when compared with exercise8,17,18,34,35,38,39 was more effective than usual care or a placebo usual care or a placebo with an SMD of 0.11 (95% CI 20.01 to 0.23, I2 = (SMD 0.24, 95% CI 0.11 to 0.36, I2 = 0%), and low-dose home-based 11%) but the data were also consistent with the possibility of an effect prescribed exercise36,41–43 was no more effective than usual care or a close to no effect (Figure 6a, see also Figure 7a on the eAddenda for placebo (SMD 0.11, 95% CI 20.14 to 0.36, I2 = 0%) (Figure 8, see also detailed forest plot). Figure 9 on the eAddenda for detailed forest plot). The effect of home-based prescribed exercise on quality of life The effect of supervision on balance-related activities was deter- beyond the intervention was reported in six trials with the length of mined by pooling data from nine trials8,17,18,34–36,38,39,42 that time after the intervention ranging from 6 to 46 weeks. When pooling data from the six trials with a total of 582 participants, with a mean examined minimally supervised exercise, totalling 1035 participants, PEDro score of 7.3 indicating good quality, there was an SMD of 0.23 (95% CI 0.06 to 0.39, I2 = 22%) in favour of home-based prescribed with a mean PEDro score of 7.4 indicating good quality; and by exercise (Figure 6b, see also Figure 7b on the eAddenda for detailed pooling data from two trials41,43 that examined fully supervised ex- forest plot). ercise, totalling 185 participants, with a mean PEDro score of 6.0 indicating good quality. When trials were grouped according to su- pervision, minimally supervised (median 13% supervised sessions, range 2 to 33) home-based prescribed exercise8,17,18,34–36,38,39,42 was more effective than usual care or a placebo (SMD 0.23, 95% CI 0.11 to 0.35, I2 = 0%), and fully supervised home-based prescribed exer- cise41,43 was no more effective than usual care or a placebo (SMD 0.11, 95% CI 20.18 to 0.40, I2 = 0%) (Figure 10, see also Figure 11 on the eAddenda for detailed forest plot).
196 Flynn et al: Home-based exercise for Parkinson’s disease Study SMD (95% CI) Study SMD (95% CI) (a) end of intervention Fixed (a) end of intervention Fixed Allen 2010 Allen 2010 Ashburn 2007 Ashburn 2007 Caglar 2005 Canning 2012 Canning 2012 Canning 2015 Canning 2015 Chivers Seymour 2019 Chivers Seymour 2019 Goodwin 2011 Goodwin 2011 Morris 2017 Khalil 2017 Nieuwboer 2007 Nieuwboer 2007 Stack 2012 Song 2018 Stack 2012 Pooled Pooled (b) follow-up Ashburn 2007 (b) follow-up Canning 2012 Ashburn 2007 Chivers Seymour 2019 Canning 2012 Goodwin 2011 Chivers Seymour 2019 Morris 2017 Goodwin 2011 Stack 2012 Stack 2012 Pooled Pooled –1.5 –1.0 –0.5 0 0.5 1.0 1.5 –1.5 –1.0 –0.5 0 0.5 1.0 1.5 Favours Favours home- control based exercise Favours Favours home- control based exercise Figure 6. a. Standardised mean difference (95% CI) of effect of home-based prescribed exercise versus control on quality of life immediately after the intervention. Figure 2. a. Standardised mean difference (95% CI) of effect of home-based prescribed b. Standardised mean difference (95% CI) of effect of home-based prescribed exercise exercise versus control on balance-related activities immediately after the intervention. versus control on quality of life beyond the intervention period. b. Standardised mean difference (95% CI) of effect of home-based prescribed exercise versus control on balance-related activities beyond the intervention period. Effect of home-based prescribed exercise compared with equivalent centre-based exercise was determined by pooling three equivalent centre-based exercise trials12,14,15 totalling 166 participants, with a mean PEDro score of 5.7 indicating fair quality. Overall, there was no effect on balance-related Balance-related activities activities for home-based prescribed exercise when compared with The effect of home-based prescribed exercise on balance-related centre-based exercise (SMD 20.04, 95% CI 20.36 to 0.27, I2 = 0%) (Figure 12, see also Figure 13 on the eAddenda for detailed forest activities immediately after the intervention when compared with plot). There were no individual mobility and balance outcome mea- sures reported by three or more trials. Study SMD (95% CI) Allen 2010 Fixed Quality of life Caglar 2005 The effect of home-based prescribed exercise on quality of life Canning 2012 Canning 2015 immediately after the intervention when compared with equivalent Khalil 2017 centre-based exercise was determined by pooling three trials13–15 Nieuwboer 2007 totalling 157 participants, with a mean PEDro score of 6.0 indi- cating good quality. Overall, there was no effect on quality of life for Pooled home-based prescribed exercise when compared with centre-based exercise (SMD 20.08, 95% CI 20.41 to 0.24, I2 = 5%) (Figure 14, see –1.5 –1.0 –0.5 0 0.5 1.0 1.5 also Figure 15 on the eAddenda for detailed forest plot). Favours Favours home- Discussion control based exercise This systematic review provides evidence that home-based pre- Figure 4. Standardised mean difference (95% CI) of effect of home-based prescribed scribed exercise improves balance-related activities and gait speed in exercise versus control on gait speed immediately after the intervention. people with mild to moderate Parkinson’s disease without substantial cognitive deficit. These improvements were not sustained beyond the intervention period. There is also a trend for home-based prescribed exercise to improve quality of life for this population. When comparing centre-based exercise with home-based prescribed exer- cise, neither model of care was superior to the other for balance-
Research 197 Study SMD (95% CI) Study SMD (95% CI) (a) high dose Fixed (a) 100% supervised Fixed Allen 2010 Nieuwboer 2007 Ashburn 2007 Stack 2012 Caglar 2005 Canning 2015 Pooled Chivers Seymour 2019 Goodwin 2011 (b) ≤33% supervised Khalil 2017 Allen 2010 Ashburn 2007 Pooled Caglar 2005 Canning 2012 (b) low dose Canning 2015 Canning 2012 Chivers Seymour 2019 Nieuwboer 2007 Goodwin 2011 Song 2018 Khalil 2017 Stack 2012 Song 2018 Pooled Pooled –1.5 –1.0 –0.5 0 0.5 1.0 1.5 –1.5 –1.0 –0.5 0 0.5 1.0 1.5 Favours Favours home- Favours Favours home- control based exercise control based exercise Figure 8. Subgroup analysis by dose on the effect of home-based prescribed exercise Figure 10. Subgroup analysis by supervision on the effect of home-based prescribed versus control on balance-related activities immediately after the intervention. exercise versus control on balanced-related activities immediately after the intervention. related activities or quality of life. The majority of the trials (75%) than motor impairments.50 Nevertheless, the improvement in quality included in the meta-analysis were of high quality, which supports of life beyond the intervention period reflects some ongoing benefit the credibility of these findings. of home-based exercise. This is the first systematic review to specifically investigate the The subgroup analysis by dose indicates that the amount of the effectiveness of home-based prescribed exercise in people with Par- intervention is important when prescribing home-based exercise for kinson’s disease. The small positive effect in balance-related activities people with Parkinson’s disease, as high-dose interventions (mini- is consistent with previous systematic reviews7,16,31 investigating the mum 150 min/wk for at least 6 weeks) improved balance-related effect of exercise, irrespective of the location. Furthermore, the activities while low-dose interventions did not. This is the first finding that the benefits on balance-related activities gained from meta-analysis to show that dose influences outcomes of exercise home-based prescribed exercise were not sustained beyond the programs in people with Parkinson’s disease, and differs from the intervention in this review is also consistent with a subgroup analysis only other meta-analysis considering dose.7 This difference may have conducted by Shen et al,7 who reported no long-term effect on bal- been due to the definition of high dose used in the current analysis, ance and gait when exercise was home-based. where dose was defined by both duration and frequency (ie, 150 min/ wk over a minimum of 6 weeks) compared with Shen et al who Home-based prescribed exercise improved gait speed. When considered dose based on the number of hours completed.7 The converted from an SMD to m/s, the increase in gait speed (0.12 m/s) current results suggest that prescribed exercise should be sustained was greater than previously reported in systematic reviews: Allen et al31 reported an increase of 0.05 m/s, and Tomlinson et al4 reported Study SMD (95% CI) an increase of 0.04 m/s. Both Allen et al and Tomlinson et al included Atterbury 2017 Fixed studies of low methodological quality, whereas five of the six trials in Gandolfi 2017 the current review were of good quality. Furthermore, four trials King 2015 included in the current meta-analysis had a specific focus on walking, King 2015a compared with the previous reviews, which included a greater range of interventions, including dance, Tai Chi and cueing strategies. This Pooled suggests that the greater increase in gait speed could be, in part, due to the specificity of the training. This increase in gait speed could also –1.5 –1.0 –0.5 0 0.5 1.0 1.5 be considered clinically significant, given it is well above the 0.06 m/s reported by Hass et al to be a small clinically important difference in Favours centre- Favours home- people with Parkinson’s disease.49 based exercise based exercise The lack of difference in quality of life immediately after the Figure 12. Standardised mean difference (95% CI) of effect of home-based prescribed intervention extends the previous work conducted by Tomlinson exercise versus centre-based exercise on balance-related activities immediately after et al,4 which reported that physiotherapy did not have an effect on the intervention. quality of life. One explanation for this could be that the home-based exercise focused primarily on addressing the motor impairments of Parkinson’s disease; however, non-motor impairments (such as depression) have been shown to have a greater effect on quality of life
198 Flynn et al: Home-based exercise for Parkinson’s disease Study SMD (95% CI) incorporated therapist support and/or direct supervision using a va- Dereli 2010 Fixed riety of methods, including: home visits by the therapist, occasional Gandolfi 2017 group-based sessions at a centre, telephones calls and Skype. In nine King 2015 of the 12 trials, where home-based prescribed exercise was compared King 2015a with usual care or a placebo, it included a minimum of one home visit. These strategies enable the therapist to provide feedback and Pooled progress the exercises to ensure that they remained appropriate and challenging. –1.5 –1.0 –0.5 0 0.5 1.0 1.5 The results of this review support minimally supervised, home- Favours centre- Favours home- based exercise to improve balance-related activities in people with based exercise based exercise mild to moderate Parkinson’s disease without substantial cognitive impairment. However, three fall-prevention trials suggest that this Figure 14. Standardised mean difference (95% CI) of effect of home-based prescribed type of exercise may increase falls in those with more advanced exercise versus centre-based exercise on quality of life immediately after the Parkinson’s disease,8,18,35 cognitive impairment and freezing of gait.18 intervention. Therefore, minimally supervised, home-based exercise is not rec- ommended for people with more advanced Parkinson’s disease, for a minimum of 150 min/wk for 6 weeks, and that if prescribed especially in the presence of cognitive impairment and freezing of exercises are not ongoing, the improvements in balance-related ac- gait. tivities will not be maintained. The ongoing need for prescribed ex- ercise is supported by Wallen et al, who showed that improvements This review had some limitations, including the use of post- in balance were only maintained up to 6 months beyond the inter- intervention data as opposed to change scores and the use of an vention in people with Parkinson’s disease.51 Importantly, a high dose SMD, which is less clinically meaningful than a mean difference. For of home-based prescribed exercise was provided with minimal su- the analysis examining the effect of home-based prescribed exercise pervision, which did not impact the effectiveness of the intervention. compared with usual care or a placebo beyond the intervention, there This indicates that prescribed exercise for people with Parkinson’s were few trials and the follow-up period was highly variable, so these disease can be provided in a sustainable manner over the long term. results should be applied cautiously. When comparing home-based prescribed exercise with centre-based exercise, the few available The subgroup analysis by supervision found no effect of fully su- trials all had small sample sizes, which could have led to small sample pervised home-based exercise programs, while programs with min- bias. The reporting of adherence to the intervention also needs to be imal supervision improved balance-related activities. However, the considered, as the trials with minimal supervision relied on self- home-based exercise programs included in the fully supervised tri- reporting and no trials reported if adherence was calculated using als were of low dose (ie, an average of 135 minutes of exercise a week capped (ie, capped data, restricting adherence to a maximum of for an average of 3.5 weeks) compared with the home-based exercise 100%) or uncapped (ie, uncapped data, allowing . 100% adherence) programs included in the minimally supervised trials (ie, an average methods. As expected, there was a wide range of balance-related of 208 minutes of exercise a week for an average of 14 weeks). activity measures reported; greater consistency of outcome mea- Furthermore, the trials with high dose had the lowest amount of sures would facilitate future research.52 The use of a predefined pri- supervision, with the average supervision over the seven trials being ority order was an effective method of addressing this concern. 15%. It is possible that the requirement for an exercise program to be fully supervised at home negatively influences the dose that can be In conclusion this review provides evidence that home-based achieved due to resource constraints. Given that Parkinson’s disease prescribed exercise can improve balance-related activities and gait is a chronic progressive condition, it is vital that effective exercise speed in people with mild to moderate Parkinson’s disease without programs can be delivered and monitored without requiring full substantial cognitive deficit. Furthermore, these improvements are supervision. likely to be similar to improvements obtained by equivalent centre- based exercise. This suggests that home-based prescribed exercise The second question in this review was to determine if home- may be an effective strategy for delivering high-quality exercise to based prescribed exercise improves balance-related activities and people with Parkinson’s disease in health services where resources quality of life when compared with centre-based exercise in people are limited. with Parkinson’s disease. Our results indicate that when exercise type and dose are equivalent, the effects on balance-related activities and What was already known on this topic: In people with quality of life are similar between centre-based and home-based Parkinson’s disease, specific exercise-based interventions prescribed exercise immediately after the intervention. Our review improve mobility, balance and quality of life. Given the progres- included four trials that directly compared home-based prescribed sive nature of the disease and its near-normal life expectancy, exercise and centre-based exercise of equivalent type and dose, exercise programs must be sustainable. Home-based prescribed ensuring that the results can be attributed primarily to location. exercise has the potential to be sustained over a long period of These results should be applied cautiously because the overall quality time with minimal resources. of these trials was fair. Any differences beyond the intervention What this study adds: Home-based prescribed exercise im- period could not be determined due to insufficient data. proves balance and gait speed in people with Parkinson’s dis- ease. Home-based and centre-based exercise were found to have This review has clinical implications for physiotherapists working similar effects on balance-related activities and quality of life. with people with Parkinson’s disease. Importantly, home-based pre- scribed exercise is effective in people with mild to moderate Par- Footnotes: a RevMan 5.3 software, The Nordic Cochrane Centre, kinson’s disease without substantial cognitive impairment, and that Copenhagen, Denmark. effect is likely to be similar in magnitude to centre-based exercise. This allows clinicians to consider the best location for intervention eAddenda: Figures 3, 5, 7, 9, 11, 13 and 15, and Appendix 1 can be based on the preference of the person with Parkinson’s disease and found online at https://doi.org/10.1016/j.jphys.2019.08.003. the resources available. It is important to note that all the home- based exercise programs were prescribed by a physiotherapist or Ethics approval: Not applicable. health professional with a degree-level qualification in exercise pre- Competing interests: Nil. scription, and the majority of the home-based exercise programs Source(s) of support: This research did not receive any specific grants from funding agencies in the public, commercial or not-for- profit sector. Acknowledgements: Nil.
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Virtual reality telerehabilitation for postural instability in Parkinson’s disease: a 41. Nieuwboer A, Kwakkel G, Rochester L, Jones D, van Wegen E, Willems AM, et al. multicenter, single-blind, randomized, controlled trial. Biomed Res Int. Cueing training in the home improves gait-related mobility in Parkinson’s disease: 2017;2017:7962826. the RESCUE trial. J Neurol Neurosurg Psychiatry. 2007;78:134–140. 15. King LA, Wilhelm J, Chen Y, Blehm R, Nutt J, Chen Z, et al. Effects of group, indi- 42. Song J, Paul SS, Caetano MJD, Smith S, Dibble LE, Love R, et al. Home-based step vidual, and home exercise in persons with Parkinson disease: a randomized clinical training using videogame technology in people with Parkinson’s disease: a single- trial. J Neurol Phys Ther. 2015;39:204–212. blinded randomised controlled trial. Clin Rehabil. 2018;32:299–311. 16. Klamroth S, Steib S, Devan S, Pfeifer K. Effects of exercise therapy on postural 43. Stack E, Roberts H, Ashburn A. The PIT SToPP trial: a feasibility randomised instability in Parkinson disease: a meta-analysis. J Neurol Phys Ther. 2016;40:3–14. controlled trial of home-based physiotherapy for people with Parkinson’s disease using video-based measures to preserve assessor blinding. Parkinsons Dis. 17. Caglar AT, Gurses HN, Mutluay FK, Kiziltan G. Effects of home exercises on motor 2012;2012:360231. performance in patients with Parkinson’s disease. Clin Rehabil. 2005;19:870–877. 44. Peto V, Jenkinson C, Fitzpatrick R, Greenhall R. The development and validation of a 18. Chivers Seymour K, Pickering R, Rochester L, Roberts HC, Ballinger C, Hulbert S, short measure of functioning and well being for individuals with Parkinson’s et al. Multicentre, randomised controlled trial of PDSAFE, a physiotherapist- disease. Qual Life Res. 1995;4:241–248. delivered fall prevention programme for people with Parkinson’s. J Neurol Neuro- surg Psychiatry. 2019;90:774–782. 45. Jenkinson C, Fitzpatrick R, Peto V, Greenhall R, Hyman N. The PDQ-8: development and validation of a short-form Parkinson’s disease questionnaire. Psychol Health. 19. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the 1997;12:805–814. PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83:713–721. 46. De Boer A, Wijker W, Speelman J, De Haes J. Quality of life in patients with Par- kinson’s disease: development of a questionnaire. J Neurol Neurosurg Psychiatry. 20. Godi M, Franchignoni F, Caligari M, Giordano A, Turcato AM, Nardone A. Com- 1996;61:70–74. parison of reliability, validity, and responsiveness of the mini-BESTest and Berg Balance Scale in patients with balance disorders. Phys Ther. 2013;93:158–167. 47. EuroQol Group. EuroQol-a new facility for the measurement of health-related quality of life. Health Policy. 1990;16:199–208. 21. Leddy AL, Crowner BE, Earhart GM. Functional gait assessment and balance eval- uation system test: reliability, validity, sensitivity, and specificity for identifying 48. Haapaniemi T, Sotaniemi K, Sintonen H, Taimela E. The generic 15D instrument is individuals with Parkinson disease who fall. Phys Ther. 2011;91:102–113. valid and feasible for measuring health related quality of life in Parkinson’s disease. J Neurol Neurosurg Psychiatry. 2004;75:976–983. 22. Huang S-L, Hsieh C-L, Wu R-M, Tai C-H, Lin C-H, Lu W-S. Minimal detectable change of the timed up & go test and the dynamic gait index in people with Par- 49. Hass CJ, Bishop M, Moscovich M, Stegemöller EL, Skinner J, Malaty IA, et al. kinson disease. Phys Ther. 2011;91:114–121. Defining the clinically meaningful difference in gait speed in persons with Par- kinson disease. J Neurol Phys Ther. 2014;38:233–238. 23. Qutubuddin AA, Pegg PO, Cifu DX, Brown R, McNamee S, Carne W. Validating the Berg Balance Scale for patients with Parkinson’s disease: a key to rehabilitation 50. van Uem JM, Marinus J, Canning C, van Lummel R, Dodel R, Liepelt-Scarfone I, et al. evaluation. Arch Phys Med Rehabil. 2005;86:789–792. Health-related quality of life in patients with Parkinson’s disease a systematic review based on the ICF model. Neurosci Biobehav Rev. 2016;61:26–34. 24. Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, et al. A short physical performance battery assessing lower extremity function: associ- 51. Wallann MB, Hagstromer M, Conradsson D, Sorjonen K, Franzen E. Long-term ef- ation with self-reported disability and prediction of mortality and nursing home fects of highly challenging balance training in Parkinson’s disease – a randomized admission. J Gerontol. 1994;49:M85–M94. controlled trial. Clin Rehabil. 2018;32:1520–1529. 52. Bloem BR, Marinus J, Almeida Q, Dibble L, Nieuwboer A, Post B, et al. Measurement instruments to assess posture, gait, and balance in Parkinson’s disease: Critique and recommendations. Mov Disord. 2016;31:1342–1355.
Journal of Physiotherapy 65 (2019) 183–185 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Editorial Improving musculoskeletal pain care for Australia’s first peoples: better communication as a first step Ivan Lin a, Charmaine Green a, Dawn Bessarab b a Western Australian Centre for Rural Health, University of Western Australia, Geraldton; b Centre for Aboriginal Medical and Dental Health, University of Western Australia, Perth, Australia In Australia there are stark disparities in a range of health and physiotherapists — such as facilitating self-management, exercise and socioeconomic indices between Aboriginal and non-Aboriginal Aus- activity — are recommended for musculoskeletal pain care3 and can tralians.1 Musculoskeletal pain amongst Aboriginal Australians has prevent the development of other chronic conditions or mitigate their received less attention than other health conditions, yet the preva- impact.9 lence and burden are high, access to care is relatively low, and the quality of care is suboptimal.2 Evidence for effective musculoskeletal Effective communication is critical for musculoskeletal pain pain management increasingly supports the type of care that phys- outcomes and access to care iotherapists provide.3 Better access to physiotherapy could reduce the burden of musculoskeletal pain for Aboriginal people and commu- Effective communication is fundamental to healthcare in- nities. Better engagement by physiotherapists in Aboriginal muscu- terventions and results in better outcomes for patients and clini- loskeletal pain care should be a priority. cians.10 In pain care, effective communication is critical. Aside from allowing accurate diagnoses to be made and increasing patient Access to care is influenced by a range of geographical, financial, concordance with care, more effective communication is associated social and cultural factors;4 however, there is increasing awareness with small but significant reductions in patients’ pain.11 Therefore, about the role of interpersonal factors, including patient/practitioner effective communication underpins high-quality musculoskeletal communication, in facilitating or impeding access.5 A simple and pain management. practical step that physiotherapists can take to improve care quality and enhance access for Aboriginal people with musculoskeletal pain Ineffective communication is a problem and consistently re- is to focus on the effectiveness of their communication. Arguably, ported as one of the biggest barriers for Aboriginal people when ineffective communication is the biggest barrier for Aboriginal people accessing healthcare.12–14 Communication issues include: clinicians with musculoskeletal pain when seeking care. Re-framing patient using medical jargon and not involving patients in decision- communication as a ‘clinical yarn’6 has the potential to improve ac- making; language barriers; a failure to use interpreters when cess to physiotherapy care and outcomes for Aboriginal people with needed; patients’ experiences of racism and prejudicial care; and musculoskeletal pain. divergent perspectives on health between Aboriginal patients and clinicians.12–14 Suboptimal communication is a primary reason why Musculoskeletal pain is an important and poorly recognised issue Aboriginal people with low back pain14 and other health condi- in Aboriginal healthcare tions12,13 choose to walk away from healthcare. Ineffective communication is a barrier to Aboriginal people with musculo- Like a number of health concerns, the prevalence of musculo- skeletal pain receiving high-value care and accessing care.3 A skeletal pain conditions is higher amongst Aboriginal Australians practical and relatively straightforward step for physiotherapists to when compared with non-Aboriginal Australians. The rate of back improve musculoskeletal pain care and encourage better access to pain is 1.1 times higher, osteoarthritis is 1.2 to 1.5 times higher, and care is to improve their communication. rheumatoid arthritis is 1.0 to 2.0 times higher.2 The overall burden due to musculoskeletal pain conditions is also higher: 1.4 times that Clinical yarning: a framework for communication in Aboriginal of the non-Aboriginal population.7 Aboriginal people are potentially healthcare at higher risk of disabling musculoskeletal pain because disabling musculoskeletal pain conditions often co-exist with other health Clinical yarning is a framework and some tools with which to help conditions and are associated with socioeconomic disadvantage.7,8 physiotherapists and other clinicians communicate with Aboriginal Despite this, access to care is low. For example, Aboriginal people patients. For Aboriginal people, having a yarn means having a talk in a with hip and knee osteoarthritis access primary care at around half way that is relaxed, reciprocal and mutual.15 A number of studies the rate of non-Aboriginal people (3.2 versus 6.5 per 1000 encounters have reported that Aboriginal patients prefer yarning approaches to for knee osteoarthritis, 1.2 versus 2.3 per 1000 encounters for hip communication in healthcare.14,16 Clinical yarning combines Aborig- osteoarthritis) and rates are lower again for hip/knee arthroplasty.2 inal communication preferences for yarning with the clinical Although there are limited data for other musculoskeletal pain communication needed to provide healthcare. Clinical yarning re- conditions or physiotherapy, access to care is likely to be similarly frames clinical communication as a social, diagnostic and manage- low. This is problematic because interventions provided by ment yarn. An open-access article outlining the clinical yarning https://doi.org/10.1016/j.jphys.2019.08.008 1836-9553/© 2019 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/).
184 Editorial framework is available.6 This editorial provides an overview and can be challenging as it requires effort, reflection and persistence. The highlights the skills relevant to physiotherapists. most common strategy used is education.19 Behavioural skills ap- proaches that involve active, practice-based learning such as role play, In a practitioner-centric patient interview, a physiotherapist feedback and small-group discussions are most effective.20 As clinical might have in their mind a list of the information content they yarning combines clinical and cultural perspectives, education programs need to gather (eg, the location and nature of pain) and then should be facilitated by people with cultural and clinical knowledge. Co- proceed to question the patient in order to gather information (eg, facilitation by an Aboriginal person (cultural knowledge) and physio- ‘What is your pain like?’). In a clinical yarning approach, the topic therapist (clinical knowledge) is recommended, although an Aboriginal of the consultation is the same (eg, the patient’s pain) but the physiotherapist could possess both these areas of knowledge. Facilita- process is different. In the first instance, the physiotherapist tor(s) should also have knowledge of the clinical yarning framework and chooses to engage in a way that is more patient-friendly and at the skills to facilitate clinical communication education through small- forefront is the intention to develop a respectful and trusting group adult learning, role play and feedback. relationship. The primary way of doing this is the social yarn. A social yarn may or may not have direct relevance to the reason Introducing clinical yarning education programs into physio- why the person is there and it may be non-existent, brief, or therapy education, and researching the impact, are future priorities. extensive; it depends on cues provided by the patient. Topics for a One perception is that clinical yarning consultations will take more social yarn could include where each party (physiotherapist and time; however, research suggests that patient-centred communica- patient) are from, the weather, other seasonal factors, shared ac- tion is more time efficient.10 This is consistent with experience that quaintances, recent community events, and sport; the topic de- clinical yarning facilitates a more efficient exchange of information pends on the patient and the skills of the physiotherapist to and allows deeper insights into a person’s health situation. More recognise social yarning cues and engage the patient with genuine development and investigation of clinical yarning is needed. Current interest about them as a person. Typically, skills to facilitate the work is, in part, addressing this, including developing an eLearning social yarn include: introducing oneself respectfully; being program to introduce learners to the knowledge/theory aspect of welcoming, open and friendly; finding common ground; sharing clinical yarning; however, there is more work to be done. information about yourself; positive non-verbal communication; demonstrating an awareness of local Aboriginal culture (eg, sea- Further considerations sonal factors); and giving attention to the patient’s physical comfort. Although clinical yarning is an important way to overcome communication-related barriers to high quality musculoskeletal pain The second part of clinical yarning is the diagnostic yarn. The aim of care, physiotherapists should be cognisant of other potential barriers, this is to gather the necessary information upon which to base clinical including: institutional racism and discrimination; mistrust of health decisions. The diagnostic yarn should feel like a comfortable conver- services; inadequate Aboriginal health staff; and financial barriers.5,21 sation as opposed to a question/answer session, which may Providing musculoskeletal pain care in partnership with Aboriginal be considered impolite and during which patients may feel interro- Community Controlled Health Services has the potential to improve gated.12 In a diagnostic yarn the physiotherapist aims to facilitate a access to care by addressing a number of institutional barriers.2 narrative telling of the patient’s health story. The skills favoured in the diagnostic yarn include: open-ended questions with non-judgmental Conclusion deep listening; allowing silence for the patient to think about their response; recognising and responding to verbal and non-verbal patient In Australia, striving for equitable musculoskeletal pain health cues; providing empathy; and utilising techniques to validate the pa- includes recognising and addressing the unmet burden of musculo- tient’s story and encourage further disclosure such as summarising, skeletal pain in Aboriginal communities. Whilst a comprehensive paraphrasing, prompting, and affirming (eg, nodding). approach is multilevel, the first step — and a simple and practical way for physiotherapists to improve the quality of and access to care — is The final part of clinical yarning is the management yarn. The aim to improve the effectiveness of communication. Clinical yarning of the management yarn is to explain health information in a way provides a framework and some tools for physiotherapists to do this. that makes sense to the patient and that allows them to engage in Such approaches should be adopted if the disproportionate burden is their management. The skills in the management yarn include: to be addressed. checking the patient’s initial understanding about their health issue; explaining health information in a direct and ‘straight up’ manner Ethics approval: Not applicable. without jargon; and using contextually suitable explanatory aids such Competing interests: The authors declare that they have no as metaphors, models, or visual/audiovisual aids. Most importantly, competing interests. the patient is involved in coming to solutions about their manage- Source(s) of support: Ivan Lin is supported by an Australian Na- ment. For example, a suitable metaphor for a patient who has me- tional Health and Medical Research Council Early Career Fellowship chanical knowledge might be to relate a stiff osteoarthritic knee to an (APP1090403). engine part: Acknowledgements: Nil. Provenance: Not invited. Peer reviewed. Physiotherapist: Think of your knee like an engine. How can we stop Correspondence: Ivan Lin, Western Australian Centre for Rural an engine seizing up? Patient: Run it regularly. Keep it moving. Phys- Health, University of Western Australia, Geraldton, Western Australia, iotherapist: That’s right. What do you think you can do to help your Australia. Email: [email protected] knee? Patient: Keep it moving or move it more. Keep it running! Phys- iotherapist: Yes! Let’s talk about options to do that. References Yarning approaches are becoming more widely used in Aboriginal 1. Australian Institute of Health and Welfare (AIHW). Australia’s health 2016. Aus- health research, healthcare delivery, health promotion, and commu- tralia’s health series no. 15. Canberra: AIHW; 2016. nity engagement.15,17,18 Clinical yarning is a patient-centred commu- nication framework in the (cultural) context of Aboriginal healthcare 2. Lin IB, et al. Arthritis Care Res. 2018;70:1335–1347. and aligns with other patient-centred communication approaches 3. Lin I, et al. Br J Sports Med. 2019:bjsports-2018-099878. that are supported by research.10 4. Davy C, et al. Int J Equity Health. 2016;15:163. 5. Peiris D, et al. Can Med Assoc J. 2008;179:985–986. Implementing clinical yarning in musculoskeletal pain 6. Lin I, et al. Aust J Prim Health. 2016;22:377–382. physiotherapy 7. Australian Institute of Health and Welfare (AIHW). The burden of musculoskeletal Although we have said clinical yarning is a simple strategy for conditions in Australia: A detailed analysis of the Australian Burden of Disease Study physiotherapists to adopt, in reality improving clinical communication 2011. Canberra: Australian Institute of Health and Welfare; 2017. 8. Schofield DJ, et al. Spine J. 2015;15:34–41. 9. Williams A, et al. BMC Med. 2018;16:167.
Editorial 185 10. Silverman J, et al. Skills for communicating with patients. Boca Raton: CRC Press; 16. Jennings W, et al. Aust J Prim Health. 2018;24:109–115. 2016. 17. Fletcher G, et al. Health Policy. 2011;103:92–97. 18. Towney LM. Int J Narrative Ther Community Work. 2005;1:39–43. 11. Finset A. Patient Educ Couns. 2018;101:175–176. 19. Dwamena F, et al. Cochrane Database Syst Rev. 2012;12:CD003267. 12. Cass A, et al. Med J Aust. 2002;176:466–470. 20. Berkhof M, et al. Patient Educ Couns. 2011;84:152–162. 13. Shahid S, et al. Med J Aust. 2009;190:574–579. 21. Artuso S, et al. BMC Health Serv Res. 2013;13:83. 14. Lin I, et al. Aust Fam Physician. 2014;43:320–324. 15. Bessarab D, Ng’andu B. Int J Crit Indig Stud. 2010;3:37–50.
Journal of Physiotherapy 65 (2019) 200–207 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Research Motor imagery training improves balance and mobility outcomes in older adults: a systematic review Vaughan Nicholson a, Naomi Watts b, Yannick Chani b, Justin WL Keogh b,c,d a School of Allied Health, Australian Catholic University, Brisbane, Australia; b Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia; c Human Potential Centre, AUT University, Auckland, New Zealand; d Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India KEY WORDS ABSTRACT Rehabilitation Question: Does motor imagery training improve measures of balance, mobility and falls in older adults Gait without a neurological condition? Design: Systematic review and meta-analysis of randomised controlled Motor skills trials. Participants: Adults aged at least 60 years and without a neurological condition. Intervention: Three Postural balance or more sessions of motor imagery training. Outcome measures: The primary outcomes were balance Aged measures (such as single leg stance and Berg Balance scale) and mobility measures (such as gait speed and the Timed Up and Go test). Falls were a secondary outcome measure. Risk of bias was evaluated using the PEDro Scale, and overall quality of evidence was assessed using the Grades of Research, Assessment, Development and Evaluation (GRADE) approach. Results: Twelve trials including 356 participants were included in the systematic review and 10 trials (316 participants) were included in the meta-analyses. All trials included either apparently healthy participants or older adults after orthopaedic surgery. There was evidence that motor imagery training can significantly improve balance (SMD 1.03, 95% CI 0.25 to 1.82), gait speed (MD 0.13 m/s, 95% CI 0.04 to 0.22) and Timed Up and Go (MD 1.64 seconds, 95% CI 0.79 to 2.49) in older adults; however, the quality of evidence was very low to low. No data regarding falls were identified. Conclusion: Motor imagery training improves balance and mobility in older adults who do not have a neurological condition. These results suggest that motor imagery training could be an adjunct to standard physiotherapy care in older adults, although it is unclear whether or not the effects are clinically worthwhile. Trial registration: PROSPERO CRD42017069954. [Nicholson V, Watts N, Chani Y, Keogh JWL (2019) Motor imagery training improves balance and mobility outcomes in older adults: a systematic review. Journal of Physiotherapy 65:200–207] © 2019 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/). Introduction Motor imagery is the imagining of an action without its physical execution14 and motor imagery elicits activity in brain regions that Age-related deteriorations in balance and mobility contribute to are normally activated during actual task performance.15 During disability, falls and mortality,1 and place greater strains on the healthcare system. Allied health professionals such as physiothera- motor imagery, also known as ‘mental practice’, the mental imagery pists are faced with increased geriatric admission rates2 and work- of the movement or task to be learned is systematically repeated.16 load pressures3 to ensure adequate rehabilitation for their older patients via targeted balance, strength and functional training.4,5 The potential benefits of motor imagery as a rehabilitation tool for Unfortunately, such training may produce smaller benefits or be unfeasible for certain patient groups, such as those with enforced older adults relies on the ability of motor imagery training to promote immobilisation6 or recently discharged from hospital.7 Furthermore, motor learning17 and enhance cortical excitability.18 The use of motor even for older adults able to undertake appropriate exercise reha- bilitation, there are additional barriers such as poor exercise imagery is particularly appealing for older patient groups that may be compliance8,9 and anxiety relating to unsupervised exercise.10,11 Importantly, the last decade has seen growth in the use of less unable to undertake traditional exercise training due to weakness, physically demanding interventions, such as motor imagery, that may surgical restrictions or immobilisation.19 improve a range of functional outcomes in older populations, including balance and mobility,12,13 while potentially minimising Most motor imagery research has been conducted in patients with some of the barriers identified with traditional exercise interventions. neurological conditions, as is evident in systematic reviews of trials in stroke12,20 and Parkinson’s disease.13 These reviews have helped to inform training recommendations for these groups.12,13,20 Within these reviews, motor imagery has been shown to promote motor planning20 and improve upper limb function,12,20 mobility12 and balance.12 Furthermore, motor imagery has recently been shown to be more effective when used in conjunction with action observation https://doi.org/10.1016/j.jphys.2019.08.007 1836-9553/© 2019 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/).
Research 201 Box 1. Inclusion criteria. listed in Box 1. Furthermore, the detail of motor imagery training dosage (time per session, weeks of training) and information relating Design to the activities trained needed to be reported. A two-stage screening Randomised controlled trials process was used to select relevant trials for this review. In the first stage, two reviewers (NW and YC) independently considered infor- Participants mation from the titles and abstracts and excluded clearly irrelevant Adults with a mean age of at least 60 years and without a studies. In the second stage, the full text for each potentially eligible neurological condition study was retrieved and assessed against the eligibility criteria by two independent reviewers (NW and YC). Disagreements were resolved Intervention by discussion with a third reviewer (VN or JK). A motor imagery intervention (with or without an action observation intervention) performed on at least three Assessment of characteristics of studies occasions Sufficient reporting of dose (eg, time per session, sessions Study quality completed, weeks of training) Study quality was assessed using the PEDro Scale by downloading Outcome measures the available scores from the PEDro database. If a study had not been At least one objective measure of mobility or balance at rated on the PEDro database, it was assessed independently by two baseline and follow-up authors (NW and YC).28 The total score on the PEDro Scale is the addition of ‘yes’ (criterion is clearly satisfied) responses for Items 2 to Comparisons 11 (Item 1 is not used for calculation of the total PEDro Scale as it Motor imagery versus either no intervention or placebo/ relates to external validity). The 10 criteria contribute 1 point each, sham intervention thereby providing a score range of 0 to 10. A PEDro score of 6 out of Motor imagery plus additional intervention (eg, usual care) 10 was considered to represent high quality.29 The PEDro score is a versus the additional intervention only (eg, usual care only) valid measure of methodological quality and completeness of reporting, and has moderate levels of inter-rater reliability.30,31 for balance activities.21 Action observation, like motor imagery, is a motor simulation technique22 that involves an individual watching Participants motor actions performed by someone else, leading to the activation of Trials were included if the mean age of the trial participants was at the same neural structures responsible for the execution of those same actions.23 least 60 years. Studies that included participants who were regarded as apparently healthy or were recovering from elective orthopaedic To date, no systematic review has assessed the impact of motor surgery were eligible. Studies that included participants with a imagery training on balance and mobility in non-neurological older neurological condition such as stroke or Parkinson’s disease were adult participants. Inspection of the literature reveals that a wide ineligible. variety of motor imagery intervention protocols have been utilised for older adults, with differences in training duration, imagery type, Intervention frequency of exposure, and tasks trained, as well as outcome mea- To be eligible for inclusion, trials had to evaluate a motor imagery sures identified. There are also many examples of methodological concerns among these studies24,25 and conflicting findings regarding training intervention targeting balance or mobility. The intervention the effects of motor imagery training on balance and mobility in older had to include multiple motor imagery training sessions. Trials were adults.25,26 These issues within the motor imagery literature make it included if they used motor imagery as an intervention in isolation or difficult to observe the overall effectiveness of motor imagery for if motor imagery was used as an intervention in addition to standard improving balance and mobility in older adults. care. Motor imagery interventions that included the combination of motor imagery and action observation (observing a video or Therefore, the research question for this systematic review and demonstration of an activity) were also included. meta-analysis is: Outcomes measures Does motor imagery training improve measures of balance, To be eligible for inclusion, trials had to report on a post- mobility and falls in older adults without a neurological condition? intervention objective outcome measure of balance or mobility. For this review, balance outcomes included static (eg, single leg stance) Method and dynamic measures of balance (eg, four step square test) as well as tasks that required participants to walk with a narrow base of support This systematic review adhered to the statement for reporting (eg, tandem type walking) or stepping on pre-determined targets (eg, systematic reviews and meta-analyses of studies that evaluate obstacle course). Mobility outcomes were limited to tasks that pri- healthcare interventions (PRISMA)27 and was prospectively marily involved normal straight-line walking with no restraint on registered. stance width or obstacle avoidance, such as the timed 10-m walk test or the Timed Up and Go test (TUG). The incidence of falls was also Identification and selection of studies included as a secondary outcome measure. A comprehensive search of five electronic databases (Medline, Comparison EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro), and The contrast between the randomised interventions was required PsychINFO) was performed from the earliest records to January 2019. The search strategy was based around synonyms and subject head- to be motor imagery versus no intervention or sham intervention. ings of the key concepts of motor imagery and older adults combined Studies with co-interventions were included provided the with the primary outcomes relating to balance and mobility. The co-intervention was delivered to both groups (eg, motor imagery plus detailed search strategy for each database is presented in Appendix 1 usual care versus usual care). (see eAddenda for Appendix 1). The database searches were sup- plemented by reference checks of the included articles. Studies Data analysis published in English and French were included; those in any other language were noted but excluded from analyses. A customised data extraction table was applied to each eligible trial by one of two study authors (NW or YC) and extracted data were Trials assessing the effectiveness of motor imagery on balance and checked for accuracy and completeness by a senior author (VN or JK). mobility outcomes were included if they met the inclusion criteria The extracted data included information regarding study design, participants (age, gender), intervention (type of imagery, frequency of
202 Nicholson et al: Motor imagery training in older adults Records identified Meta-analysis was completed using RevMan32 version 5.3 to database searches (n = 3449) provide evidence of the pooled effect size of the motor imagery in- other sources (n = 1) terventions. Heterogeneity was tested with chi-square measured by inspection of the I2 values that described the percentage of the Records excluded variability in effect estimates that was due to heterogeneity rather duplicates (n = 1070) than sampling error. A fixed-effect model was used if the I2 value was ineligible based on title and abstract 50% and a random-effects model was used if the I2 value was . (n = 2328) 50%. Additionally, where substantial (. 50%) heterogeneity was observed,36 sensitivity analyses were conducted to check whether the Full-text articles assessed for eligibility (n = 52) heterogeneity was caused by a single study. In this case, the leave- one-out approach was performed by removing the outlying study. Excluded after full text evaluation (n = 40) no balance or mobility outcome (n = 15) The overall quality of evidence was assessed for each intervention not randomised (n = 8) contrast and rated as high, moderate, low, or very low, as recom- non-training study (n = 6) mended by the Grading of Recommendations Assessment, Develop- action observation only (n = 3) ment and Evaluation (GRADE) system.37 The GRADE classification was non-English or French language (n = 3) downgraded one level per study flaw, from high quality, if any of the no comparator (n = 2) following flaws were present: design limitation (if the majority of too young (n = 1) studies in the meta-analysis had a PEDro score , 6); inconsistency of not healthy (n = 1) results (substantial heterogeneity, I2 . 50%) and imprecision based on single session only (n = 1) small samples (, 400 for each pooled outcome). This review did not consider the indirectness criterion because the eligibility criteria Studies included in qualitative synthesis (n = 12) ensured a specific population with relevant outcomes. In addition, the Studies included in meta-analysis (n = 10) review did not assess publication bias due to insufficient study numbers (ie, , 10 studies per meta-analysis). Sensitivity analyses Sensitivity analyses were conducted to examine the robustness of the primary meta-analyses for balance and mobility measures. The sensitivity analyses explored the effect of including only high-quality (PEDro 6) studies in the analysis, to account for methodological aspects that may bias the overall result. Results Figure 1. Flow of studies through the review. Flow of studies through the review sessions, setting, supervision), comparison group characteristics The electronic database search resulted in a yield of 3449 articles, (standard care, sham imagery, no training), outcome measures and which was reduced to 2380 after duplicates were removed. Following main findings. title and abstract screening, 52 articles were obtained in full text and further assessment reduced the yield to 12 articles that were included Means and standard deviations for post-intervention outcomes in the systematic review (Figure 1). Ten studies were included in the (all continuous variables) were entered in Review Manager meta-analysis, with two studies not included in the meta-analysis (RevMan)32 software, version 5.3. Some outcome measures for due to insufficient post-intervention data.25,38 mobility and balance function indicate improvement by increases in values (eg, gait speed) while others indicate improvement by de- Characteristics of studies creases in values (eg, TUG time). To adjust for the different outcome directions, for those outcomes that report improvement with Quality decreasing values, the values were transformed by multiplying the The mean score of the included trials was 4.8 (SD 1.6) on the values by 21. Raw data (means and SD) of post-intervention data were extracted from each paper. Authors were contacted if there PEDro Scale. Four39–42 of the 12 included studies were regarded as were insufficient published data for analysis. high-quality studies as they had PEDro scores of 6. Blinding, con- cealed allocation and intention-to-treat analysis were the main items Balance and mobility measures were analysed separately because, susceptible to bias amongst the included studies. The PEDro Scale although mobility requires inherent dynamic balance,33 these out- responses for individual items and the total score for each included comes may assess different aspects of function relevant to the older randomised controlled trial are presented in Table 1. adult. For this review, balance outcomes included static and dynamic measures of balance as well as tasks that required participants to Participants walk with a narrow base of support or stepping on pre-determined The 12 included studies were conducted between 1985 and 2018, targets. Mobility was defined as the ability to move independently from one point to another34 and included tasks that primarily and involved 356 participants (Table 2). The mean age of participants involved normal straight-line walking or stair climbing (eg, timed 10- among the included studies ranged from 64 to 79 years. The majority m walk test, TUG, stair climb test) as these assessments are widely of participants were female (66%). Eight studies24–26,38,42–45 assessed used to quantify mobility capabilities in older adults.35 apparently healthy older adults, three studies39,40,46 assessed older adults following non-traumatic orthopaedic surgery (knee or hip For balance, due to differences in outcomes assessed and mea- arthroplasty), and one study assessed apparently healthy older adults surement scales used between studies, the standardised mean dif- with a fear of falling.41 ference (SMD) with 95% CI was calculated for each study and then pooled to compare the control and intervention groups. For mobility Intervention measures, gait speed and TUG were assessed across multiple studies; All trials included at least three sessions of motor imagery training therefore, mean differences (MD) with 95% CI were calculated for gait speed and TUG, so a clinically meaningful unit (eg, gait speed in m/s (Table 2). Motor imagery training was undertaken in the home in four or time to complete the TUG in seconds) could be presented. trials,25,41,42,45 in a clinic or laboratory setting in four trials,24,38,43,44 in a hospital then at home in three trials,39,40,46 and in a library for one
Research 203 Table 1 PEDro criteria and scores for included trials (n = 12). Study Random Concealed Groups Participant Therapist Assessor , 15% Intention Between- Point Total allocation allocation similar at blinding blinding blinding dropouts -to-treat group estimate and (0 to 10) baseline analysis N N N Y difference variability 3 Batson26 Y NN N N Y N Y reported reported 5 Chiacchiero38 YNY N Y Y N N 5 N N N Y N N N 5 Fansler24 Y NN N N N N N Y Y 2 N Y Y N N Y Y 7 Goudarzian43 YNY Y N N Y N Y Y 6 N N N Y N Y N 6 Hamel and Lajoie25 Y N N N N N N Y Y Y 4 N N N N N Y Y 3 Jacobson39 YYY N N N Y N Y Y 7 N N N Y Y Y Y 4 Kim41 YNY N Y Y Linden42 YNY Y Y Y Y Marusic46 YNY Moshref-Razavi44 Y N N Moukarzel40 YYY Tunney45 Y NN N = no, PEDro = Physiotherapy Evidence Database, Y = yes. trial.26 Motor imagery was delivered via audio guidance in six Mobility studies,25,26,38,39,41,42 where participants listened to pre-recorded in- The influence of motor imagery on mobility was assessed with structions. Four studies24,40,43,44 used trainer-guided motor imagery, which involved a trainer (eg, a physiotherapist) reading a motor separate meta-analyses for gait speed and TUG, to allow for presen- imagery script in real time to guide participants’ imagery practice. tation of results as mean difference in their respective units. One study used independent motor imagery that was preceded by initial training and written instructions,45 and one study used video- Meta-analysis of three studies with a total of 107 participants guided motor imagery (combined action observation with motor provided low-quality evidence that motor imagery had a positive imagery).46 Motor imagery interventions ranged from three sessions effect on gait speed when compared with controls (MD 0.13 m/s, 95% conducted over consecutive days24 to seven sessions per week for 6 CI 0.04 to 0.22, I2 = 0%) (Figure 4, see also Figure 5 on the eAddenda weeks.25 Three studies prescribed three sessions per week for 8 for a detailed forest plot). The evidence was low quality due to design weeks.43,44,46 The duration of motor imagery sessions ranged from , limitations (two of three trials had PEDro of , 6) and imprecision 30 seconds45 to 30 minutes25,46 including rest breaks. The total time (sample size , 400). spent performing motor imagery training over the course of the in- terventions ranged from 2 minutes45 to 21 hours.25 The tasks trained Meta-analysis of six studies with a total of 175 participants pro- during the motor imagery interventions included static stand- vided low-quality evidence that motor imagery had a positive effect ing,24,25,38,44 rising from a chair,26 mobility tasks such as the TUG,43 on time to complete the TUG when compared with controls (MD 1.64 walking,39,41,46 stairs39,45,46 and obstacle course.42 The tasks trained seconds, 95% CI 0.79 to 2.49, I2 = 0%) (Figure 6, see also Figure 7 on the in all but one study40 included tasks that closely matched an outcome eAddenda for a detailed forest plot). The evidence was low quality measure of balance or mobility assessed after the intervention. In the due to design limitations (four of six trials had PEDro of , 6) and other study, participants were instructed to imagine muscle con- imprecision (sample size , 400). tractions and knee joint movements following knee joint surgery.40 Falls Adherence None of the eligible studies reported data on falls incidence. Adherence to motor imagery was poorly reported and was only Sensitivity analyses explicitly measured in one study. In that 5-week program, 90% of A sensitivity analysis could only be conducted for the TUG, as participants reported listenening to the imagery tracks as prescrbed during the preoperative and postoperative periods.39 there was only one high-quality study within the overall meta- analysis for both balance and gait speed. When only high-quality Effects of motor imagery on balance and mobility outcomes trials (PEDro score 6) were included in the meta-analysis for the TUG (n = 2, total of 111 participants), motor imagery still had a pos- Balance itive effect on time to complete TUG compared with controls (MD Meta-analysis of six studies with a total of 114 participants pro- 1.67 seconds, 95% CI 0.50 to 2.83, I2 = 0%) (Figure 8, see also Figure 9 on the eAddenda for a detailed forest plot). vided very low-quality evidence that motor imagery had a positive effect on balance when compared with controls (SMD 1.03, 95% CI Discussion 0.25 to 1.82, I2 = 67%) (Figure 2, see also Figure 3 on the eAddenda for a detailed forest plot). The evidence was downgraded from high This systematic review provides evidence that motor imagery quality to very low quality due to design limitations (five of six can improve measures of balance and mobility, such as gait trials had PEDro of , 6), imprecision (sample size , 400) and sub- speed, in neurologically normal older adults. These findings stantial heterogeneity (I2 = 67%) (Table 3). Due to substantial het- partly align with a recent systematic review and meta-analysis of erogeneity (I2 . 50%), a sensitivity analysis was performed, which data from stroke patients, which also identified improvements in revealed that the pooled estimate was most influenced by one balance and mobility outcomes following motor imagery study.26 When this study was removed, heterogeneity remained training.12 Encouragingly, the meta-analyses for gait speed and substantial (I2 = 58%). When this outlying study was omitted, the TUG had mean differences that would be considered clinically pooled result remained significant (SMD 1.18, 95% CI 0.52 to 1.85, I2 = worthwhile. The mean difference of 0.13 m/s for gait speed ex- 58%) in favour of motor imagery training. ceeds the estimated level of substantial change (0.1 m/s) for older adults47,48 and aligns with the minimal detectable change identified for short-term rehabilitation in older adults.49
204 Nicholson et al: Motor imagery training in older adults Table 2 Characteristics of the included trials. Study Participants a Motor imagery intervention Target Comparator/control group Outcome measure description; setting movement/activity description; setting trained during MI Mobility Balance Batson N = 6 apparently 20 min of physical practice Functional tasks such as 20 min physical practice TUG (s) BBS (0 to 56) (2007)26 healthy (eg, sit to stand) + 20 min rising from a chair and (eg, sit to stand) + 20 min Age (yr) = 65 to 80 audiotape-guided MI with body scanning educational control (eg, falls TUG (s) FRT forward, left, Chiacchiero Gender = 6 F visual and kinaesthetic prevention, footwear) 2/wk 10MWT (s) right (cm) (2015)38 b cueing, 2/wk for 6 wks; Standing and reaching for 6 wks; library Body sway: N= 20 apparently library tasks 10MWT (s) length (cm) and Fansler healthy Audiotape-guided MI: 20 Control group instructed velocity (cm/s) (1985)24 Age (yr) = 79 min MI, 3/wk for 4 wks; Single leg balance not to actively listen to tape, TUG (s) Single leg Gender = 3 M, 17 F clinic 3/wk for 4 wks; clinic stance (s) Goudarzian TUG TUG (s) (2017)43 N = 30 apparently Trainer-guided MI: 10 min Physical one leg balance + 10 Gait speed 6-m tandem healthy consisting of graded Static standing on a min progressive relaxation (as (m/s) Gait (s) Hamel and Age (yr) = 78 relaxation and MI over 3 d; platform per start of intervention group) TUG (s) Lajoie Gender = 30 F clinic over 3 d; clinic TUG (s) Body sway (2005)25 b N = 24 apparently Trainer-guided: 10 min Activities to facilitate Nil training, continue with (anteroposterior healthy relaxation then 5 to 8 mins mind-body connections normal daily routine Stair climbing and lateral) Jacobson Age (yr) = 68 MI, 3 d/wk for 8 wks; to promote confidence in (0 to 20) (2016)39 Gender = 24 M laboratory operated knee, plus Nil training, continue with Obstacle course N = 20 apparently Audiotape-guided: 5 min guided imagery related normal daily routine with narrow gait Kim healthy relaxation followed by 30 to standing posture, and balance (2012)41 Age range (yr) = 65 kinaesthetic MI, 7/wk for walking and stairs 20 min commercially available reactions (0 to 20) to 90 6 wks; home Guided relaxation and audio recordings (poetry, short Four Step Square Linden Gender = 6 M, 14 F progressively challenging stories); 7 x/wk for 5 wks Test (s) (1989)42 N = 58 post- Audiotape-guided MI with locomotor tasks such as (2 wks preop, 3 wks postop); orthopaedic surgery background relaxation walking in the house hospital and home Marusic Age (yr) = 65 (8) music; 20 mins, 7/wk for and on an icy road (2018)46 Gender = NR 5 wks (2 wks preop, Obstacle course Audiotape-guided relaxation 3 wks postop); hospital and music: 10 to 15 mins, Moshref-Razavi N = 91 apparently and home Locomotor tasks such as 2/wk for 6 wks; home (2017)44 healthy, with FoF normal walking, stair Age (yr) = 76 Audiotape-guided climbing, walking on Memory games; 6 mins daily Moukarzel Gender = 35 M, 56 F relaxation and MI: narrow surfaces for 8 d; home (2017)40 10 to 15 mins, N = 23 apparently 2/wk for 6 weeks; Single leg balance Standard physical rehabilitation Tunney healthy home plus watching documentary (2006)45 Age (yr) = 67 to 90 Audiotape-guided: 6 mins Muscle contractions and videos; 3/wk for 8 wks; hospital Gender = 23 F daily for 8 d to assist with knee joint movement and home imagining walking up a N = 21 post- ramp, balance beam and Ascending/descending Nil training, continue with orthopaedic surgery step off; home stairs with a 4-point normal daily routine Age (yr) = 64 Standard physical stick Gender = 14 M, 7 F rehabilitation + video- 60 min physical guided (action observation) rehabilitation (passive N = 24 apparently followed by MI: 30 mins, ROM, quads strength, healthy 3/wk for 8 wks; hospital gait re-ed), 3/wk for 4 wks; Age (yr) = 60 to 82 and home hospital and home Gender = NR Trainer-guided: 10 min N = 20 post- relaxation, 15 min MI, Nil training, continue with orthopaedic 3/wk for 8 wks; normal daily routine surgery laboratory Age (yr) = 69 60 min physical Gender = 4 M, 16 F rehabilitation (passive ROM, quads strength, gait N = 19 apparently re-ed) + 15 min healthy trainer-guided MI; Age (yr) = 76 3/wk for 4 wks; Gender = 6 M, 13 F hospital and home Participant derived with a live demonstration and scripted verbal instruction: 4 sessions over 48 hours; home BBS = Berg Balance Scale, F = female, FoF = fear of falling, FRT = Functional reach test, M = male, MI = motor imagery, NR = not reported, TUG = Timed Up and Go test, 10MWT = 10-m walk test, re-ed = re-education, ROM = range of motion. a Age is presented as mean, mean (SD), or range. b Not included in meta-analysis due to lack of post-intervention data. Similarly, the mean difference of 1.64 seconds for TUG exceeds It is more challenging to identify the clinical significance of im- the minimum clinically important difference of approximately 1.3 provements seen for balance, because although an SMD of 1.03 in- seconds identified for patients with lower limb osteoarthritis.50,51 dicates a moderate-to-large effect size, multiple balance outcomes However, the confidence interval around each of these estimates were assessed, a substantial degree of heterogeneity was identified, does extend below the nominated threshold; therefore, it must and large 95% CIs were present in the meta-analysis. be acknowledged that the effects may or may not be clinically worthwhile. While one of the strengths of this systematic review and meta- analysis was that it included only randomised controlled trials, a
Research 205 Study SMD (95% CI) Study MD (95% CI) Batson 2007 Random Goudarzian 2017 Fixed Fansler 1985 Jacobson 2016 Goudarzian 2017 Marusic 2018 Linden 1989 Marusic 2018 Pooled Tunney 2006 –0.50 –0.25 0 0.25 0.50 Pooled Favours (m/sec) Favours control experimental –4 –2 0 24 Figure 4. Mean difference (95% CI) in the effect of motor imagery training versus no intervention or sham on gait speed. Favours Favours control experimental Further information regarding program compliance and participant perceptions of motor imagery and action observation should also be Figure 2. Standardised mean difference (95% CI) in the effect of motor imagery training included in future studies. versus no intervention or sham on balance measures. Another strength of this systematic review was that all but three limited number of high-quality studies were included in the meta- studies24,42,45 prescribed a motor imagery training intervention of at analysis. This is highlighted by the GRADE quality ratings of low least 4 weeks, which appears to be a sufficient duration to promote and very low assigned to the outcomes of the meta-analyses. gains in performance.52 Although not established for balance or Such ratings suggest that the true effect may be markedly different mobility measures, a recent meta-analysis identified that a training from the estimated effect.37 Downgrading of quality was largely period of 4 weeks, involving a training frequency of three times per based on design limitations (predominantly low-quality studies: week and a session duration of 15 minutes, was associated with PEDro , 6) and low sample sizes. The low PEDro scores were enhanced strength improvements following motor imagery primarily related to issues with allocation concealment, blinding of training.52 Furthermore, most motor imagery training studies in the assessors and intention-to-treat analysis. Another limitation was present review were conducted in a group setting or were self- that post-intervention data were used instead of change data. directed with the aid of audiotape guidance. This has clinical rele- Change data may have provided a more precise estimate of effect of vance, as the use of effective training programs in group settings or motor imagery training on balance and mobility but change data unsupervised environments reduces therapist burden,3 reduces was not consistently presented across all studies. Post-intervention ‘wasted’ time outside of structured therapy53 and typically represents data were used in preference to change data because these were low-cost interventions,54 suggesting that the inclusion of motor im- the most commonly provided data in studies. Despite these limi- agery training in rehabilitation programs for older adults is very tations, it is important to note that the positive results associated feasible. with motor imagery training still existed for TUG when only high- quality studies were included in the meta-analysis. Such a result is The improvements in mobility associated with motor imagery in contrast to a previous review of stroke patients, where the training identified in this systematic review are thought to be largely benefits in lower limb function and gait speed were no longer explained by improvements in motor planning that promote motor evident when only high-quality studies were included in ana- learning.19,55 Motor learning associated with motor imagery training lyses.12 The effect of assessing only high quality studies for balance has long been established in sport,56 in rehabilitation settings,57,58 and gait speed was not possible, as each meta-analysis included and more recently in older adults.59 Motor imagery elicits activity just one high quality study. in brain regions that are normally activated during actual task per- formance60,61 and the spatiotemporal characteristics of imagined and Clearly, further motor imagery research that incorporates appro- priate research design characteristics including blinded assessors, Study MD (95% CI) concealed allocation and larger sample sizes will help to provide Batson 2007 Fixed more robust evidence in this area. Future studies should also focus on Goudarzian 2017 patient groups that are less able to undertake traditional rehabilita- Kim 2012 tion, such as those with enforced immobilisation or restricted weight- Marusic 2018 bearing, as they may most benefit from motor imagery training. Moshref-Razavi 2017 Moukarzel 2017 Table 3 Grades of Recommendation, Assessment, Development and Evaluation (GRADE) Pooled quality of evidence. Outcome Trials Participants SMD or MD (95% CI), I2 Quality of Evidence (n) (GRADE) Balance 6 114 SMD 1.03 (0.25, 1.82), 67% Very low a Gait speed (m/s) 3 TUG (s) 6 107 MD 0.13 (0.04, 0.22), 0% Low b 175 MD 1.64 (0.79, 2.49), 0% Low c MD = mean difference, SMD = standardised mean difference, TUG = Timed Up and Go test. –4 –2 0 2 4 a Downgraded due to design limitations (five of six trials had PEDro of , 6), Favours (s) Favours imprecision (low sample size) and substantial heterogeneity. control experimental b Downgraded due to design limitations (two of three trials had PEDro of , 6), Figure 6. Mean difference (95% CI) in the effect of motor imagery training versus no imprecision (low sample size). intervention or sham on time to complete the Timed Up and Go test. c Downgraded due to design limitations (four of six trials had PEDro of , 6) and imprecision (low sample size).
206 Nicholson et al: Motor imagery training in older adults Study MD (95% CI) 3. Scurlock-Evans L, Upton P, Upton D. Evidence-based practice in physiotherapy: a Kim 2012 Fixed systematic review of barriers, enablers and interventions. Physiotherapy. Moukarzel 2017 2014;100:208–219. Pooled 4. Lesinski M, Hortobágyi T, Muehlbauer T, Gollhofer A, Granacher U. Effects of bal- ance training on balance performance in healthy older adults: a systematic review –4 –2 0 24 and meta-analysis. Sports Med. 2015;45:1721–1738. (s) Favours Favours 5. Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, et al. control experimental Exercise to prevent falls in older adults: an updated systematic review and meta- analysis. Br J Sports Med. 2017;51:1750–1758. Figure 8. Mean difference (95% CI) in the effect of motor imagery training versus no intervention or sham on time to complete the Timed Up and Go test (high quality 6. Gauthé R, Desseaux A, Rony L, Tarissi N, Dujardin F. Ankle fractures in the elderly: studies only). treatment and results in 477 patients. Orthop Traumatol Surg Res. 2016;102:S241– S244. physical movements are closely matched for mobility tasks.62,63 Im- provements in motor task execution (such as increased gait speed) 7. Naseri C, Haines TP, Etherton-Beer C, McPhail S, Morris ME, Flicker L, et al. following motor imagery training are believed to be due to the Reducing falls in older adults recently discharged from hospital: a systematic re- development and refining of the internal representation of the motor view and meta-analysis. Age Ageing. 2018;47:512–519. task via activation of the movement-related neural network.61 The refinement of these internal motor representations makes motor 8. Haines TP, Russell T, Brauer SG, Erwin S, Lane P, Urry S, et al. Effectiveness of a imagery training an attractive option for patient groups that require video-based exercise programme to reduce falls and improve health-related motor task enhancement but are unable to complete traditional quality of life among older adults discharged from hospital: a pilot randomized physical training interventions due to illness, surgical restrictions or controlled trial. Clin Rehabil. 2009;23:973–985. enforced immobilisation. 9. Fairhall N, Sherrington C, Cameron ID, Kurrle SE, Lord SR, Lockwood K, et al. In conclusion, the present systematic review and meta-analysis A multifactorial intervention for frail older people is more than twice as effective showed that motor imagery training improves measures of balance among those who are compliant: complier average causal effect analysis of a and mobility in older adults that do not have neurological conditions. randomised trial. J Physiother. 2017;63:40–44. 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Journal of Physiotherapy 65 (2019) 208–214 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Research Physiotherapist advice to older inpatients about the importance of staying physically active during hospitalisation reduces sedentary time, increases daily steps and preserves mobility: a randomised trial Nayara Alexia Moreno a, Bruno Garcia de Aquino a, Isabel Fialho Garcia a, Lucas Spadoni Tavares a, Larissa Francielly Costa a, Ivens Willians Silva Giacomassi b, Adriana Cláudia Lunardi a,c a Master and Doctoral Program in Physical Therapy, Universidade Cidade de São Paulo; b Physical Therapy Service, Instituto de Assistência Médica ao Servidor Público Estadual; c Department of Physical Therapy, School of Medicine, Universidade de São Paulo, São Paulo, Brazil KEY WORDS ABSTRACT Elderly Questions: Does advice from a physiotherapist about the importance of staying physically active during Hospitalisation hospitalisation improve activity, mobility, strength, length of stay, and complications in older inpatients? Immobility What barriers to physical activity during hospitalisation do older inpatients perceive? Design: Randomised Exercise controlled trial with concealed allocation, intention-to-treat analysis, and blinded assessment. Participants: Accelerometry Sixty-eight people who were aged . 60 years and admitted to a university hospital ward. Intervention: In addition to usual hospital care, the experimental group received a booklet with content about the deleterious effects of hospitalisation and the importance of staying active during hospitalisation. The control group received usual hospital care only. Outcome measures: The amount of physical activity was measured via accelerometry during the hospital admission. Mobility was assessed using the de Morton Mobility Index (DEMMI), and muscle strength was assessed using a handgrip dynamometer. Length of stay and complica- tions were extracted from hospital records. The barriers to staying active during hospitalisation were investigated via a questionnaire. Results: Accelerometry showed a mean between-group difference of 974 steps/day (95% CI 28 to 1919) in favour of the experimental group. The intervention also increased moderate- intensity physical activity and reduced sedentary time, although these effects might be trivially small. Experimental group participants were about one-fifth as likely to lose mobility during their hospital admission (two of 33) than control group participants (10 of 35), relative risk 0.21 (95% CI 0.05 to 0.90). Effects of the intervention were unclear regarding muscle strength, length of stay and incidence of com- plications between the groups. Patients reported that the main barriers to remaining active during hospi- talisation were dyspnoea, lack of space, and fear of contracting infection. Conclusion: In older inpatients, the addition of advice from a physiotherapist about maintaining activity during hospitalisation increases the level of physical activity and prevents loss of mobility. Registration: ClinicalTrials.gov NCT03297567. [Moreno NA, de Aquino BG, Garcia IF, Tavares LS, Costa LF, Giacomassi IWS, Lunardi AC (2019) Physio- therapist advice to older inpatients about the importance of staying physically active during hospi- talisation reduces sedentary time, increases daily steps and preserves mobility: a randomised trial. Journal of Physiotherapy 65:208–214] © 2019 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/). Introduction hospitalisation can lead to impairment of independence,4 with losses in muscle strength and functional performance.5,6 Older adults have The level of physical activity decreases progressively with ageing. less capacity to fully recover from such losses than younger adults.7 Older adults who are physically active have lower rates of morbidity and mortality than older adults with sedentary behaviour.1 Physical These losses are associated with important outcomes after hospital activity is associated with 30% lower mortality rates in older adults discharge, including disability and mortality.8,9 Decreasing sedentary without chronic diseases and 47% lower mortality rates in older pa- tients with various comorbidities.2 behaviour time as well as maintaining muscular strength and func- During hospitalisation, sedentary behaviour is common, with in- tional performance during hospitalisation can prevent loss of inde- patients spending long periods resting in bed, regardless of their pendence after hospital discharge.10,11 primary reason for admission.3 Low physical activity during For the reasons outlined above, various strategies have been considered for the early incorporation of physical activity into the hospital environment. Among these, early mobilisation of inpatients https://doi.org/10.1016/j.jphys.2019.08.006 1836-9553/© 2019 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/).
Research 209 has been increasingly promoted.12 One example is stimulation of physical activity during their hospital admission. The study design is ambulation to reduce functional decline.13 However, despite these presented in Figure 1. initiatives, many patients still spend much of their hospitalisation lying in bed.3 Participants, therapists, centres The barriers to patient mobility during hospitalisation are We consecutively screened people admitted to the Respiratory complex and poorly studied.14 The most common barriers that and Clinical Medicine Clinics of the Instituto de Assistência Médica ao limit physical activity appear to include disease symptoms and Servidor Público Estadual, Sao Paulo, Brazil. To be eligible for inclu- health professional behaviour. One-third of older hospitalised pa- sion in the study, patients had to be: aged 60 years;16 hospitalised tients are kept at rest or with low levels of physical activity for no for any clinical condition for , 48 hours; and able to mobilise without reason.15 professional assistance or an accompanying person. Potential partic- ipants were also required to be able to understand the advice and The overarching hypothesis for this study was that specific advice evaluations involved in the study (outlined further below). This cri- to maintain physical activity from a relevant healthcare professional terion was verified through Mini Mental State Examination in the would help to combat a lack of advice or unhelpful advice from other version proposed by Brucki et al,17 which corrects the total score hospital-based healthcare professionals regarding physical activity. according to the level of the formal education of the patients. Patients Therefore, the primary objective of this study was to evaluate the were ineligible for this study if they did not reach the expected score impact of an orientation program for older hospital inpatients about for their educational levels. Patients were also excluded from the the importance of staying physically active during hospitalisation. study if they: were placed in isolation; were scheduled for elective The outcomes that were hypothesised to be affected by this inter- surgery during their admission; had a medical restriction to leaving vention were the level of physical activity, mobility, muscle strength, the bed; had undergone emergency surgery; or had a condition that length of hospital stay and incidence of complications. In addition, would limit the placement of the accelerometer (skin infections, this study also sought to identify the main barriers to staying phys- amputation or fracture in the dominant limb). ically active during hospitalisation. Therefore, the research questions for this randomised controlled trial were: 1. Does advice from a physiotherapist about the importance of Intervention staying physically active during hospitalisation improve activity, mobility, strength, length of stay, and complications in older Participants in the experimental group received a booklet con- inpatients? taining advice in the form of text and illustrations about the impor- tance and benefits of moving around during hospitalisation. In 2. What barriers to physical activity during hospitalisation do older addition, the booklet showed what the participant should do to in- inpatients perceive? crease their level of physical activity in the hospital. A physiotherapist delivered the booklet individually to each participant and verbally Method oriented them to the contents of the booklet, during a single orien- tation session lasting 20 minutes. The booklet was easy to understand Design and inexpensive. An English translation of the booklet is provided in Appendix 1 (see eAddenda for Appendix 1). The participants were This was a randomised clinical trial with concealed allocation, instructed to read the booklet every time they had any doubts about blinding of assessors, and intention-to-treat analysis. After a detailed physical activity or forgot the advice during the hospitalisation explanation of the study protocol, eligible and willing participants period. The participants were also instructed to keep the booklet in signed the informed consent form. The participants were then eval- the drawer of their bedside tables, to maintain blinding of the as- uated for clinical characteristics, including age, gender, limb domi- sessors. Participants in the control group did not receive a booklet or nance, educational level, anthropometric data, diagnosis, pre-existing other verbal advice. diseases, current medications, use of oxygen therapy, smoking his- tory, alcohol use, and previous physical activity. Participants were All participants in both groups received the usual hospital care to then allocated to an experimental group or a control group with a 1:1 treat the condition that lead to their hospitalisation, as determined by allocation ratio, according to a random allocation schedule generated the hospital clinicians treating them. using a free randomisation website. The randomisation process was implemented by a researcher not involved in the selection, evaluation Outcome measures or treatment of study participants. The random allocation schedule was kept concealed from other investigators. All evaluations were performed by an assessor who was kept unaware of the group to which each participant belonged. In the ward where the study was conducted, the rooms accom- modated two to four participants. Although the intervention was Primary outcome administered to one participant at a time, each participant’s physical Physical activity level: This was assessed by an accelerometera placed activity behaviour could have influenced other participants’ behav- on the wrist18 of the dominant limb, according to the participant’s iour if they stayed in the same room, thus affecting the results. Par- report. Accelerometry was performed 24 hours a day, from baseline ticipants allocated to different groups were allocated to different to hospital discharge. The equipment was waterproof, so there was rooms to minimise the potential for this problem to occur. no need to remove it for bathing or personal hygiene. The acceler- ometer battery lasted for up to 20 days of consecutive collection. Both groups received usual hospital care for their clinical condi- The accelerometer recorded the number of steps and time at tion, as determined by the hospital staff. In addition, the experi- different intensities of activity (Table 1) and estimated the mental group received verbal advice and a booklet with information metabolic rate.19 about the deleterious effects of hospitalisation and the importance of staying physically active during hospitalisation. At baseline, the par- Secondary outcomes ticipants in both groups had an accelerometer attached to their wrist, Mobility: This was assessed via the de Morton Mobility Index which recorded physical activity throughout the hospital admission. (DEMMI) at baseline and at hospital discharge. The DEMMI has been In addition, participants were evaluated for mobility, peripheral validated for older hospitalised patients.20 Mobility was assessed muscle strength, length of hospital stay, and incidence of complica- using 15 activities divided into five groups: in a bed, in a chair, static tions during the admission. After discharge from hospital, partici- balance, gait and dynamic balance. The assessor evaluated the pants were requested to complete a questionnaire about barriers to performance of the older patients in each of the activities. Scores
210 Moreno et al: Advice about activity for older inpatients People admitted to the ward and assessed for eligibility (n = 94) Excluded (n = 26) did not meet inclusion criteria (n = 9) declined to participate (n = 17) First 48 h Measured DEMMI and grip strength Randomised (n = 68) During admission (n = 33) (n = 35) Experimental group Control group educational booklet usual care 20-min session with physiotherapist to discuss the booklet usual care Measured accelerometry, complications, physiotherapy sessions, and length of stay (n = 33) (n = 35) Loss to follow-up Loss to follow-up died (n = 2) (n = 0) Discharge (n = 31) Measured DEMMI and grip strength (n = 35) (n = 33) a Analysed (n = 35) b Unable to Unable to contact (n = 3) contact (n = 5) After Answered questionnaire about barriers to physical activity during hospitalisation discharge (n = 28) (n = 30) Figure 1. Design and flow of participants through the trial. DEMMI = de Morton Mobility Index. a Most data were available for the two participants who died; the remaining data were imputed. b Two participants contributed no data to the accelerometry analysis due to device malfunction. ranged from 0 to 19. Higher scores indicated greater patient mobility. 90 degrees of flexion without support and the forearm remained in a neutral position.21 The other upper limb rested on the thigh of the A conversion table allowed the transformation of the raw score into a participant.21 The participant was instructed to perform the handgrip movement three times, with one minute of rest between attempts.21 specific scale score, called the DEMMI score, which ranges from 0 to A mean of the three trials22 was used in the analysis. To characterise 100 points.20 The current study analysed the variation of mobility. the study participants, the absolute values and the predicted values Participants with loss of mobility (defined as a decrease in DEMMI for the Brazilian population were used.22 In the analysis of this score at hospital discharge compared with baseline) were recorded. outcome measure, the data were dichotomised; loss of peripheral Peripheral muscle strength: This was assessed using a handgrip dynamometerb at baseline and at hospital discharge. Participants muscle strength was defined as a decrease in absolute force at were instructed to sit comfortably in a chair with their feet resting on hospital discharge compared to baseline. the floor.21 The participant’s dominant upper limb remained in
Research 211 Table 1 Table 2 Accelerometer movements/minute rating by Actigraph GTX3. Characteristics of the participants (n = 68). Levels Movements/minute Characteristic Exp Con (n = 33) (n = 35) Sedentary behaviour 0 to 99 Light activity 100 to 759 Age (yr), mean (SD) 69 (7) 69 (7) Daily life activity 760 to 1951 Sex, n male (%) 16 (48) 24 (69) Moderate activity 1952 to 5724 BMI (kg/m2), mean (SD) 25.5 (4.6) 24.9 (5.5) Intense activity Education (yr), n (%) . 5725 7 (21) 5 (14) According to Freedson et al, 1998.16 ,8 14 (43) 22 (63) 8 to 11 12 (37) 8 (23) Length of stay: The period from admission to the ward until hospital 12 23 (70) 25 (72) discharge was recorded in days. History of smoking, n (%) 4 (12) Complications: Complications were defined as a new clinical Alcoholism, n (%) 0 (0) 8 (23) condition requiring treatment, such as pneumonia, atelectasis with Previous PA practice, n (%) 11 (33) clinical repercussion, severe hypoxaemia, or deep venous thrombosis. Reason for admission, n (%) 15 (43) The diagnosis of complications was given by a physician who was pneumonia 14 (42) 6 (17) blind to the intervention groups. exacerbation of COPD 9 (28) 5 (14) Physiotherapy input: The number of physiotherapy sessions was neoplasm 5 (15) 4 (12) extracted from the participant’s hospital record. diagnostic investigation 1 (3) 5 (14) Barriers to activity in hospital: A questionnaire was developed to other 4 (12) 15 (43) determine barriers to staying active during hospitalisation. The Antibiotic use, n (%) 15 (45) 12 (35) questionnaire was evaluated by 30 physiotherapists who had each Inpatient use of oxygen, n (%) 14 (43) 24 (67) worked in hospitals for 5 years. All suggestions were accepted. The Companion, n (%) 18 (58) 26.7 (1.6) final version of the questionnaire comprised 16 questions with ‘yes’ MMSE (0 to 30), mean (SD) 27.1 (2.0) or ‘no’ answers. The questions concerned fears, symptoms, external Muscle strength, mean (SD) 25.7 (8.0) factors and infrastructure. Two open-ended questions were also (kgf) 24.2 (8.5) 75 (6) included; these asked about the importance of staying active and (% predicted)19 75 (6) 79 (12) factors that made it difficult to remain active. The questionnaire was DEMMI (0 to 100), mean (SD) 77 (14) administered to participants via a telephone call 72 hours after hospital discharge. A copy of the questionnaire is provided in BMI = body mass index; COPD = chronic obstructive pulmonary disease; DEMMI = de Appendix 2 (see eAddenda for Appendix 2). Morton Mobility Index; MMSE = Mini Mental State Examination; PA = physical activity. Data analysis Compliance with the study protocol The calculation of the required sample size was based on power of No ineligible participants were randomised. No assessors were 80%, an alpha of 5%, a smallest worthwhile effect of 618 steps/day, and unblinded during the study. All participants received the an anticipated standard deviation of 817 steps/day.23 This calculation designated intervention. Two participants were moved, later in their gave a sample size of 58 participants (29 per group); this was admission, to a room where they were with a participant in the increased to 68 participants, to allow for some potential loss to opposite group of the study, but all participants were still analysed in follow-up. the group to which they had been randomly allocated. There was minimal missing data for the randomised trial outcomes, as shown in All study data were entered into an electronic database after being Figure 1. Fifty-eight participants (88% of those still alive) answered collected. Access to the data was provided to the researcher who the questionnaire about barriers to physical activity during performed the statistical analysis blindly using a coded form. Access hospitalisation. to the database was restricted to researchers involved in data collection and analysis. Participant confidentiality was maintained Baseline characteristics of the participants through secure data storage, both during and after the study. The data in the database were carefully monitored for any errors. Descriptive The groups were similar with respect to demographic data, analysis was used to identify outliers and possible data transcription anthropometric data, range of reasons for hospitalisation, use of errors. supplemental oxygen, use of intravenous antibiotics, cognitive status, and baseline measures of strength and mobility (Table 2). Statistical analysis was performed according to the principle of intention to treat by a researcher not involved in the recruitment, Effect of the intervention assessment and intervention aspects of the study. If there were missing data for an outcome measure, data were imputed for 15% Primary outcome of the participants by carrying forward the baseline value. Physical activity level: There was high diversity among the daily step Continuous outcomes were compared between groups using a t-test. counts of the participants, ranging from 825 to 9350 steps/day. The Dichotomous outcomes were compared between groups using the experimental group recorded a greater average number of chi-square test. The level of statistical significance was set at p , 0.05. steps (4945 steps/day, SD 2117) than the control group Data from the questionnaire were summarised using descriptive (3971 steps/day, SD 1706). The mean between-group difference was statistics. 974 steps/day (95% CI 28 to 1919), as presented in Table 3. The percentage of time that participants were sedentary ranged from 42 Results to 92% of the total hospitalisation time. The mean between-group difference was 6% less sedentary time in the experimental group Flow of participants, therapists, centres through the study (95% CI 0 to 11). The percentage of time that participants were engaged in moderate-intensity activity ranged from 0 to 13% of the After screening of 94 patients, 68 were enrolled in the study: 33 total hospitalisation time. The mean between-group difference was were allocated to the experimental group and 35 to the control group. 1% more moderate-intensity activity time in the experimental group The flow of participants through the study is shown in Figure 1. (95% CI 0 to 3). Although the light activity time was 4% more in the experimental group than the control group, the 95% CI spanned from 21 to 8. These results are also presented in Table 3. Individual participant data are presented in Table 4 (see eAddenda for Table 4).
212 Moreno et al: Advice about activity for older inpatients Table 3 Table 5 Between-group comparison of physical activity level, mobility and muscle strength. Number (%) of participants exhibiting loss of mobility and muscle strength, and relative risk (95% CI) between groups. Outcomes Exp Con Between-group (n = 33) (n = 33)a difference (95% CI) Outcomes Exp Con Relative risk (n = 33) (n = 35) (95% CI) Exp – Con Loss of mobility, n (%) 2 (6) 10 (29) 0.21 (0.05 to 0.90) Loss of muscle strength, n (%) 7 (21) 14 (40) 0.53 (0.25 to 1.15) Steps (n/day), mean (SD) 4945 (2117) 3971 (1706) 974 (28 to 1919) Accelerometry category 63 (11) 68 (10) 26 (0 to 211) the size of the effect. While these confirm that the effects are (% of time) 33 (9) 29 (9) 4 (21 to 8) beneficial, they do not exclude the possibility that the benefits may be sedentary 4 (3) 3 (2) 1 (0 to 3) trivially small. light activity moderate activity Regardless of the exact size of these effects on the amount of physical activity maintained during hospitalisation, the amount of a Missing data for two participants due to accelerometer malfunction. extra physical activity that was stimulated appears to be enough to carry over into the prevention of loss of mobility. The study’s best Secondary outcomes estimate was that the risk of losing mobility was reduced to almost Mobility: The mobility assessment using the DEMMI at hospital one-fifth of the risk in the control group. Whilst this estimate again discharge identified similar results for the experimental group comes with some uncertainty, even the milder limit of the confidence (77 points, SD 11) and the control group (81 points, SD 13). However, interval (ie, a reduction of 10% in the risk of losing mobility) is participants in the experimental group were almost one-fifth as likely probably worthwhile, given that the only thing required to achieve it to lose mobility during their hospital admission (two of 33, 6%) than is a very brief and low-cost intervention. participants in the control group (10 of 35, 29%). This equated to a relative risk of 0.21 (95% CI 0.05 to 0.90), as presented in Table 5. The effect of the intervention on physical activity was not clearly Individual participant data are presented in Table 4 (see eAddenda for sufficient to prevent loss of peripheral muscle strength, reduce length Table 4). of stay, or prevent complications. These effects do, however, appear Peripheral muscle strength: The absolute values of handgrip strength worthy of further investigation. For example, the main estimate that in the experimental group (24.65 kgf, SD 2.5) and the control group the intervention halves the risk of loss of muscle strength would (25.97 kgf, SD 3.1) remained similar during the hospital admission. certainly be clinically worthwhile; further data could therefore help The percentage predicted values were also similar between the to give a more precise estimate. groups: 76% (SD 6) versus 75% (SD 6), respectively. The proportion of participants who lost strength was seven of 33 (21%) in the experi- Another welcome finding was that there were no clinical mental group and 14 of 35 (40%) in the control group. Although this complications in either group in this study. This indicates that suggests that the intervention almost halves the risk of loss of patients can follow the advice of the booklet and the physiotherapist strength during an admission (ie, relative risk 0.53), there was sub- without increasing their risk of complications. stantial uncertainty inherent in this estimate (95% CI 0.25 to 1.15); that is, the intervention might substantially reduce or marginally The verbal advice associated with the illustrated booklet kept increase the risk of losing strength during a hospital admission, as older patients more active during hospitalisation. Other studies have presented in Table 5. Individual participant data are presented in used the same strategy to increase the level of physical activity and Table 4 (see eAddenda for Table 4). decrease sedentary behaviour in community-dwelling older Other outcomes: The mean duration of hospitalisation was 5.8 days adults;23,24 however, this is the first study to focus on hospitalised (SD 2.9) in the experimental group and 5.3 days (SD 2.9) in the patients. In a study with older adults with chronic obstructive control group. This result strongly suggests that any effect of the pulmonary disease, verbal advice for 12 weeks was also an efficient intervention on length of stay would not exceed 1 day (MD 0.4 days, strategy, with a difference of 803 daily steps (p , 0.001) compared to 95% CI 20.2 to 0.9). None of the prespecified complications were the group that received only usual care. The intervention consisted of recorded for any participant in either group. The mean number of individualised verbal advice and determination of weekly goals to physiotherapy sessions was 0.8 (SD 1.3) in the experimental group increase the level of physical activity.23 In another study, a pulmonary and 0.4 (SD 0.8) in the control group (MD 0.4, 95% CI 20.2 to 0.9). rehabilitation program associated with eight verbal counselling ses- Barriers to activity in hospital: The main barriers to staying active sions on physical activity increased levels of daily physical activity during hospitalisation that the participants reported were: lack of (daily steps and time of light and moderate activities) of older infrastructure (space and mobile oxygen therapy equipment); lack of outpatients with chronic obstructive pulmonary disease.24 The staff; symptoms; and fear (Table 6). In addition, 44 (76%) participants reported knowing the importance of moving during hospitalisation Table 6 and 39 (67%) received some advice about staying active during their Number (%) of participants who agreed that the nominated reasons were barriers to admission. Phrases such as ‘moving during hospitalisation improves staying active during hospitalisation (n = 58). or maintains function’, ‘staying immobile is bad for health’, and ‘moving improves the breathing’ were answered on the open-ended Reason Participants questions. The open-ended questions also elicited some barriers that n (%) were additional to those listed in the questionnaire: ‘debilitated due to prolonged fasting for exams’ and ‘equipment in the corridor Lack of space 44 (76) hindered walking’. Continuous oxygen therapy 14 (61)a Fear of infection 29 (50) Discussion Dyspnoea 28 (48) Lack of professional help 24 (41) The results from this study showed that older patients who Lack of companion encouragement 26 (66)a received advice about staying physically active during hospitalisation Pain in any part of the body 18 (31) spent less time being sedentary, accrued more moderate physical Fear of losing venous access 13 (22) activity, and took approximately 1000 more steps per day, compared Dizziness 11 (19) with the control group. The confidence intervals associated with Unwillingness to move 11 (19) these results, however, indicate that there is some uncertainty about Lack of equipment 9 (16) Use of intravenous medications 7 (12) Fear of falling Fear of missing a doctor’s visit 5 (9) 1 (2) a The percentages of the barriers ‘continuous oxygen therapy’ and ‘lack of companion encouragement’ were calculated based on the elderly respondents who used oxygen (n = 23) and who had a companion (n = 39).
Research 213 increase in the level of physical activity achieved in these studies has less loss of mobility in older patients hospitalised for clinical reasons. been previously tested as a strategy with which to prevent the In addition, the main barriers to staying active during hospitalisation decrease in the mobility of older adults.25 In a group with almost 900 reported by the patients were related to infrastructure. outpatients with no dementia, higher levels of physical activity were associated with lower loss of mobility.25 What was already known on this topic: Older inpatients spend long periods resting in bed, regardless of their reason for Interestingly, in our study, prevention of loss of mobility caused by hospitalisation. Low physical activity during hospitalisation is increased levels of physical activity was not associated with the risk associated with loss of muscle strength and function. These of loss of muscle strength. Our study showed that muscle strength losses are associated with important outcomes after hospital was maintained during hospitalisation. This finding was probably due discharge, including disability and mortality. to the fact that older patients had preserved muscle strength and What this study adds: Verbal and written advice to remain body mass index at hospital admission. In addition, the hospital- active during hospitalisation improves physical activity levels isation period was insufficient to impair these factors. A previous among older inpatients. While the size of these benefits is un- study showed that reduced handgrip at hospital admission was certain, they appear to be large enough to carry over into the related to functional decline at hospital discharge;26 therefore, the prevention of loss of mobility. preserved nutritional status of the participants in the present study should have been a protective factor against weakening of the pe- Footnotes: a ActiGraph GT3X accelerometer, ActiGraph Corp, USA. ripheral muscles. On the other hand, a study with inpatients showed b Smedley dynamometer, Smedley, Sahean, Belgium. that the handgrip remained unchanged over a period of 10 days of hospitalisation.27 Karlsen et al27 showed that mobility assessed via eAddenda: Table 4 and Appendices 1 and 2 can be found online at DEMMI gradually improved between the sixth and tenth days of https://doi.org/10.1016/j.jphys.2019.08.006. hospitalisation. An improvement in mobility during hospitalisation was observed in patients with a higher level of physical activity.27 Ethics approval: This study was approved by the Ethics Com- However, patients with a low level of physical activity during hos- mittee of Instituto de Assistência Médica ao Servidor Público Estad- pitalisation presented functional decline,28 as in the current study. ual, Sao Paulo, Brazil (71339417.4.0000.5463 and protocol number Our results show that older patients who did not receive guidelines 2.251.125). All participants gave written informed consent before data and remained in sedentary behaviour for longer lost more mobility collection began. compared with the more active elderly patients during hospital- isation. Our hypothesis was that functional physical activities may not Competing interests: Funders had no role in the execution, anal- be sufficient to prevent loss of mobility in older eutrophic patients. ysis, interpretation of data or decision to present the results in this On the other hand, these same functional activities appear to be study and were only involved with funding. sufficient for the maintenance of muscular strength for a short period of hospitalisation, without the need for specific muscle strengthening Sources of support: The purchase of the equipment was financed exercises when patients are eutrophic. by the Foundation for Research Support of the State of Sao Paulo (FAPESP), grant number: 2015/25763-2. The scholarship was also There was minimal difference between the groups in the length of awarded by the Foundation for Research Support of the State of São hospital stay. This result can possibly be explained by pneumonia Paulo (FAPESP), scholarship: 2017/09815-8. being the most frequent cause of hospitalisation in both groups. The duration of antibiotic use would have determined the duration of Acknowledgements: Nil. hospitalisation to complete the course of treatment. Provenance: Not invited. Peer reviewed. Correspondence: Adriana Cláudia Lunardi, Departament of Phys- The use of intravenous medications such as antibiotics was one of ical Therapy, School of Medicine, Universidade de São Paulo, São the barriers reported by participants to performing physical activity Paulo, Brazil. Email: [email protected] during hospitalisation. Others factors that were widely reported included lack of space, use of continuous oxygen therapy, fear of References infection upon leaving the room, and dyspnoea. Similar factors were previously reported by 28 older hospitalised patients during a semi- 1. U.S. Department of Health and Human Services. Physical activity and health; A structured interview.13 They pointed out that facilitators of physical Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human activity for them included: knowledge of the negative effects of Services, Centers for Disease Control and Prevention, National Center for Chronic prolonged bed rest, the feeling of wellbeing that occurs with activity, Disease Prevention and Health Promotion; 1996. www.cdc.gov/nccdphp/sgr/pdf/ and knowledge that they are regaining their function. As in our re- chap5.pdf [accessed 2 April 2019]. sults, the reported barriers were disease-related symptoms, infra- structure and fear of injury.13 In addition, 85% of these patients 2. Martinez-Gomez D, Guallar-Castillon P, Garcia-Esquinas E, Bandinelli S, Rodriguez- reported that they could be influenced by whether the physician had Artalejo F. Physical activity and the effect of multimorbidity on all-cause mortality suggested exercise.13 Presumably, sedentary behaviour of older in- in older adults. Mayo Clin Proc. 2017;92:376–382. patients could be decreased if the healthcare teams increased their attention to keeping the corridors free of extraneous equipment, 3. Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low purchased mobile equipment for oxygen therapy, and engaged in a mobility during hospitalization of older adults. J Am Geriatr Soc. 2009;57:1660– more integrated multiprofessional approach. This would be likely to 1665. prevent the deleterious effects of poor mobility. 4. Lamont CT, Sampson S, Matthias R, Kane R. The outcome of hospitalization for This study had some limitations, the main one being the lack of acute illness in the elderly. J Am Geriatr Soc. 1983;31:282–288. control over the advice that other healthcare professionals gave participants (including the control group) about physical activity. 5. Coker RH, Hays NP, Williams RH, Wolfe RR, Evans WJ. Bed rest promotes reductions However, at the beginning of the protocol, all clinicians were in walking speed, functional parameters, and aerobic fitness in older, healthy instructed not to give advice about physical activity to participants, in adults. J Gerontol A Biol Sci Med Sci. 2015;70:91–96. order to reduce study bias. In addition, we believe that usual advice is similar for all hospitalised patients. Another limitation was the oc- 6. Pedersen MM, Petersen J, Bean JF, Damkjaer L, Juul-Larsen HG, Andersen O, et al. casional existence of one participant from the experimental group Feasibility of progressive sit-to-stand training among older hospitalized patients. and another from the control group in the same room; this situation Peer J. 2015;3:21. could have affected the results. 7. Chen CC, Wang C, Huang GH. Functional trajectory 6 months posthospitalization: a Overall, this study’s results suggest that verbal advice and an cohort study of older hospitalized patients in Taiwan. Nurs Res. 2008;57:93–100. illustrated booklet on the benefits of staying active during hospital- isation increased the level of physical activity, ultimately reflecting 8. Carey EC, Covinsky KE, Lui LY, Eng C, Sands LP, Walter LC. Prediction of mortality in community-living frail elderly people with long-term care needs. J Am Geriatr Soc. 2008;56:68–75. 9. Boyd CM, Landefeld CS, Counsell SR, Palmer RM, Fortinsky RH, Kresevic D, et al. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc. 2008;56:2171–2179. 10. Suetta C, Magnusson SP, Rosted A, Aagaard P, Jakobsen AK, Larsen LH, et al. Resistance training in the early postoperative phase reduces hospitalization and leads to muscle hypertrophy in elderly hip surgery patients—a controlled, ran- domized study. J Am Geriatr Soc. 2004;52:2016–2022. 11. Henriksen MG, Jensen MB, Hansen HV, Jespersen TW, Hessov I. Enforced mobili- zation, early oral feeding, and balanced analgesia improve convalescence after colorectal surgery. Nutrition. 2002;18:147–152.
214 Moreno et al: Advice about activity for older inpatients 12. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 21. Geraldes AAR, Oliveira ARMd, Albuquerque RBd, Carvalho JMd, Farinatti PTV. The 1993;118:219–223. hand-grip forecasts the functional performance of fragile elder subjects: a multiple-correlation study. Rev Bras Med Esporte. 2008;14:12–16. 13. So C, Pierluissi E. Attitudes and expectations regarding exercise in the hospital of hospitalized older adults: a qualitative study. J Am Geriatr Soc. 22. Novaes RD, Miranda ASd, Silva JdO, Tavares BVF, Dourado VZ. Reference equations 2012;60:713–718. for predicting of handgrip strength in Brazilian middle-aged and elderly subjects. Fisioter Pesqui. 2009;16:217–222. 14. Mudge AM, McRae P, McHugh K, Griffin L, Hitchen A, Walker J, et al. Poor mobility in hospitalized adults of all ages. J Hosp Med. 2016;11:289–291. 23. Altenburg WA, ten Hacken NH, Bossenbroek L, Kerstjens HA, de Greef MH, Wempe JB. Short- and long-term effects of a physical activity counselling pro- 15. Beveridge C, Knutson K, Spampinato L, Flores A, Meltzer DO, Van Cauter E, et al. gramme in COPD: a randomized controlled trial. Respir Med. 2015;109:112–121. Daytime physical activity and sleep in hospitalized older adults: association with demographic characteristics and disease severity. J Am Geriatr Soc. 2015;63:1391– 24. Burtin C, Langer D, van Remoortel H, Demeyer H, Gosselink R, Decramer M, et al. 1400. Physical activity counselling during pulmonary rehabilitation in patients with COPD: a randomised controlled trial. PLoS One. 2015;10:e0144989. 16. WHO. Active ageing: a policy framework. A Contribution of the World Health Organization to the second United Nations World Assembly on Aging. Geneva: 25. Buchman AS, Wilson RS, Boyle PA, Tang Y, Fleischman DA, Bennett DA. Physical World Health Organization; 2002:60. activity and leg strength predict decline in mobility performance in older persons. J Am Geriatri Soc. 2007;55:1618–1623. 17. Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Suggestions for utilization of the mini-mental state examination in Brazil. Arq Neuro-Psiquiatr. 26. Olguin T, Bunout D, de la Maza MP, Barrera G, Hirsch S. Admission handgrip 2003;61:777–781. strength predicts functional decline in hospitalized patients. Clin Nutr ESPEN. 2017;17:28–32. 18. Kamada M, Shiroma EJ, Harris TB, Lee IM. Comparison of physical activity assessed using hip- and wrist-worn accelerometers. Gait Posture. 2016;44:23–28. 27. Karlsen A, Loeb MR, Andersen KB, Joergensen KJ, Scheel FU, Turtumoeygard IF, et al. Improved functional performance in geriatric patients during hospital stay. Am J 19. Freedson PS, Melanson E, Sirard J. Calibration of the Computer Science and Ap- Phys Med Rehabil. 2017;96:e78–e84. plications, Inc. accelerometer. Med Sci Sports Exerc. 1998;30:777–781. 28. Zisberg A, Shadmi E, Sinoff G, Gur-Yaish N, Srulovici E, Admi H. Low mobility during 20. De Morton NA, Davidson M, Keating JL. The de Morton Mobility Index (DEMMI): hospitalization and functional decline in older adults. J Am Geriatri Soc. an essential health index for an ageing world. Health Qual Life Outcomes. 2011;59:266–273. 2008;6:63.
Journal of Physiotherapy 65 (2019) 222–229 j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s Research Physiotherapists’ views about providing physiotherapy services to people with severe and persistent mental illness: a mixed methods study Eleanor Andrew a, Kathy Briffa a, Flavie Waters b,c, Samantha Lee a, Robyn Fary a a School of Physiotherapy and Exercise Science, Curtin University; b Clinical Research Centre, Graylands Campus, North Metropolitan Health Service Mental Health; c School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia KEY WORDS ABSTRACT Physiotherapy Questions: What perceptions do physiotherapists have about their role in managing the physical health of Physical therapy people with severe and persistent mental illness (SPMI)? What are the barriers to treating physical health Severe mental illness conditions in this clinical population, and what enablers may improve access to physiotherapy services? Mental health Design: Mixed-methods research design combining focus groups, interviews and an online survey. Physical activity Participants: Eighty-eight Australian registered physiotherapists: 31 in the focus groups and interviews (mean age 32 years, 68% female) and 57 in the survey (mean age 38 years, 86% female). Methods: Focus groups and interviews explored participants’ understanding of mental illness; their role in managing the physical health of people with SPMI; and the barriers and enablers to service delivery. Key themes were derived using an inductive approach. The survey was used to determine physiotherapists’ attitudes and knowledge regarding mental illness; perceived role of physiotherapy in mental health; and need for pro- fessional development in the mental health area. Participant characteristics and survey information were analysed using descriptive statistics. Results: Qualitative and quantitative results were confirmatory. Par- ticipants indicated that physiotherapists can play a role in the management of physical health conditions in people with SPMI. Participants also stated that such treatment was part of their job, given the extensive evidence that physiotherapy interventions are effective for the comorbidities that are common among people with SPMI. Barriers included: limited education about and confidence in how to manage people with SPMI; health system structure; and stigmatisation of people with SPMI. Conclusion: Physiotherapists are ideally poised to become leaders in managing the physical health of people with SPMI. To improve the physical health in this important yet overlooked population, it is recommended that: physiotherapists take up general mental health training opportunities; undergraduate physiotherapy education increases content in this clinical area; physiotherapy-specific professional development opportunities are developed further; and health system barriers are addressed. [Andrew E, Briffa K, Waters F, Lee S, Fary R (2019) Physiotherapists’ views about providing physiotherapy services to people with severe and persistent mental illness: a mixed methods study. Journal of Physiotherapy 65:222–229] © 2019 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/). Introduction which are associated with metabolic and endocrine abnormalities.7 Lower socio-economic status and unhealthy lifestyles (such as high Disorders such as schizophrenia spectrum disorders, bipolar dis- rates of smoking, substance use, obesity and a lack of physical ac- order, and major depression are typically labelled as ‘severe and tivity) also contribute to poor physical health outcomes.4,8 persistent mental illnesses’ (SPMI)1–3 because they are often associ- ated with recurrent and persistent symptoms that have an over- The Australian Physiotherapy Association (APA) position state- powering influence on an person’s social, occupational and personal ment on mental health and physiotherapy states that physiothera- function.1,2 Most people with SPMI have poor physical health and pists are well trained in managing the musculoskeletal and high rates of comorbid health conditions (such as respiratory and cardiorespiratory conditions that are common among people with cardiovascular disease, diabetes and obesity).1,4 People with SPMI are SPMI.9 Despite this, evidence suggests that people with SPMI are not two to three times more likely to have cardiovascular disease, have accessing or utilising physiotherapy services for management of their higher prevalence of metabolic syndrome, and have an estimated 15 physical health problems.9,10 to 25 year shorter life expectancy compared with the general popu- lation.5,6 This poor physical health is a result of both the mental Recently, the barriers and enablers to accessing physiotherapy health condition itself and the use of antipsychotic medications, services by people with SPMI have been explored from the perspec- tives of mental health professionals (mental health nurses, social workers, occupational therapists and psychologists) and people living https://doi.org/10.1016/j.jphys.2019.08.001 1836-9553/© 2019 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/).
Research 223 with SPMI.11 Both groups of participants in that study identified that a Box 1. Stimulus questions used in the focus groups and key barrier was a lack of awareness and understanding about the role interviews. and scope of physiotherapy in mental health. In addition, they revealed a need for better education about the role and benefits of What sorts of ideas come to you when you think about people physiotherapy, clearer referral pathways, and reduced costs for peo- with severe mental illness? ple on a pension. The participants were also unclear about physio- therapists’ knowledge about mental health, and confidence in being Within your practice, what is your understanding of the role of able to manage people with SPMI.11 The perspectives of physiother- physiotherapists in the treatment and management of apists in engaging people with SPMI were not addressed in that study someone with severe mental illness? and remain unexplored. It is important to understand the perceptions of physiotherapists about assessing, managing and treating people Have you ever treated a patient with severe mental illness? with SPMI, and to identify areas in which they may have concerns. The current research was undertaken to better understand physio- Are there any things that might stop you from treating the therapists’ views, and enablers of and barriers to the provision of physical health of this population? physiotherapy services for people with SPMI so that potential issues or professional development needs may be addressed. Can you suggest anything that may facilitate you treating these people? The aim of this study was to determine factors influencing the provision of physiotherapy services to manage the physical wellbeing Has anyone got anything further to add such as questions they of people with SPMI from the perspective of the physiotherapist. would like to touch on again or answers they have withheld? Therefore, the research questions for this mixed methods study other lines of questioning to explore unexpected information in more were: detail. Information was collected regarding age, gender, number of years as a physiotherapist, current primary area of professional 1. What perceptions do physiotherapists have about their role in practice, current area of work, and location of practice. managing people with SPMI? Emails containing recruitment flyers were specifically directed to 2. What barriers do physiotherapists face when treating the physical physiotherapists from regional and urban areas, as well as from pri- wellbeing of people with SPMI and what enablers may improve vate practice and hospital settings in Western Australia to facilitate provision of physiotherapy services? the inclusion of physiotherapists from a broad range of clinical en- vironments. Recruitment continued until saturation (defined as no Method new information emerging from the final focus group and the final two consecutive interviews) was achieved. The recruitment process Design meant that not all participants had prior experience with people with SPMI, enabling an unfiltered perspective across the physiotherapy A mixed-methods design including both qualitative and quantita- community and which might inform about workforce capacity- tive approaches was used. Qualitative data were collected through building. Physiotherapists who fulfilled the eligibility criteria and focus groups and interviews with physiotherapists. These research indicated interest in participation were given detailed information methods provide deeper understanding of the complex beliefs that regarding the study and their role as participants. Participants were participants hold.12 Focus groups were chosen as the main method to made aware that the researcher was an honours student studying at collect data, because they promote discussion amongst participants Curtin University. The duration of the focus groups ranged from 60 to and enhance the communication of strongly held beliefs and per- 100 minutes and interviews 20 to 30 minutes. Each focus group and spectives.12 However, interviews were conducted where participants interview was audio-recorded using an iPad and transcribed could not attend a scheduled focus group. Qualitative data were re- verbatim. Each participant received a copy of the written transcript ported in accordance with the COREQ-32 checklist.13 Quantitative data for verification and appropriate amendments were made if requested. were collected via an online survey. Surveys allow for specific types of answers and opinions to be collected, whilst complementing the focus Quantitative component procedure of, and responses to, questions asked through qualitative methods.12 The Qualtrics platform was used for the web-based survey. The Participants survey hyperlink took potential participants to an online welcome screen containing Curtin-branded information about the study. A link Physiotherapists were recruited for the qualitative component to the survey was included in the emails sent out to physiotherapists from the city of Perth and regional Bunbury (Western Australia) by via the APA. Data analysis took place after the survey was closed. word of mouth and by email snowballing through local physiotherapy networks. The survey component was advertised using the APA’s The survey contained 16 close-ended, single-choice or multiple- email communication forum. There were no relationships between choice questions designed to better understand how often physio- the researchers and the participants prior to commencement of the therapists provide services to people with SPMI; physiotherapists’ at- study. Participants were required to be a registered physiotherapist titudes and knowledge regarding SPMI; the perceived role of currently working as a physiotherapist in Australia. No exclusion physiotherapy in mental health; and the need for professional devel- criteria were implemented. opment in the area of mental health. The survey took between 10 to 15 minutes to complete. The descriptive data that were collected Qualitative component procedure included: age, gender, years of experience as a physiotherapist, primary area of professional practice, area of work, primary place of employ- Focus groups and interviews took place between the 1 February ment, location of employment, and prior experience working in a 2018 and 30 June 2018 at the participants’ places of work. Prior to mental health setting. No identifying information was collected. commencement of data collection, the interviewer (EA) received training in qualitative research methods and analyses. An interview Data analysis schedule of open-ended questions and follow-up prompts (Box 1, with a more detailed version available as Appendix 1 on the eAd- Qualitative data were analysed by the interviewer. Key themes denda) was then developed and pilot tested. The interview schedule and subthemes were derived from the focus groups and interviews allowed direct discussion about the research questions and to follow primarily using an inductive approach. A component of deductive analysis was derived from our previous research.11 Interview tran- scripts were independently analysed by a second researcher (RF) to
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