Journal of Physiotherapy 68 (2022) 282 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: Physical Therapy Management of Older Adults With Hip Fracture Date of latest update: February 2022. Date of next update: Not stated. Patient link between recommendations and evidence, management options and statement group: Older adults with hip fracture. Intended audience: Physiotherapists. Addi- describing the influence of funding on guideline development; consideration of tional versions: N/A. Funded by: The Academy of Orthopaedic Physical Therapy benefits and harms; specific recommendations; and comprehensive implementation (AOPT) and Academy of Geriatric Physical Therapy (AGPT). Expert working group: advice and resources. Some weaknesses include limited information on: how the Physiotherapist clinicians and researchers, and a doctor. Consultation with: AOPT views of the end user and external reviewers informed the recommendations; and AGPT members, consumer/patient representatives and external stakeholders, strengths and limitations of the available evidence; how recommendations were claims reviewers, medical coding experts, academic and clinical educators, physician formulated; updating procedures; facilitators and barriers to implementation; specialists, and researchers. Approved by: Guideline authors and editors. Location: resource implications (eg, intervention costs); monitoring/auditing criteria for suc- https://doi.org/10.2519/jospt.2021.0301. cess of implementation; and how competing interests influenced processes and the development of recommendations.1 Key recommendations for future research Description: Recommendations for physiotherapy assessment and management were include: establish reliability estimates for assessment/measurement tools in developed by a series of author groups, with feedback from review panels. There were settings other than acute care (eg, the community), for both sexes, and when using 36 recommendations, of which 12 were strong recommendations (Level A evidence). assistive devices; establish predictive validity, sensitivity to change, responsiveness Assessment recommendations were (n = 5): test and document knee extension and minimal clinically important difference for assessment/measurement tools strength; administer and document the verbal rating scale for pain; use the gait speed where these are missing; establish reference values across the continuum of care test, documenting features of test administration (eg, use of an aid); use the Cumulated and recovery; and better reporting of effect size and minimal clinically important Ambulation Score in the acute and postacute settings to measure mobility until difference. ambulating independently; and use the Timed Up and Go test to measure mobility and falls risk, documenting features of test administration. Interprofessional management Provenance: Invited. Not peer reviewed. recommendations were (n = 7): participate in multicomponent, interprofessional non- pharmacological interventions for at-risk older adults undergoing surgery to prevent Joshua R Zadro delirium; assess risk factors for falls; and provide high-intensity resistance, balance, The University of Sydney, Australia weight-bearing and functional mobility training; treat patients in a multidisciplinary orthogeriatric program, providing physiotherapy and early mobilisation; assist transfer https://doi.org/10.1016/j.jphys.2022.08.007 out of bed and ambulation as soon as possible after hip fracture surgery and at least daily, unless contraindicated; provide opportunities for additional therapies to address Reference deficits in strength, balance and function, if deficits remain beyond 8 to 16 weeks after fracture; and provide recommendations to maximise safe physical activity. 1. Mcdonough CM, et al. J Orthop Sports Phys Ther. 2021;51:CPG1–CPG81. https://doi. org/10.2519/jospt.2021.0301 Commentary: The strengths of this guideline include: clear guideline objectives and research questions, description of the population, search methods, selection criteria, Appraisal of Clinical Practice Guideline: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU Date of latest update: September 2018. Date of next update: 2023. Patient group: management targeting light sedation, regular assessment of delirium using a valid tool, Critically ill adults. Intended audience: Clinicians, stakeholders and decision-makers in and management of delirium and immobility through rehabilitation or mobilisation. the intensive care area. Additional versions: Executive Summary https://doi.org/10.1 The guidelines recognise the low quality of existing evidence for rehabilitation and 097/CCM.0000000000003259. Expert working group: Thirty-two international ex- mobilisation but support performing these interventions over usual care. Imple- perts from a variety of multidisciplinary backgrounds plus four methodologists and four mentation is expected to be affected by feasibility issues such as the availability of critical illness survivors. Funded by: Nil disclosed. Consultation with: Four critical sufficient staff and resources. The guidelines are supported by an implementation illness survivors included in the guideline development panel. Approved by: Society of guide (https://doi.org/10.1097/CCM.0000000000003307) as well as teaching slides Critical Care Medicine. Location: https://doi.org/10.1097/CCM.0000000000003299. and translations available at www.sccm.org/iculiberation/guidelines. Evidence gaps are identified for each key topic area. Further research on rehabilitation and mobi- Description: Recommendations were made for five key topics (pain, agitation/seda- lisation is recommended to determine optimal modality, timing, dosage, staff expertise tion, delirium, immobility/rehabilitation/mobilisation and sleep disruption) pertaining and patient selection, as well as to standardise reporting and outcome measurement. to the management of adults in intensive care. A rigorous guideline development process was undertaken utilising the Grading of Recommendations, Assessment, Provenance: Invited. Not peer reviewed. Development and Evaluate (GRADE) approach. The guidelines provide 37 recom- mendations (two strong and 35 conditional) and two good practice statements. The Jenna Lang authors recommend that, due to the interrelated nature of the key topics, the guide- Monash University, Melbourne, Australia lines should be considered in their entirety rather than as individual recommenda- tions. Of relevance for physiotherapists, key recommendations and practice statements https://doi.org/10.1016/j.jphys.2022.08.005 support: the use of routine pain assessment, protocol-based pain and sedation 1836-9553/© 2022 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 68 (2022) 282 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: Physical Therapy Management of Older Adults With Hip Fracture Date of latest update: February 2022. Date of next update: Not stated. Patient link between recommendations and evidence, management options and statement group: Older adults with hip fracture. Intended audience: Physiotherapists. Addi- describing the influence of funding on guideline development; consideration of tional versions: N/A. Funded by: The Academy of Orthopaedic Physical Therapy benefits and harms; specific recommendations; and comprehensive implementation (AOPT) and Academy of Geriatric Physical Therapy (AGPT). Expert working group: advice and resources. Some weaknesses include limited information on: how the Physiotherapist clinicians and researchers, and a doctor. Consultation with: AOPT views of the end user and external reviewers informed the recommendations; and AGPT members, consumer/patient representatives and external stakeholders, strengths and limitations of the available evidence; how recommendations were claims reviewers, medical coding experts, academic and clinical educators, physician formulated; updating procedures; facilitators and barriers to implementation; specialists, and researchers. Approved by: Guideline authors and editors. Location: resource implications (eg, intervention costs); monitoring/auditing criteria for suc- https://doi.org/10.2519/jospt.2021.0301. cess of implementation; and how competing interests influenced processes and the development of recommendations.1 Key recommendations for future research Description: Recommendations for physiotherapy assessment and management were include: establish reliability estimates for assessment/measurement tools in developed by a series of author groups, with feedback from review panels. There were settings other than acute care (eg, the community), for both sexes, and when using 36 recommendations, of which 12 were strong recommendations (Level A evidence). assistive devices; establish predictive validity, sensitivity to change, responsiveness Assessment recommendations were (n = 5): test and document knee extension and minimal clinically important difference for assessment/measurement tools strength; administer and document the verbal rating scale for pain; use the gait speed where these are missing; establish reference values across the continuum of care test, documenting features of test administration (eg, use of an aid); use the Cumulated and recovery; and better reporting of effect size and minimal clinically important Ambulation Score in the acute and postacute settings to measure mobility until difference. ambulating independently; and use the Timed Up and Go test to measure mobility and falls risk, documenting features of test administration. Interprofessional management Provenance: Invited. Not peer reviewed. recommendations were (n = 7): participate in multicomponent, interprofessional non- pharmacological interventions for at-risk older adults undergoing surgery to prevent Joshua R Zadro delirium; assess risk factors for falls; and provide high-intensity resistance, balance, The University of Sydney, Australia weight-bearing and functional mobility training; treat patients in a multidisciplinary orthogeriatric program, providing physiotherapy and early mobilisation; assist transfer https://doi.org/10.1016/j.jphys.2022.08.007 out of bed and ambulation as soon as possible after hip fracture surgery and at least daily, unless contraindicated; provide opportunities for additional therapies to address Reference deficits in strength, balance and function, if deficits remain beyond 8 to 16 weeks after fracture; and provide recommendations to maximise safe physical activity. 1. Mcdonough CM, et al. J Orthop Sports Phys Ther. 2021;51:CPG1–CPG81. https://doi. org/10.2519/jospt.2021.0301 Commentary: The strengths of this guideline include: clear guideline objectives and research questions, description of the population, search methods, selection criteria, Appraisal of Clinical Practice Guideline: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU Date of latest update: September 2018. Date of next update: 2023. Patient group: management targeting light sedation, regular assessment of delirium using a valid tool, Critically ill adults. Intended audience: Clinicians, stakeholders and decision-makers in and management of delirium and immobility through rehabilitation or mobilisation. the intensive care area. Additional versions: Executive Summary https://doi.org/10.1 The guidelines recognise the low quality of existing evidence for rehabilitation and 097/CCM.0000000000003259. Expert working group: Thirty-two international ex- mobilisation but support performing these interventions over usual care. Imple- perts from a variety of multidisciplinary backgrounds plus four methodologists and four mentation is expected to be affected by feasibility issues such as the availability of critical illness survivors. Funded by: Nil disclosed. Consultation with: Four critical sufficient staff and resources. The guidelines are supported by an implementation illness survivors included in the guideline development panel. Approved by: Society of guide (https://doi.org/10.1097/CCM.0000000000003307) as well as teaching slides Critical Care Medicine. Location: https://doi.org/10.1097/CCM.0000000000003299. and translations available at www.sccm.org/iculiberation/guidelines. Evidence gaps are identified for each key topic area. Further research on rehabilitation and mobi- Description: Recommendations were made for five key topics (pain, agitation/seda- lisation is recommended to determine optimal modality, timing, dosage, staff expertise tion, delirium, immobility/rehabilitation/mobilisation and sleep disruption) pertaining and patient selection, as well as to standardise reporting and outcome measurement. to the management of adults in intensive care. A rigorous guideline development process was undertaken utilising the Grading of Recommendations, Assessment, Provenance: Invited. Not peer reviewed. Development and Evaluate (GRADE) approach. The guidelines provide 37 recom- mendations (two strong and 35 conditional) and two good practice statements. The Jenna Lang authors recommend that, due to the interrelated nature of the key topics, the guide- Monash University, Melbourne, Australia lines should be considered in their entirety rather than as individual recommenda- tions. Of relevance for physiotherapists, key recommendations and practice statements https://doi.org/10.1016/j.jphys.2022.08.005 support: the use of routine pain assessment, protocol-based pain and sedation 1836-9553/© 2022 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 68 (2022) 262–268 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 Ballistic resistance training has a similar or better effect on mobility than non-ballistic exercise rehabilitation in people with a traumatic brain injury: a randomised trial Gavin Williams a,b, Leanne Hassett c,d, Ross Clark e, Adam L Bryant b, Meg E Morris f, John Olver g, Louise Ada c aPhysiotherapy Department, Epworth Healthcare, Melbourne, Australia; bSchool of Physiotherapy, Faulty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; cSydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; dInstitute for Musculoskeletal Health, The University of Sydney, Sydney Local Health District, Sydney, Australia; eSchool of Health and Behavioural Sciences, University of the Sunshine Coast, Sippy Downs, Australia; fThe Victorian Rehabilitation Centre Healthscope & Academic and Research Collaborative in Health (ARCH), La Trobe University, Melbourne, Australia; gRehabilitation Medicine, Epworth Healthcare, Melbourne, Australia KEYWORDS ABSTRACT Brain injuries Questions: In people recovering from traumatic brain injury, is a 3-month ballistic resistance training Traumatic program targeting three lower limb muscle groups more effective than non-ballistic exercise rehabilitation Resistance training for improving mobility, strength and balance? Does improved mobility translate to better health-related Mobility limitation quality of life? Design: A prospective, multicentre, randomised trial with concealed allocation, intention- Rehabilitation to-treat analysis and blinded measurement. Participants: A total of 144 people with a neurological move- ment disorder affecting mobility as a result of traumatic brain injury. Intervention: For 3 months, the experimental group had three 60-minute sessions of non-ballistic exercise rehabilitation per week replaced by ballistic resistance training. The control group had non-ballistic exercise rehabilitation of equivalent time. The non-ballistic exercise rehabilitation consisted of balance exercises, lower limb stretching, conventional strengthening exercises, cardiovascular fitness training and gait training. Outcome measures: The primary outcome was mobility measured using the High-Level Mobility Assessment Tool (HiMAT). Secondary out- comes were walking speed, strength, balance and quality of life. They were measured at baseline (0 months), after completion of the 3-month intervention (3 months) and 3 months after cessation of intervention (6 months). Results: After 3 months of ballistic resistance training, the experimental group scored 3 points (95% CI 0 to 6) higher on the 54-point HiMAT than the control group and remained 3 points (95% CI –1 to 6) higher at 6 months. Although there was a transient decrement in balance at 3 months in the experimental group, the interventions had similar effects on all secondary outcomes by 6 months. Participants with a baseline HiMAT , 27 gained greater benefit from ballistic training: 6 points (1 to 10) on the HiMAT. Conclusion: This randomised trial shows that ballistic resistance training has a similar or better effect on mobility than non- ballistic training in people with traumatic brain injury. It may be better targeted towards those with more severe mobility limitations. Trial registration: ACTRN12611001098921. [Williams G, Hassett L, Clark R, Bryant AL, Morris ME, Olver J, Ada L (2022) Ballistic resistance training has a similar or better effect on mobility than non-ballistic exercise rehabilitation in people with a traumatic brain injury: a randomised trial. Journal of Physiotherapy 68:262–268] © 2022 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 important for many social, leisure and sporting activities, yet Traumatic brain injury (TBI) is the leading cause of death and approximately 75% of people with moderate to severe TBI do not disability in adolescents and adults aged up to 45 years.1 The inci- resume their pre-morbid activities.2 Mobility limitations can have dence of TBI in Australia is 300 per 100,000.1 Mobility limitations are common in people with moderate to severe TBI.2,3 Reduced walking pervasive and extensive physiological and psychological sequelae, speed and endurance can restrict the ability to perform everyday and are associated with reduced cardiovascular fitness, increased activities, access the community, cross roads or keep up with peers. susceptibility to fatigue and reduced ability to exercise aerobically Higher level mobility skills, such as the ability to run and jump, are after TBI,4-6 as well as poor emotional health.7,8 Despite the prevalence and severity of motor impairments such as poor balance and spasticity, the main contributor to mobility https://doi.org/10.1016/j.jphys.2022.09.004 1836-9553/© 2022 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 263 limitations following TBI is low muscle power generation from envelopes, which were opened after completion of the baseline paretic muscles.9–11 Many clinical trials have shown strength training measurement by the therapist delivering the intervention. Due to the to be effective for improving muscle strength for people with nature of the intervention the participants and the therapist deliv- neurological conditions, yet these improvements have often failed to ering the intervention could not be blinded to the participants’ group translate into improved mobility.12,13 They appear to have failed for allocation. two main reasons: exercises were performed slowly with low power production,12 and most exercises did not target the three main For 3 months, participants in the experimental group had three of muscle groups (ie, ankle plantarflexors, hip flexors and hip extensors) their 60-minute sessions of usual physiotherapy intervention that provide the majority of power generation for forward propul- replaced by three 60-minute sessions of ballistic resistance training sion.12,14,15 The American College of Sports Medicine publishes per week (including ballistic resistance and gait training), while the guidelines for resistance training,16 which highlight the importance of control group had three of their 60-minute sessions of usual phys- exercise specificity. Past failures of clinical trials in neurological co- iotherapy intervention standardised (including conventional horts to improve walking have led to the development of a new strength, balance, stretch, cardiovascular fitness and gait training) so biomechanics-driven framework for resistance training,17 which aims that all participants had equivalent overall therapy time. The acute to implement resistance exercises that replicate muscle function for recovery phase following TBI is longer than in other areas of neuro- walking. logical rehabilitation, partly due to cognitive deficits affecting learning. However, prior research has shown that a 3-month inter- Muscle strength reflects the maximum amount of force a muscle vention is sufficient to detect gains in mobility in people who have can produce, whereas muscle power reflects how quickly force can be sustained a TBI within the last 12 months.29 The therapists were generated, or the ‘rate of force production’. Ballistic, or fast, resistance dedicated trial therapists for both groups and the timing of sessions exercises are used to improve muscle power generation,16 yet are was organised so that participants were unaware of who the other relatively novel in neurological rehabilitation.18 Ballistic resistance participants were and what their intervention was. An independent exercises are feasible for people with TBI to improve power genera- clinician trained in collecting outcome measures and blinded to the tion for mobility;19,20 they are important as they train muscles to group allocations measured outcomes at baseline (0 months), after contract quickly, which is required for walking21 and higher levels of completion of the 3-month intervention (3 months), and 3 months mobility such as stair climbing and running. In people with neuro- after cessation of intervention (6 months). logical conditions, ballistic resistance training is safe and feasible,18 and associated with a 60 to 74% increase in peak power genera- Participants, therapists, centres tion.19 Further, ballistic exercises can improve lower-limb power generation during walking and, in some cases, can reverse compen- To be eligible to participate in the study, patients were required to satory patterns that may develop during the early recovery phase.22 have a neurologically based movement disorder affecting mobility as Most importantly, improved mobility is associated with greater a result of TBI (TBI severity determined by duration of post-traumatic health-related quality of life in TBI,23 and improved physical out- amnesia measured prospectively using the Westmead post-traumatic comes have been identified as an international research priority.24 amnesia scale30). The other inclusion and exclusion criteria are detailed in Box 1. Therefore, the research questions for this prospective, multicentre, randomised trial were: Information such as age, sex, height, weight, severity of injury (length of time of post-traumatic amnesia), time since injury and In people recovering from TBI, orthopaedic injuries was collected to describe the sample. 1) is a 3-month ballistic resistance training program more effec- Therapists delivering the intervention were included if they were tive than non-ballistic exercise rehabilitation for improving physiotherapists or exercise physiologists with a minimum of 3 years mobility, leg strength and balance? of experience working in TBI and neurological rehabilitation. 2) does improved mobility translate to better health-related Dedicated brain injury units were included if they had 50 pa- quality of life? tients with TBI admitted acutely per year. Methods Intervention Design The experimental group received ballistic resistance training (Appendix 3 on the eAddenda) that was performed according to the A prospective, multicentre, randomised, single blind trial of a American College of Sports Medicine guidelines governing frequency, 3-month exercise program was conducted during the early phase of duration, intensity and progression to ensure an optimal training rehabilitation following TBI (Figure 1). The trial protocol was stimulus and transfer of training gains.16 The muscle groups targeted registered (Australian New Zealand Clinical Trials Registry for power generation were the ankle plantarflexors, hip flexors and ACTRN12611001098921), published,25 conformed to the CONSORT hip extensors, and the muscle groups targeted for power absorption guidelines26 (Appendix 1 on the eAddenda) for reporting clinical were the knee extensors. Ballistic resistance training was tailored to trials and the CONSERVE statement for reporting trials affected by the severity of strength deficits with initial loads being low to facil- coronavirus (COVID-19),27 and was reported using the template for itate high contraction velocities. When participants could consistently intervention description and replication (TIDieR) checklist (Appendix perform the high velocity exercises, the load was progressively 2 on the eAddenda).28 People with TBI were recruited from brain increased.16 The exercises included: leg extension jumps on a ‘leg injury units in Victoria, New South Wales and South Australia in sled’; calf raises on a ‘leg sled’; stair ascent and descent; reciprocal leg Australia. Participants were randomised to the experimental or con- extension on a mini-trampoline; and fast cyclical hip and knee flexion trol group via a randomisation schedule that was prepared by the in standing.25 trial biostatistician who was not involved in recruitment or mea- surement. Allocation was stratified according to site and level of The control group received balance exercises, lower limb disability such that participants scoring 27 on the High-level stretching, conventional strengthening exercises, cardiovascular Mobility Assessment Tool (HiMAT) were classified as moderate, and fitness training and gait training.6,8,31 The exercises included: static those scoring , 27 were classified as severe. Random permuted balance exercises (single limb or tandem stance); dynamic balance blocks were used so that after every block, the two groups contained exercises (figure of eight or heel-to-toe walk); stretching of major approximately equal numbers of each level of disability. Group allo- muscle groups; conventional strengthening exercises on a leg press or cation was concealed using consecutively numbered, opaque quadriceps curl focusing on high resistance and slow force produc- tion; and cardiovascular fitness training using an exercise bike or arm ergometer.
264 Williams et al: Ballistic training for traumatic brain injury Screening of people admittedfor rehabilitation after TBI (n = 2,074) Reasons for exclusiona • no movement disorder as a result of TBI (n = 1,108) • not correct age or time after injury (n = 266) • not mobile enough (n = 174) • had conditions preventing participation (n = 194) • did not consent (n = 32) • other (n = 155) • randomised in error (n = 1) Measured mobility, walking speed, strength, balance, HRQoL (n = 144) Month 0 n = 70 n = 74 Lost to follow-up (n = 8) Experimental group Control group Lost to follow-up (n = 5) • Ballistic resistance and • Non-ballistic exercises (strength, • withdrew (n = 2) • withdrew (n = 1) • unavailable (n = 5) gait training, 60 min x 3 balance, stretch, cardiovascular • unavailable (n = 2) • COVID (n = 1) sessions/wk x 12 wk fitness, gait training), 60 min x 3 • COVID (n = 2) • Standard rehabilitation sessions/wk x 12 wk • Standard rehabilitation Month 3 Measured mobility, walking speed, strength, balance, HRQoL (n = 131) Lost to follow-up (n = 6) n = 62 n = 69 • withdrew (n = 2) • unavailable (n = 3) • Standard rehabilitation • Standard rehabilitation Lost to follow-up (n = 11) • COVID (n = 1) • withdrew (n = 2) • unavailable (n = 6) • COVID (n = 3) Month 6 Measured mobility, walking speed, strength, balance, HRQoL (n = 114) n = 56 n = 58 Figure 1. Design and flow of participants through the trial. a Participants could be excluded for more than one reason. COVID = coronavirus, HRQoL = health-related quality of life, TBI = traumatic brain injury. Box 1. Eligibility criteria for participants. Both groups received up to 10 minutes of gait training each ses- sion focusing on: the quality of walking; walking outdoors and over Patients with TBI were included if they: uneven surfaces; and road crossing for community access. had a neurologically based movement disorder affecting Dedicated trial therapists received training in delivery of the mobility as a result of TBI experimental and control interventions to ensure consistency. Inde- pendent annual inspections were conducted at each facility to ensure out of post-traumatic amnesia the fidelity of the intervention. The content of sessions for both groups were aged 15 to 65 years was recorded so that adherence to the protocol could be reported. were , 12 months post-injury could fully weight bear and walk independently (without Outcome measures assistance from an aid or therapist) for 10 m Primary outcome had a mobility limitation (scored , 50 for males, , 44 for The primary outcome was mobility measured using the females on the HiMAT) HiMAT.32,33 It consists of 13 mobility items such as walking, stair use, Patients were excluded if they: running, skipping, hopping and jumping. The HiMAT was selected as the primary outcome measure because people with TBI are typically or their proxy, were unwilling or unable to provide informed younger than people with other neurological health conditions and consent therefore require higher levels of mobility to participate fully in their community. Each item is measured using either a stopwatch or tape had a previously diagnosed central nervous system disorder measure and scored and summed for a total HiMAT score (0 to 54), had severe cognitive or behavioural problems that prevented where higher scores indicate better performance. The HiMAT has been validated for use in TBI, with a 4-point improvement being participation considered clinically worthwhile.33 had orthopaedic conditions (eg, osteoarthritis) or injuries restricting mobility. HiMAT = High-level Mobility Assessment Tool, TBI = traumatic brain injury.
Research 265 Table 1 Characteristics of participants and centres at baseline. Characteristic All Randomised Lost to month 3 follow-up Lost to month 6 follow-up (n = 144) (n = 144) (n = 13) (n = 30) Exp (n = 70) Con (n = 74) Exp (n = 8) Con (n = 5) Exp (n = 14) Con (n = 16) Participants 34 (14) 34 (14) 34 (14) 33 (17) 38 (18) 31 (14) 33 (16) Age (yr), mean (SD) 112 (78) 54 (77) 58 (78) 6 (75) 3 (60) 12 (86) 11 (69) Sex, n males (%) 1.77 (0.09) 1.77 (0.09) 1.77 (0.09) 1.71 (0.09) 1.80 (0.13) 1.73 (0.08) 1.76 (0.09) Height (m), mean (SD) 76 (14) 75 (16) 77 (12) 70 (19) 69 (9) 73 (17) 73 (10) Weight (kg), mean (SD) 115 (76) 114 (76) 116 (77) 88 (24) 81 (36) 117 (93) 103 (77) Time since trauma (days), mean (SD) 59 (40) 61 (41) 57 (40) 48 (23) 45 (39) 61 (39) 53 (53) Time in PTA (days), mean (SD) (n = 68) (n = 73) (n = 15) 122 (85) 7 (88) 4 (80) 12 (81) Lower-limb orthopaedic injuries, n (%) 16 (11) 58 (83) 64 (86) 1 (12) 1 (20) 2 (14) 13 (81) 0 fractures 6 (4) 10 (14) 6 (8) 0 (0) 0 (0) 0 (0) 2 (13) 1 fracture 6 (4) 4 (5) 5 (2) 7 (5) 6 (3) 1 (6) 2 fractures 64 (44) 2 (3) 6 (4) 3 (38) 2 (40) 6 (43) 7 (4) 6 (4) 6 (38) Glasgow Coma Scale (1 to 15), mean (SD) 91 (63) 30 (43) 34 (46) 5 (63) 2 (40) 8 (57) Affected side, n right (%) 16 (11) 1 (13) 0 (0) 1 (7) 7 (44) Centres, n participants (%) 25 (17) 45 (64) 46 (62) 2 (25) 2 (40) 4 (29) 2 (13) A 1 (1) 7 (10) 9 (12) 0 (0) 0 (0) 0 (0) 5 (31) B 11 (8) 12 (17) 13 (18) 0 (0) 1 (20) 1 (7) 0 (0) C 1 (1) 0 (0) 2 (13) D 5 (7) 6 (8) E PTA = post-traumatic amnesia. Secondary outcomes Results Self-selected walking speed was measured using the 10-m walk Flow of participants through the trial test and reported in metres per second. A total of 144 people with TBI were recruited from five Muscle strength was measured with a six-repetition maximum rehabilitation centres across Australia. Participants in the experi- seated single leg press performed on the participant’s more-affected mental and control groups were similar in terms of age, sex, leg and reported in kilograms. height/weight, affected side, orthopaedic injuries, time in post- traumatic amnesia and Glasgow Coma Scale scores (Table 1). By Balance was measured with the Single Leg Stance test for each leg month 3, 13 participants (9%) were lost to follow-up and by with eyes open and eyes closed, and the average of the four condi- month 6, 30 participants (21%) were lost to follow-up (Figure 1). tions reported in seconds (maximum 30 seconds). The reasons for loss to follow-up were: unavailability due to returning to a regional area (n = 16), COVID restrictions (n = 7) Health-related quality of life was measured with the Assessment and withdrawal or refusal (n = 7). The primary outcome was of Quality of Life (AQOL-6D) and reported as a score from –0.04 to collected from 100% of the retained participants at month 3 and 1.00, with higher scores indicating better quality of life. It consists of month 6. 20 questions across six domains (independent living, social, mental health, coping, pain and sensory perception). It has been validated in Eight therapists delivered the intervention (mean 28 participants, an Australian sample of people with TBI, and has been used to SD 8): they had on average 6 years of clinical experience (SD 2) and demonstrate that improved mobility is associated with better quality four (50%) had postgraduate qualifications. of life following TBI.23 An adolescent version was used for partici- pants aged , 18 years. Data analysis Compliance with trial method Sample size calculations were based on data obtained from For the participants who were analysed at 3 months, the mean two studies where the HiMAT was the primary outcome mea- number of sessions delivered was 31 (SD 3) out of a possible 36 (ie, sure.10,29 These data were from TBI populations similar to the 86%) and this was similar between the experimental group (mean 30, current sample. The planned sample size of 66 patients per group SD 2) and the control group (mean 32, SD 4). The mean session time (ie, 132 in total) was based on an analysis of covariance (ANCOVA) was 43 minutes (SD 8). A total of 191 sessions were missed due to primary endpoint analysis. This sample size allowed reporting of COVID, and recruitment was placed on hold for extended periods at a clinically worthwhile difference in HiMAT scores ( 4 points out three sites. Participants in the experimental group spent an average of of 54) at the 5% level (two-tailed), with a power of 90%. Allowing 41 minutes exercising per 60-minute session (total time 2,878 mi- for a drop-out rate of 20% equated to 83 per group (ie, a total nutes) compared with 45 minutes for the control group (total time sample size of 166). 3,252 minutes). There were two study-related adverse events in the experimental group; both were non-injurious falls that did not pre- The endpoint was 6 months after admission to the study. vent the participant from continuing the session. The secondary ANCOVA was used to estimate group differences at 3 and 6 months. outcome measure–muscle power generation–was not measured in The analysis was adjusted for baseline HiMAT score, patient age, sex this trial as originally intended. A preliminary study used a string and severity of injury (length of time of post-traumatic amnesia). potentiometer as a surrogate measure of muscle power generation.19 The three missing post-traumatic amnesia scores were replaced Further testing of this method demonstrated that it was not a valid with the group mean. The primary analysis was intention-to-treat. measure of muscle power in a clinical setting, which meant that this Given that there was a high delivery of the intervention, the plan- secondary outcome measure had to be removed from the protocol. ned per protocol analysis was not undertaken but the analysis ac- Examination of protocol adherence did not find any other protocol cording to initial mobility (ie, baseline , 27 or 27 on HiMAT) was breaches. undertaken. Statistical analysisa was carried out by an independent statistician.
266 Williams et al: Ballistic training for traumatic brain injuryDifference between groupsaExp minus Con 3 (–1 to 6) Month 3 minus Month 0 Month 6 minus Month 0 –0.01 (–0.13 to 0.11) Effect of intervention 0 (–9 to 9) In terms of mobility, the experimental group scored 3 points (95% –1.0 (–3.0 to 0.9) CI 0 to 6) higher on the HiMAT than the control group (Table 2) after 3 –0.01 (–0.04 to 0.04) months of ballistic resistance training. By 6 months, they scored 3 points (95% CI –1 to 6) higher than the control group.Exp minus Con3 (0 to 6) AQOL-6D = Assessment of Quality of Life, Con = control group, Exp = experimental group, HiMAT = High-level Mobility Assessment Tool, HRQoL = health-related quality of life, 6RM = six-repetition maximum. 0.01 (–0.10 to 0.11) a ANCOVA adjusted for baseline HiMAT score, age, sex and length of time in post-traumatic amnesia. For walking speed, the groups had similar results. At 3 months, the experimental group walked 0.01 m/s (95% CI –0.10 to 0.11) faster than–3 (–11 to 4) the control group. By 6 months, they were 0.01 m/s (95% CI –0.11 to –1.9 (–3.6 to –0.3) 0.14) slower than the control group. –0.03 (–0.06 to 0.01) For muscle strength, the groups had similar results. The experi-Month 6 minus Month 0Exp (n = 70) Con (n = 74) Exp (n = 62) Con (n = 69) Exp (n = 56) Con (n = 58) Exp Con Exp Con11 (10)0.27 (0.34) 0.28 (0.29) 0.34 (0.36) 0.35 (0.33)24 (24)5.0 (6.3)–0.07 (0.09) –0.04 (0.10) –0.06 (0.11) –0.06 (0.11)(n = 53) mental group was 3 kg (95% CI –4 to 11) weaker than the control group at 3 months and they were equivalent (95% CI –9 to 9) by 6Difference within groups14 (11) 25 (24) 3.8 (4.8) (n = 53) months. Month 3 minus Month 0 8 (9) 22 (24) 5.0 (5.5) (n = 63) In terms of balance, the experimental group could stand on one Table 2 leg for 1.9 s (95% CI 0.3 to 3.6) less than the control group at 311 (9) 19 (18) 3.0 (4.2) (n = 58) Mean (SD) of groups, mean (95% CI) difference within groups, and mean (95% CI) difference between groups (intention-to-treat analysis). months; however, the groups were again similar by 6 months, when the experimental group could stand on one leg for 1.0 s (95% CI –0.9Month 628 (15) to 3.0) less. 1.31 (0.43) For health-related quality of life, the groups had similar results. At63 (33) 3 months, the experimental group scored 0.03 points (95% CI –0.01 to 11.7 (7.9) 0.06) lower on the AQOL-6D than the control group. By 6 months, 0.41 (0.11) they scored 0.01 points (95% CI –0.04 to 0.04) lower than the control (n = 54) group. 32 (14) Subgroup analysis 1.39 (0.35) At 3 months, ballistic resistance training produced an extra 655 (32) points (95% CI 1 to 10) on the 54-point HiMAT in the subgroup of (n = 51) participants with a baseline HiMAT , 27 (Table 3). 12.9 (7.0) 0.40 (0.14) For all outcomes, individual participant data are presented in (n = 54) Table 4 on the eAddenda. Groups 25 (15) DiscussionMonth 3 1.24 (0.42) This randomised trial found that replacing three sessions per59 (35) week of non-ballistic exercise rehabilitation with ballistic resistance(n = 68) training resulted in similar or better mobility. This was largely 11.7 (7.7) maintained at 6 months. The two types of exercise rehabilitation had 0.42 (0.10) similar effects on the secondary outcome measures. An exploratory (n = 64) subgroup analysis found the use of ballistic resistance training led to even greater improvements in mobility among those with more se-30 (13) vere disability. 1.34 (0.35) Although the 3 months of ballistic resistance training resulted in50 (24) better mobility than non-ballistic exercise rehabilitation, it was not as a(n = 60) consequence of faster walking. The increase in HiMAT scores reflected 12.2 (7.6) an increase in the ability to perform tasks that involve a flight phase (ie, 0.39 (0.11) running, skipping, hopping and jumping). In addition, there was no (n = 58) important between-group difference in strength, probably because strength was measured as force production rather than power gener-Month 018 (12) ation, which was trained in the experimental group. There was a0.98 (0.41) transient observation at 3 months, where the control group had better balance than the experimental group and this may have been because37 (22) balance training was included in their intervention, which reflected 7.1 (6.2) usual physiotherapy intervention. By 6 months, the between-group 0.46 (0.11) difference had weakened to only 1 second, with enough uncertainty (n = 67) that it became unclear whether any effect is sustained. 19 (12) The participants in this trial had extremely severe traumatic brain1.06 (0.41) injuries.30 They were 4 months post injury and had spent around two of those months in post-traumatic amnesia. Their Glasgow Coma 33 (20) Scale score was on average 6, which is considered to be a very severe 9.1 (6.7) brain injury. They were mostly male, in their mid-30s and although 0.46 (0.11) they walked at about two-thirds of normal speed, their balance was (n = 64) poor. Nevertheless, both groups made marked gains over the 6 months of the trial, with walking speed and strength increasing to normal levels, although balance remained fairly poor. However, quality of life did not change over this time; this may be because the participants, who were primarily recruited as hospital inpatients, were subsequently faced with restrictions to societal participation Outcome Mobility HiMAT (0 to 54) Walking speed 10-m walk test (m/s) Muscle strength 6RM seated leg press (kg) Balance Single Leg Stance Test (s) HRQoL AQOL-6D (–0.04 to 1.00)
Research 267 Table 3 Post-hoc subgroup analysis of low scorers (, 27 on HIMAT) versus high scorers ( 27 on HiMAT) for 3-month mobility. Outcome Groups Between-group difference within subgroupsa Subgroup , 27 Subgroup 27 Subgroup , 27 Subgroup 27 Exp (n = 55) Con (n = 58) Exp (n = 16) Con (n = 15) Exp minus Con Exp minus Con Mobility at 3 months 25 (12) 21 (13) 42 (9) 44 (9) 6 (1 to 10) 0 (–7 to 6) HiMAT (0 to 54) (n = 46) (n = 56) (n = 16) (n = 13) (n = 102) (n = 29) Con = control group, Exp = experimental group, HiMAT = High-level Mobility Assessment Tool. a Linear regression model adjusted for baseline HiMAT score, age, sex and length of time in post-traumatic amnesia. once they had been discharged from hospital. In general, higher levels Research and Ethics Committee (project number: 144/16). Data were of mobility are associated with greater societal participation and collected after informed consent was gained. quality of life after traumatic injury.23 However, transitioning home in the subacute rehabilitative phase is a time of considerable adjustment Competing interests: Nil. and likely to have impacted quality of life. Source(s) of support: Epworth Healthcare and the Royal Auto- mobile Club of Victoria funded the pilot of this project. National The improvement in mobility is in line with an earlier study of Health and Medical Research Council Project Grant (APP1104237) ballistic resistance training in stroke.34 The differential benefit for funded the main project. Gavin Williams, Adam Bryant and Ross Clark those with lower mobility at baseline is an unusual finding in are supported by National Health and Medical Research Council neurological mobility studies, where the trend is for the more mobile Fellowships. to benefit more from clinical interventions.35,36 However, the more Acknowledgements: The authors wish to acknowledge all the mobile participants in studies of stroke are comparable with the less therapists and blinded assessors who assisted in the delivery of this mobile people with TBI in this current study. Taken together, it ap- trial, and the assistance of Sean McGuigan, Dean McKenzie and Stella pears that people walking . 0.5 m/s but scoring , 27 on the HiMAT May Gwini for their contribution to the data analysis section and may be most likely to benefit from ballistic resistance training. sample size calculations. Provenance: Not invited. Peer reviewed. This randomised trial had both strengths and weaknesses. Its Correspondence: Gavin Williams, Physiotherapy Department, main strengths were that it was fully powered, the groups were Epworth Healthcare, Australia. Email: [email protected] similar in baseline characteristics, there was concealed allocation to groups, measurers were blinded to group allocation, and an References intention-to-treat analysis was performed. Furthermore, most of the intervention was delivered despite the disruptions caused by the 1. O’Connor P. Hospitalisation due to traumatic brain injury (TBI), Australia 1997-98. COVID-19 pandemic. However, there was no blinding of participants In: Injury Research & Statistics. Adelaide: Australian Institute of Health and Welfare; or therapists, which is difficult in complex physiotherapy in- 2002. terventions. Furthermore, there was . 20% loss to follow-up at 6 months, so these results need to be interpreted with caution. 2. Ponsford JL, Olver JH, Curran C. A profile of outcome: 2 years after traumatic brain injury. Brain Inj. 1995;9:1–10. The main clinical implications of this study are two-fold. First, specific resistance training,16,17 which requires exercises to be pre- 3. Olver JH, Ponsford JL, Curran CA. Outcome following traumatic brain injury: a scribed in a way that replicates how muscles function (ie, is fast or comparison between 2 and 5 years after injury. Brain Inj. 1996;10:841–848. ballistic), has a similar or better effect on mobility than non-ballistic exercise rehabilitation in people recovering from TBI. Second, the 4. Hassett L, Moseley A, Harmer A. The Aetiology of Reduced Cardiorespiratory exploratory subgroup analysis indicates that it may be beneficial to Fitness Among Adults with Severe Traumatic Brain Injury and the Relationship target those who can walk independently yet still score , 27 on the with Physical Activity: A Narrative Review. Brain Impairment. 2015;17:43–54. HiMAT. 5. Sullivan SJ, Richer E, Laurent F. The role of and possibilities for physical condi- In conclusion, this randomised trial suggests that ballistic resis- tioning programmes in the rehabilitation of traumatically brain-injured persons. tance training has a similar or better effect on mobility than non- Brain Inj. 1990;4:407–414. ballistic exercise rehabilitation in people following TBI and may be particularly helpful for individuals with more severe mobility limi- 6. Bateman A, Culpan FJ, Pickering AD, Powell JH, Scott OM, Greenwood RJ. The effect tations, but not at the expense of balance training. of aerobic training on rehabilitation outcomes after recent severe brain injury: a randomized controlled evaluation. Arch Phys Med Rehabil. 2001;82:174–182. What was already known on this topic: Mobility limitations are common in people with a traumatic brain injury. Although 7. Curran CA, Ponsford JL, Crowe S. Coping strategies and emotional outcome poor balance and spasticity are common, the main contributor to following traumatic brain injury: a comparison with orthopedic patients. J Head mobility limitations after traumatic brain injury is low muscle Trauma Rehabil. 2000;15:1256–1274. power generation. What this study adds: Ballistic resistance training has a similar 8. Basford JR, Chou LS, Kaufman KR, Brey RH, Walker A, Malec JF, et al. An assessment or better effect on mobility than non-ballistic exercise rehabili- of gait and balance deficits after traumatic brain injury. Arch Phys Med Rehabil. tation in people with a traumatic brain injury. Using ballistic 2003;84:343–349. resistance training in place of some non-ballistic exercise reha- bilitation seems particularly useful among those with low base- 9. Williams GP, Morris ME. Tests of static balance do not predict mobility perfor- line mobility. mance following traumatic brain injury. Physiother Can. 2011;63:58–64. Footnotes: aStata Statistical Package v17, StataCorp, College 10. Williams GP, Schache AG, Morris ME. Mobility after traumatic brain injury: re- Station, TX, USA. lationships with ankle joint power generation and motor skill level. J Head Trauma Rehabil. 2013;28:371–378. eAddenda: Appendices 1 to 3, Table 4 available at https://doi.org/ 10.1016/j.jphys.2022.09.004 11. Williams G, Banky M, Olver J. Distribution of Lower Limb Spasticity Does Not In- fluence Mobility Outcome Following Traumatic Brain Injury: An Observational Ethics approval: Human Research Ethics Committee, Epworth Study. J Head Trauma Rehabil. 2015;30:E49–E57. Healthcare, Melbourne, Australia (53211) and Alfred Health Human 12. Williams G, Kahn M, Randall A. Strength Training for Walking in Neurologic Rehabilitation Is Not Task Specific: A Focused Review. Am J Phys Med Rehabil. 2014;93:511–522. 13. Dorsch S, Ada L, Alloggia D. Progressive resistance training increases strength after stroke but this may not carry over to activity: a systematic review. J Physiother. 2018;64:84–90. 14. Neptune RR, Sasaki K, Kautz SA. The effect of walking speed on muscle function and mechanical energetics. Gait Posture. 2008;28:135–143. 15. Liu MQ, Anderson FC, Pandy MG, Delp SL. Muscles that support the body also modulate forward progression during walking. J Biomech. 2006;39:2623–2630. 16. Ratamess NA, Alvar BA, Evetoch TK, Housh TJ. Progression Models in Resistance Training for Healthy Adults. Med Sci Sports Exercise. 2009;41:687–708. 17. Williams G, Hassett L, Clark R, Bryant A, Olver J, Morris ME, et al. Improving Walking Ability in People With Neurological Conditions: A Theoretical Framework for Biomechanics-Driven Exercise Prescription. Arch Phys Med Rehabil. 2019;100:1184–1190. 18. Cordner T, Egerton T, Schubert K, Wijesinghe T, Williams G. Ballistic Resistance Training: Feasibility, Safety, and Effectiveness for Improving Mobility in Adults
268 Williams et al: Ballistic training for traumatic brain injury With Neurologic Conditions: A Systematic Review. Arch Phys Med Rehabil. 28. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better 2021;102:735–751. reporting of interventions: template for intervention description and replication 19. Williams GP, Clark RAP, Hansson JB, Paterson KP. Feasibility of Ballistic Strength- (TIDieR) checklist and guide. BMJ. 2014;348:g1687. ening Exercises in Neurologic Rehabilitation. Am J Phys Med Rehabil. 2014;96:828– 833. 29. Williams GP, Morris ME. High-level mobility outcomes following acquired brain 20. Williams GP, Schache AG. Evaluation of a conceptual framework for retraining injury: a preliminary evaluation. Brain Inj. 2009;23:307–312. high-level mobility following traumatic brain injury: two case reports. J Head Trauma Rehabil. 2010;25:164–172. 30. Shores EA, Marosszeky JE, Sandanam J, Batchelor J. Preliminary validation of a 21. Mentiplay BF, Banky M, Clark RA, Kahn MB, Williams G. Lower limb angular ve- clinical scale for measuring the duration of post-traumatic amnesia. Med J Aust. locity during walking at various speeds. Gait Posture. 2018;65:190–196. 1986;144:569–572. 22. Williams G, Schache AG. The distribution of positive work and power generation amongst the lower-limb joints during walking normalises following recovery from 31. Marshall S, Teasell R, Bayona N, Lippert C, Chundamala J, Villamere J, et al. Motor traumatic brain injury. Gait Posture. 2016;43:265–269. impairment rehabilitation post acquired brain injury. Brain Inj. 2007;21:133–160. 23. Williams G, Willmott C. Higher levels of mobility are associated with greater so- cietal participation and better quality-of-life. Brain Inj. 2012;26:1065–1071. 32. Williams G, Robertson V, Greenwood K, Goldie P, Morris M. The high-level mobility 24. Zitnay GA, Zitnay KM, Povlishock JT, Hall ED, Marion DW, Trudel T, et al. Traumatic assessment tool (HiMAT) for traumatic brain injury. Part 2: content validity and brain injury research priorities: the Conemaugh International Brain Injury Sym- discriminability. Brain Inj. 2005;19:833–843. posium. J Neurotrauma. 2008;25:1135–1152. 25. Williams G, Ada L, Hassett L, Morris ME, Clark R, Bryant AL, et al. Ballistic strength 33. Williams G, Robertson V, Greenwood K, Goldie P, Morris ME. The concurrent val- training compared with usual care for improving mobility following traumatic idity and responsiveness of the high-level mobility assessment tool for measuring brain injury: protocol for a randomised, controlled trial. J Physiother. 2016;62:164. the mobility limitations of people with traumatic brain injury. Arch Phys Med 26. Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for Rehabil. 2006;87:437–442. reporting parallel group randomised trials. BMJ. 2010;340:c332. 27. Orkin AM, Gill PJ, Ghersi D, Campbell L, Sugarman J, Emsley R, et al. Guidelines for 34. Hendrey G, Clark RA, Holland AE, Mentiplay BF, Davis C, Windfeld-Lund C, et al. Reporting Trial Protocols and Completed Trials Modified Due to the COVID-19 Feasibility of Ballistic Strength Training in Subacute Stroke: A Randomized, Pandemic and Other Extenuating Circumstances: The CONSERVE 2021 State- Controlled, Assessor-Blinded Pilot Study. Arch Phys Med Rehabil. 2018;99:2430– ment. JAMA. 2021;326:257–265. 2446. 35. Dean CM, Rissel C, Sherrington C, Sharkey M, Cumming RG, Lord SR, et al. Exercise to Enhance Mobility and Prevent Falls After Stroke: The Community Stroke Club Randomized Trial. Neurorehab Neural Repair. 2012;26:1046–1057. 36. Dean CM, Ada L, Lindley RI. Treadmill training provides greater benefit to the subgroup of community-dwelling people after stroke who walk faster than 0.4 m/s: a randomised trial. J Physiother. 2014;60:97–101.
Journal of Physiotherapy 68 (2022) 280 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: Bioelectrical Impedance Analysis in Clinical Practice Summary Description: Body mass index (BMI) is commonly used as a Clinimetric properties: BIA has excellent inter-rater and intra- rater reliability for repeated measurements;2 however, this method measure of health status. However, research indicates that BMI, relies on multiple assumptions for fat mass and fat-free mass es- which fails to differentiate between individual body compartments, timations, and violation of these underlying assumptions at an individual level can compromise accuracy.7 Specifically, this has significant limitations for diagnosing clinical conditions (eg, methodology assumes a constant distribution between intracel- malnutrition and sarcopenia), evaluating therapeutic interventions lular and extracellular water, stable hydration of fat-free mass at (eg, diet and exercise) and predicting health outcomes.1 This high- 73% and predictable body geometry.2,7 Violation of these assump- lights the importance of body composition techniques that can easily tions raises potential for error in individuals who differ from normal weight, shape and density, including the obese and clinical be applied in clinical practice. populations where significant fluid shifts are common (eg, critical Bioelectrical impedance analysis (BIA) is of particular interest as it illness, renal and liver failure). Moreover, the commonly used fat- free mass cut-points to identify individuals with muscle deple- provides a portable, low-cost, quick, safe and non-invasive method tion (and recommended in clinical guidelines) are derived from a with which to measure muscle mass at the bedside.2 Acceptance of BIA healthy Caucasian population and require further evaluation to determine their applicability in specific clinical and other in clinical practice is reflected by international nutrition guidelines populations.3 recommending BIA to identify muscle depletion when diagnosing malnutrition.3 Additionally, updated guidelines emphasise the need to Due to the limitations of using BIA to estimate body compart- combine both muscle strength and muscle mass measurements (with ments in the clinical setting, there is increasing interest in the raw BIA variable: phase angle. Phase angle is directly measured from the BIA being an accepted method with which to identify muscle deple- arctangent of the ratio of reactance to resistance (most commonly at tion) when diagnosing sarcopenia.4 BIA measures the opposition to an 50 kHz) and is thought to reflect cellular health and body cell mass.5,8 Several studies have identified phase angle as a potential alternating current through body compartments (resistance) and the prognostic indicator for clinical outcomes, including increased delay in conduction by cell membranes (reactance) via the application postoperative length of stay and mortality in a range of clinical populations.5,8,9 of electrodes attached to, or in contact with, the hands and feet of the subject. The drop in voltage as the current passes through the body Multiple factors during test preparation can introduce error in the interpretation of results, including: patients not being in a fasted (the impedance) is detected via electrodes and the device records raw state, inadequate limb separation, fluid and electrolyte shifts, fevers impedance data (resistance, reactance and phase angle).5 Raw causing skin temperature elevations, impaired skin integrity inter- fering with electrode placement, and the presence of medical devices impedance data are combined with variables such as age, weight, interfering with the bioimpedance device.2 height and gender into population-specific equations to generate an estimate of total body water, and from this fat mass and fat-free mass are estimated.6 There are different types of BIA, including single frequency, multifrequency and bioimpedance spectroscopy.2 Clinicians using the technique need to understand the underlying theory and limitations of each of these methods; an in-depth discussion can be found elsewhere.2 Commentary Although BIA shows potential for body composition assessment Clare E Ferguson and Kate J Lambell and prognostication in clinical environments, clinicians must Australian and New Zealand Intensive Care Research Centre, School of consider the limitations with the BIA device they are using and the Public Health and Preventive Medicine, Monash University, Melbourne, population they are using it with. The same device should be used for repeated measures. Clinicians need to be aware of factors that Australia; Nutrition Department, Alfred Health, Melbourne, Australia introduce error, the need for adequate training and for standardised protocols, which can mitigate many of these issues. Overall, BIA References provides a simple, cheap and non-invasive method with which to measure body composition and cellular health at the bedside. The 1. Prado CM, et al. Ann Med. 2018;50:675–693. data in combination with other clinical information can be utilised to 2. Earthman CP. JPEN. 2015;39:787–822. assess the risk of disease, diagnose clinical conditions and/or evaluate 3. Cederholm T, et al. Clin Nutr. 2019;38:1–9. the response to interventions in a range of clinical populations. 4. Donini LM, et al. Obesity Facts. 2022. 5. Mulasi U, et al. Nutr Clin Pract. 2015;30:180–193. Provenance: Invited. Not peer reviewed. 6. Gonzalez MC, et al. Curr Opin Clin Nutr Metab Care. 2018:366–774. 7. Price KL, Earthman CP. Eur J Clin Nutr. 2019;73:187–193. 8. Lukaski HC, et al. Curr Opin Clin Nutr Metab Care. 2017;20:330–339. 9. Barbosa-Silva MC, Barros AJ. Curr Opin Clin Nutr Metab Care. 2005;8:311–317. https://doi.org/10.1016/j.jphys.2022.05.007 1836-9553/© 2022 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 68 (2022) 281 Appraisal 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 Clinimetrics: Modified Rankin Scale (mRS) The modified Rankin Scale (mRS) is a single-item, global mRS is a more global scale that skips smaller, incremental steps of outcome rating scale that was developed to measure the degree of improvement in rehabilitation.8 disability or dependence in the daily activities of people who have One of the key strengths of the mRS is its reference to the patient’s suffered from stroke or other neurological disorders.1 The mRS is the function prior to their neurological deficit. This makes the mRS a superior prognosticator to scales that do not refer to previous activ- most commonly used Patient Reported Outcome Measure (PROM) ities;1 for example: a study conducted by the University of Glasgow for acute stroke trials.2 It is currently cited within the Australian concluded that the pre-stroke mRS is a moderately valid measure of Clinical Practice Guidelines for its use regarding long-term care.3 As pre-stroke disability and a robust predictor of poststroke prognosis.12 This helps physiotherapists and other members of the healthcare well as being the consensus-based core recommendations from the team to plan for service delivery and ongoing care. In addition, a stroke recovery and rehabilitation roundtable,4 it is also included in study conducted in the Interuniversity Centre for Health Economics the core outcome set for patients following cardiac arrest.5 The mRS Research used the mRS as a determinant of direct medical costs after stroke.13 The researchers found that the mRS rating of the level of was originally introduced in 1957 and was later modified in the disability was a major determinant of resource use, irrespective of 1980s as part of the United Kingdom Transient Ischaemic Attack age, gender, atrial fibrillation and vascular risk factors. (UK-TIA) trial. The modification was to accommodate language dis- In conclusion, the mRS has shown true value in being a global orders and cognitive difficulties.1 The mRS has a range between scale that reflects the interaction with and adaptation to a person’s 0 and 6, where a score of 0 is ‘no symptoms at all’ and a score of 6 is disability, particularly as it refers to the functioning prior to the ‘dead’; there are no subscales. The mRS is free and does not require disabling event. While the inter-rater reliability can be enhanced any specialised equipment to administer.2 A modified Rankin Scale using a structured interview, there are concerns about its respon- Structured Interview (mRS-SI) takes 5 to 15 minutes to complete.6 siveness. However, its strengths in content, construct, criterion val- idity and intra-rater reliability outweigh its weaknesses. A simplified modified Rankin questionnaire (smRSq) can also be used and takes 1.67 minutes; it can be used by multidisciplinary Provenance: Invited. Not peer reviewed healthcare professionals, from junior staff to consultants.7 The Hammazah Haggag and Carol Hodgson National Institute of Health Stroke Scales (NIHSS) has validated School of Public Health and Preventative Medicine, Monash University, translations of the scale to English and 11 other languages, including Melbourne, Australia Mandarin and Spanish.8 References The mRS has been shown to have acceptable inter-rater reli- 1. Van Swieten J, et al. Stroke. 1988;19:604–607. ability, and excellent test-retest and intra-rater reliability. The inter- 2. Broderick JP, et al. Stroke. 2017;48:2007–2012. 3. Stroke Foundation. Clinical Guidelines for Stroke Management. 2017:chap 8. https:// rater reliability was found to be higher when using the mRS-SI compared with the mRS (k 0.78 versus 0.56).9 Furthermore, the informme.org.au/guidelines/clinical-guidelines-for-stroke-management 4. Kwakkel G, et al. Int J Stroke. 2017;12:451–461. mRS has good criterion validity, as it has a strong correlation with 5. Haywood K, et al. Circulation. 2018;137:e783–e801. 6. Wilson JL, et al. Stroke. 2002;33:2243–2246. multiple scales that reflect the current gold standard of scoring 7. Bruno A, et al. Stroke. 2010;41:1048–1050. impairment, disability and/or handicap. For instance, excellent cor- 8. Lees KR, et al. Stroke. 2012;43:1163–1170. 9. Banks JL, et al. Stroke. 2007;38:1091–1096. relations were displayed between the Barthel Index with r = –0.81, 10. Cup EHC, et al. Clin Rehabil. 2003;17:402–409. Frenchay Activities Index (FAI) with r = –0.80 and EuroQol-5 11. New PW, et al. Neuroepidemiology. 2006;26:4–15. Dimension with r = 0.68.10 The mRS construct validity has also 12. Quinn TJ, et al. Front Neurol. 2017;8:275. 13. Dewilde S, et al. Int J Stroke. 2017;12:392–400. been confirmed by multiple studies. The relationship between severity of disability and mRS score has been defined in numerous investigations as a poor outcome with mRS . 2 or . 3.9 The mRs is less sensitive to changes in disability compared with the Barthel Index;8 as a result, stroke trials using mRS as their PROM may fail to detect a clinically significant difference between stroke treatments. It is recommended that a ‘favourable outcome’ be defined as an improvement in grade, rather than using a dichotomisation pro- cess.11 However, the mRS has a stronger performance than the Barthel Index at the floor and ceiling of the scale. This is because the https://doi.org/10.1016/j.jphys.2022.05.017 1836-9553/© 2022 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 68 (2022) 278 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: An intervention to reduce household recreational screen media usage improves physical activity in children Synopsis Summary of: Pedersen J, Rasmussen MGB, Sørensen SO, Mortensen electroencephalography and change in the adult’s non-sedentary SR, Olesen LG, Brønd JC, et al. Effects of Limiting Recreational Screen activity. In addition, changes in moderate-to-vigorous physical Media Use on Physical Activity and Sleep in Families With Children: A activity and non-sedentary activity on weekends and weekdays were Cluster Randomized Clinical Trial. JAMA Pediatr 2022:e221519. assessed for both adults and children. Results: Eighty-three households completed the study (157 children, 87% with primary Question: Does reducing household recreational screen media use outcome data). At the end of the 2-week intervention, the change in improve physical activity and sleep in children and adults? Design: leisure non-sedentary activity in the intervention group children Cluster randomised controlled trial with concealed allocation and was greater than the control group by 46 minutes (95% CI 28 to blinded assessment. Setting: Ten municipalities in Southern 64 minutes). Children in the intervention group also had greater Denmark. Participants: A household of more than one child aged 6 to moderate-to-vigorous activity leisure time and both weekday and 10 years residing full time and one adult with self-reported weekend non-sedentary time. There was no difference in outcomes recreational screen use . 2.4 hours/day. Households with children for sleep measures or any adult outcomes. Conclusion: A household aged , 4 years or where the responding parent was unemployed or a intervention to reduce recreational screen media use increased shift worker were excluded. Randomisation of 89 households physical activity levels in children but not adults, and had no effect on allocated 45 households to the screen media reduction group and 44 sleep outcomes for children or adults. households to screens as usual group. Interventions: The screen media reduction group surrendered portable media devices for 2 Provenance: Invited. Not peer reviewed. weeks. Participants were provided with a phone that could only be used for calls and text messages, and instructed to reduce recreation Alicia Spittle screen use to , 3 hours/week during the intervention. The control Department of Physiotherapy, University of Melbourne, Australia group was able to use screen media as usual. Outcome measures: The primary outcome was change in the child’s non-sedentary activity, https://doi.org/10.1016/j.jphys.2022.08.003 which was measured with accelerometery. Secondary outcome measures included sleep measured at home using single-channel Commentary The benefits of participating in physical activity in childhood are intervention, at least one parent and all children were required to well established, including more favourable cardiometabolic status, hand over their smartphones/tablets. Screen media use was tracked bone health, fitness and cognitive and motor development.1,2 However, using a non-commercial app and a custom-made television monitor, many children are failing to meet the 24-hour movement guidelines,3 which was installed by a researcher. Given these stringent methods to ensure compliance, it is unclear whether it is realistic to expect fam- which are an integration of physical activity, sedentary behaviour and ilies to abide by such an intervention in the real-world context. sleep recommendations.4 Given that adherence to the 24-hour move- Provenance: Invited. Not peer reviewed. ment guidelines is linked with many favourable outcomes, including healthy dietary patterns and better health-related quality of life,3 Tara L FitzGerald Department of Physiotherapy, The University of Melbourne, Australia effective interventions are needed to improve children’s physical activity, decrease their sedentary behaviour and optimise their sleep. https://doi.org/10.1016/j.jphys.2022.08.004 The SCREENS trial demonstrated that a 2-week screen media References reduction intervention increased children’s physical activity but had 1. Carson V, et al. BMC Public Health. 2017;17:854. little effect on their sleep. The intervention had minimal effect on adult 2. Poitras V, et al. Appl Physiol Nutr Metab. 2016;41:S197–S239. 3. Rollo S, et al. J Sport Health Sci. 2020;9:493–510. physical activity outcomes. The long-term effects of the intervention 4. Australian Government Department of Health. 2019. 5. Sekhon M, et al. BMC Health Serv Res. 2017;17:88. are unclear due to the short length of follow-up. Intervention compliance, defined as 7 hours of screen media use over the study period, was excellent (96% for families); however, it is unclear if it was acceptable for families. Measuring intervention acceptability is important, as it can increase the likelihood that the intervention ad- dresses the needs/preferences of the communities who will use it,5 supporting translation into practice. To be eligible for the https://doi.org/10.1016/j.jphys.2022.08.004 1836-9553/© 2022 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 68 (2022) 278 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: An intervention to reduce household recreational screen media usage improves physical activity in children Synopsis Summary of: Pedersen J, Rasmussen MGB, Sørensen SO, Mortensen electroencephalography and change in the adult’s non-sedentary SR, Olesen LG, Brønd JC, et al. Effects of Limiting Recreational Screen activity. In addition, changes in moderate-to-vigorous physical Media Use on Physical Activity and Sleep in Families With Children: A activity and non-sedentary activity on weekends and weekdays were Cluster Randomized Clinical Trial. JAMA Pediatr 2022:e221519. assessed for both adults and children. Results: Eighty-three households completed the study (157 children, 87% with primary Question: Does reducing household recreational screen media use outcome data). At the end of the 2-week intervention, the change in improve physical activity and sleep in children and adults? Design: leisure non-sedentary activity in the intervention group children Cluster randomised controlled trial with concealed allocation and was greater than the control group by 46 minutes (95% CI 28 to blinded assessment. Setting: Ten municipalities in Southern 64 minutes). Children in the intervention group also had greater Denmark. Participants: A household of more than one child aged 6 to moderate-to-vigorous activity leisure time and both weekday and 10 years residing full time and one adult with self-reported weekend non-sedentary time. There was no difference in outcomes recreational screen use . 2.4 hours/day. Households with children for sleep measures or any adult outcomes. Conclusion: A household aged , 4 years or where the responding parent was unemployed or a intervention to reduce recreational screen media use increased shift worker were excluded. Randomisation of 89 households physical activity levels in children but not adults, and had no effect on allocated 45 households to the screen media reduction group and 44 sleep outcomes for children or adults. households to screens as usual group. Interventions: The screen media reduction group surrendered portable media devices for 2 Provenance: Invited. Not peer reviewed. weeks. Participants were provided with a phone that could only be used for calls and text messages, and instructed to reduce recreation Alicia Spittle screen use to , 3 hours/week during the intervention. The control Department of Physiotherapy, University of Melbourne, Australia group was able to use screen media as usual. Outcome measures: The primary outcome was change in the child’s non-sedentary activity, https://doi.org/10.1016/j.jphys.2022.08.003 which was measured with accelerometery. Secondary outcome measures included sleep measured at home using single-channel Commentary The benefits of participating in physical activity in childhood are intervention, at least one parent and all children were required to well established, including more favourable cardiometabolic status, hand over their smartphones/tablets. Screen media use was tracked bone health, fitness and cognitive and motor development.1,2 However, using a non-commercial app and a custom-made television monitor, many children are failing to meet the 24-hour movement guidelines,3 which was installed by a researcher. Given these stringent methods to ensure compliance, it is unclear whether it is realistic to expect fam- which are an integration of physical activity, sedentary behaviour and ilies to abide by such an intervention in the real-world context. sleep recommendations.4 Given that adherence to the 24-hour move- Provenance: Invited. Not peer reviewed. ment guidelines is linked with many favourable outcomes, including healthy dietary patterns and better health-related quality of life,3 Tara L FitzGerald Department of Physiotherapy, The University of Melbourne, Australia effective interventions are needed to improve children’s physical activity, decrease their sedentary behaviour and optimise their sleep. https://doi.org/10.1016/j.jphys.2022.08.004 The SCREENS trial demonstrated that a 2-week screen media References reduction intervention increased children’s physical activity but had 1. Carson V, et al. BMC Public Health. 2017;17:854. little effect on their sleep. The intervention had minimal effect on adult 2. Poitras V, et al. Appl Physiol Nutr Metab. 2016;41:S197–S239. 3. Rollo S, et al. J Sport Health Sci. 2020;9:493–510. physical activity outcomes. The long-term effects of the intervention 4. Australian Government Department of Health. 2019. 5. Sekhon M, et al. BMC Health Serv Res. 2017;17:88. are unclear due to the short length of follow-up. Intervention compliance, defined as 7 hours of screen media use over the study period, was excellent (96% for families); however, it is unclear if it was acceptable for families. Measuring intervention acceptability is important, as it can increase the likelihood that the intervention ad- dresses the needs/preferences of the communities who will use it,5 supporting translation into practice. To be eligible for the https://doi.org/10.1016/j.jphys.2022.08.004 1836-9553/© 2022 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 68 (2022) 279 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: Fall prevention program delivered electronically to community-dwelling older people can reduce fall rate over 24 months Synopsis Summary of: Delbaere K, Valenzuela T, Lord SR, Clemson L, Zijlstra months. Secondary outcomes were rate of falls and number of GAR, Close JCT, et al. E-health StandingTall balance exercise for fall injurious falls over 24 months, and common fall risk factors prevention in older people: results of a two year randomised measured at baseline, 6, 12, 18 and 24 months. Results: A total of controlled trial. BMJ. 2021;373:n740. 413 participants completed the study. At 12 months, there were no clear differences between groups in fall rate (incidence rate ratio for Question: Does a home-based e-health balance exercise program intervention compared with control: 0.82, 95% CI 0.66 to 1.02) or (StandingTall) reduce falls in older people? Design: Randomised the proportion who fell (relative risk in intervention compared with controlled trial with concealed allocation. Setting: Home-based control 0.90, 95% CI 0.72 to 1.12). At 24 months, the intervention program in Australia. Participants: Community-dwelling adults group had a lower fall rate (incidence rate ratio compared with aged 70 years, independent in activities of daily living and able to control 0.84, 95% CI 0.72 to 0.98) and lower rate of injurious falls walk household distances without an assistive device. Key exclusion (incidence rate ratio 0.80, 95% CI 0.66 to 0.98). The intervention criteria were unstable or acute medical conditions precluding ex- group also had small improvements in quality of life and standing ercise, progressive neurological condition, and cognitive impair- balance compared with control. Conclusion: A fall prevention pro- ment. Randomisation of 503 participants allocated 254 to gram delivered electronically can reduce fall rates and injurious fall intervention and 249 to the control group. Interventions: Both rates over 24 months in community-dwelling older adults. groups received a tablet computer with a health promotion edu- cation program consisting of 104 weekly fact sheets. In addition, the Provenance: Invited. Not peer reviewed. intervention group received the StandingTall program and exercise equipment. The tablet-delivered program included tailored and Prudence Plummer progressive balance exercises (2 hours/week), behavioural change Department of Physical Therapy, MGH Institute of Health Professions, techniques, goal setting, additional fact sheets, and two home visits (to initiate and monitor the StandingTall program). Control partic- USA ipants received two phone calls about the health promotion edu- cation program. Outcome measures: The primary outcomes were https://doi.org/10.1016/j.jphys.2022.09.003 the rate of falls and proportion of people who fell in the first 12 Commentary We have strong evidence on how to reduce falls through exercise modified rating of perceived exertion scale. As balance intensity was programs that target balance.1 Despite this, falls and fall-related in- not reported, it is difficult to determine whether the intensity of the juries persist and continue to rise globally.2 This trial showed that a prescribed exercises was sufficiently ‘challenging’.1 This is likely falls prevention exercise program delivered electronically related to the absence of a validated balance intensity measure until (StandingTall) was able to reduce the rate of falls and injurious falls recently.4 It will be interesting to observe in future trials whether a in community-dwelling older adults over 24 months. There were no higher degree of balance challenge will offer more protection against serious adverse events recorded, which indicate that balance exercises falls and related injuries. can be safely delivered through e-health technology. Adherence to StandingTall was also higher (30% fully adherent over 24 months) Provenance: Invited. Not peer reviewed. compared with pooled estimates reported in previous studies.3 There is promise that StandingTall may be a falls prevention program that Sze-Ee Soh older adults will engage with over a longer period of time. The Physiotherapy, Monash University, Melbourne, Australia digital delivery is particularly appealing given the current COVID-19 pandemic, as it overcomes physical access barriers, giving older https://doi.org/10.1016/j.jphys.2022.09.002 adults the option to participate in a home-based program that may reduce falls. References There are, however, a few considerations worth noting before 1. Sherrington C, et al. Int J Behav Nutr Phys Act. 2020;17:44. incorporating an e-health falls prevention intervention into clinical 2. James SL, et al. Inj Prev. 2020;26:i3–i11. practice. Participants in this trial had a relatively low risk of falls. The 3. Simek EM, et al. Prev Med. 2012;55:262–275. implications of using this program with older adults at heightened risk 4. Farlie M, et al. Phys Ther. 2019;99:1394–1404. of falling require further investigation. Further, the intensity of balance exercises in StandingTall was self-monitored using a self-report https://doi.org/10.1016/j.jphys.2022.09.002 1836-9553/© 2022 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 68 (2022) 279 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: Fall prevention program delivered electronically to community-dwelling older people can reduce fall rate over 24 months Synopsis Summary of: Delbaere K, Valenzuela T, Lord SR, Clemson L, Zijlstra months. Secondary outcomes were rate of falls and number of GAR, Close JCT, et al. E-health StandingTall balance exercise for fall injurious falls over 24 months, and common fall risk factors prevention in older people: results of a two year randomised measured at baseline, 6, 12, 18 and 24 months. Results: A total of controlled trial. BMJ. 2021;373:n740. 413 participants completed the study. At 12 months, there were no clear differences between groups in fall rate (incidence rate ratio for Question: Does a home-based e-health balance exercise program intervention compared with control: 0.82, 95% CI 0.66 to 1.02) or (StandingTall) reduce falls in older people? Design: Randomised the proportion who fell (relative risk in intervention compared with controlled trial with concealed allocation. Setting: Home-based control 0.90, 95% CI 0.72 to 1.12). At 24 months, the intervention program in Australia. Participants: Community-dwelling adults group had a lower fall rate (incidence rate ratio compared with aged 70 years, independent in activities of daily living and able to control 0.84, 95% CI 0.72 to 0.98) and lower rate of injurious falls walk household distances without an assistive device. Key exclusion (incidence rate ratio 0.80, 95% CI 0.66 to 0.98). The intervention criteria were unstable or acute medical conditions precluding ex- group also had small improvements in quality of life and standing ercise, progressive neurological condition, and cognitive impair- balance compared with control. Conclusion: A fall prevention pro- ment. Randomisation of 503 participants allocated 254 to gram delivered electronically can reduce fall rates and injurious fall intervention and 249 to the control group. Interventions: Both rates over 24 months in community-dwelling older adults. groups received a tablet computer with a health promotion edu- cation program consisting of 104 weekly fact sheets. In addition, the Provenance: Invited. Not peer reviewed. intervention group received the StandingTall program and exercise equipment. The tablet-delivered program included tailored and Prudence Plummer progressive balance exercises (2 hours/week), behavioural change Department of Physical Therapy, MGH Institute of Health Professions, techniques, goal setting, additional fact sheets, and two home visits (to initiate and monitor the StandingTall program). Control partic- USA ipants received two phone calls about the health promotion edu- cation program. Outcome measures: The primary outcomes were https://doi.org/10.1016/j.jphys.2022.09.003 the rate of falls and proportion of people who fell in the first 12 Commentary We have strong evidence on how to reduce falls through exercise modified rating of perceived exertion scale. As balance intensity was programs that target balance.1 Despite this, falls and fall-related in- not reported, it is difficult to determine whether the intensity of the juries persist and continue to rise globally.2 This trial showed that a prescribed exercises was sufficiently ‘challenging’.1 This is likely falls prevention exercise program delivered electronically related to the absence of a validated balance intensity measure until (StandingTall) was able to reduce the rate of falls and injurious falls recently.4 It will be interesting to observe in future trials whether a in community-dwelling older adults over 24 months. There were no higher degree of balance challenge will offer more protection against serious adverse events recorded, which indicate that balance exercises falls and related injuries. can be safely delivered through e-health technology. Adherence to StandingTall was also higher (30% fully adherent over 24 months) Provenance: Invited. Not peer reviewed. compared with pooled estimates reported in previous studies.3 There is promise that StandingTall may be a falls prevention program that Sze-Ee Soh older adults will engage with over a longer period of time. The Physiotherapy, Monash University, Melbourne, Australia digital delivery is particularly appealing given the current COVID-19 pandemic, as it overcomes physical access barriers, giving older https://doi.org/10.1016/j.jphys.2022.09.002 adults the option to participate in a home-based program that may reduce falls. References There are, however, a few considerations worth noting before 1. Sherrington C, et al. Int J Behav Nutr Phys Act. 2020;17:44. incorporating an e-health falls prevention intervention into clinical 2. James SL, et al. Inj Prev. 2020;26:i3–i11. practice. Participants in this trial had a relatively low risk of falls. The 3. Simek EM, et al. Prev Med. 2012;55:262–275. implications of using this program with older adults at heightened risk 4. Farlie M, et al. Phys Ther. 2019;99:1394–1404. of falling require further investigation. Further, the intensity of balance exercises in StandingTall was self-monitored using a self-report https://doi.org/10.1016/j.jphys.2022.09.002 1836-9553/© 2022 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 68 (2022) 277 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: In adults with severe lower limb burns, adding a Wii Fit program to usual physiotherapy improves lower limb function and functional mobility Synopsis Summary of: Basha MA, Abdel-Aal NM, Kamel FAH. Effects of Wii Fit Wii Fit program sessions were 30 minutes long. Outcome measures: rehabilitation on lower extremity functional status in adults with The primary outcomes were lower limb function measured with the severe burns: a randomized controlled trial. Arch Phys Med Rehabil. Lower Limb Functional Index (0 worst to 100 best) and functional 2022;103:289–296. mobility measured with the High-Level Mobility Assessment Tool (0 worst to 54 best) and the Timed Up and Go test. Results: All participants Question: In adults with severe lower limb burns, how much does completed the study. At 12 weeks, the experimental group demon- adding a Wii Fit program to usual physiotherapy improve lower limb strated higher scores in both the Lower Limb Functional Index (MD 11, function and functional mobility? Design: Randomised controlled trial 95% CI 5 to 17) and High-Level Mobility Assessment Tool (MD 7, 95% CI 3 with concealed allocation and blinded assessor. Setting: University to 11), and had better performance in the Timed Up and Go test hospital in Cairo, Egypt. Participants: Adults following hospitalisation (MD 24.9 seconds, 95% CI 27.3 to 22.4). Conclusion: In adults with for deep partial and full-thickness burn injury in the lower limbs due to severe lower limb burns, adding a Wii Fit program to usual physio- scald or flame. Exclusion criteria: inhalation injury, peripheral nerve therapy caused several small to moderate improvements in lower limb disease, infection, diabetes, mental/cognitive dysfunction, fracture, function and functional mobility. degenerative joint diseases or previous lower limb surgery. Random- isation of 34 participants allocated 17 to the experimental group and 17 Provenance: Invited. Not peer reviewed. to the control group. Interventions: The control group received 12 weeks of thrice-weekly usual physiotherapy, which included scar Vinicius Cavalheri management, hand therapy, splinting, and stretching, aerobic and Curtin School of Allied Health, Curtin University, Australia resistance exercises; the sessions were 1 hour long. In addition to usual physiotherapy, the experimental group received 12 weeks of a thrice- https://doi.org/10.1016/j.jphys.2022.08.002 weekly Wii Fit program that included strength and aerobic training as well as balance training conducted on the Wii Fit balance board; the Commentary Given the immense psychological stress and treatment burden coordination exercises improved outcomes involving balance. As during recovery, it is unsurprising that exercise reduces following therapy occurred in an outpatient setting without therapist blinding, burn injury.1 In Australia, w40% of burns occur in rural/remote potential bias from increased clinical contact should be considered. settings,2 where limited resources amplify this decline. Translation of VR into community/home-based rehabilitation re- quires evaluation of cost, technological competence and safety, as This trial adds to the evidence about virtual reality (VR) in burn assisted mobility may preclude its use. rehabilitation. From a comparable baseline, greater improvements in balance (ie, High-Level Mobility Assessment Tool) and functional Although stretching and scar management are paramount, VR exercise capacity (6-minute walk distance MD 73 m, 95% CI 36 to exercise is a practical therapeutic adjunct due to its usability, 110) occurred when VR exercise was added to standard rehabilita- affordability and gameplay. It can improve global function, irre- tion for severe lower limb burns. In a population where spective of scar profile, bridging geographical and social barriers to re-establishing autonomy is essential for recovery, higher patient- engagement. rated scores (ie, Lower Limb Functional Index) following VR are promising. These results suggest that VR is a viable method of Provenance: Invited. Not peer reviewed. increasing exercise volume and subsequent physical function in adults with severe burns. Vincent Costanzo Concord Hospital, Sydney, Australia It is unclear whether these benefits occurred because VR exercise is more effective than the aerobic/resistance exercise used in both https://doi.org/10.1016/j.jphys.2022.08.001 groups, or because the experimental group received a higher cumu- lative exercise dose (270 versus 180 minutes/week). Either way, VR References may explain the 100% adherence observed with additional exercise, given that adoption of independent exercise is typically low.1 1. Baldwin JB, Li F. J Burn Care Res. 2013;34:529–536. 2. Burns Registry of Australia and New Zealand (2022). Annual Report 2020/21. Highlighted above is the need to consider sufficient exercise dosing with therapeutic specificity; additional proprioceptive and https://doi.org/10.1016/j.jphys.2022.08.001 1836-9553/Crown Copyright © 2022 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 68 (2022) 277 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: In adults with severe lower limb burns, adding a Wii Fit program to usual physiotherapy improves lower limb function and functional mobility Synopsis Summary of: Basha MA, Abdel-Aal NM, Kamel FAH. Effects of Wii Fit Wii Fit program sessions were 30 minutes long. Outcome measures: rehabilitation on lower extremity functional status in adults with The primary outcomes were lower limb function measured with the severe burns: a randomized controlled trial. Arch Phys Med Rehabil. Lower Limb Functional Index (0 worst to 100 best) and functional 2022;103:289–296. mobility measured with the High-Level Mobility Assessment Tool (0 worst to 54 best) and the Timed Up and Go test. Results: All participants Question: In adults with severe lower limb burns, how much does completed the study. At 12 weeks, the experimental group demon- adding a Wii Fit program to usual physiotherapy improve lower limb strated higher scores in both the Lower Limb Functional Index (MD 11, function and functional mobility? Design: Randomised controlled trial 95% CI 5 to 17) and High-Level Mobility Assessment Tool (MD 7, 95% CI 3 with concealed allocation and blinded assessor. Setting: University to 11), and had better performance in the Timed Up and Go test hospital in Cairo, Egypt. Participants: Adults following hospitalisation (MD 24.9 seconds, 95% CI 27.3 to 22.4). Conclusion: In adults with for deep partial and full-thickness burn injury in the lower limbs due to severe lower limb burns, adding a Wii Fit program to usual physio- scald or flame. Exclusion criteria: inhalation injury, peripheral nerve therapy caused several small to moderate improvements in lower limb disease, infection, diabetes, mental/cognitive dysfunction, fracture, function and functional mobility. degenerative joint diseases or previous lower limb surgery. Random- isation of 34 participants allocated 17 to the experimental group and 17 Provenance: Invited. Not peer reviewed. to the control group. Interventions: The control group received 12 weeks of thrice-weekly usual physiotherapy, which included scar Vinicius Cavalheri management, hand therapy, splinting, and stretching, aerobic and Curtin School of Allied Health, Curtin University, Australia resistance exercises; the sessions were 1 hour long. In addition to usual physiotherapy, the experimental group received 12 weeks of a thrice- https://doi.org/10.1016/j.jphys.2022.08.002 weekly Wii Fit program that included strength and aerobic training as well as balance training conducted on the Wii Fit balance board; the Commentary Given the immense psychological stress and treatment burden coordination exercises improved outcomes involving balance. As during recovery, it is unsurprising that exercise reduces following therapy occurred in an outpatient setting without therapist blinding, burn injury.1 In Australia, w40% of burns occur in rural/remote potential bias from increased clinical contact should be considered. settings,2 where limited resources amplify this decline. Translation of VR into community/home-based rehabilitation re- quires evaluation of cost, technological competence and safety, as This trial adds to the evidence about virtual reality (VR) in burn assisted mobility may preclude its use. rehabilitation. From a comparable baseline, greater improvements in balance (ie, High-Level Mobility Assessment Tool) and functional Although stretching and scar management are paramount, VR exercise capacity (6-minute walk distance MD 73 m, 95% CI 36 to exercise is a practical therapeutic adjunct due to its usability, 110) occurred when VR exercise was added to standard rehabilita- affordability and gameplay. It can improve global function, irre- tion for severe lower limb burns. In a population where spective of scar profile, bridging geographical and social barriers to re-establishing autonomy is essential for recovery, higher patient- engagement. rated scores (ie, Lower Limb Functional Index) following VR are promising. These results suggest that VR is a viable method of Provenance: Invited. Not peer reviewed. increasing exercise volume and subsequent physical function in adults with severe burns. Vincent Costanzo Concord Hospital, Sydney, Australia It is unclear whether these benefits occurred because VR exercise is more effective than the aerobic/resistance exercise used in both https://doi.org/10.1016/j.jphys.2022.08.001 groups, or because the experimental group received a higher cumu- lative exercise dose (270 versus 180 minutes/week). Either way, VR References may explain the 100% adherence observed with additional exercise, given that adoption of independent exercise is typically low.1 1. Baldwin JB, Li F. J Burn Care Res. 2013;34:529–536. 2. Burns Registry of Australia and New Zealand (2022). Annual Report 2020/21. Highlighted above is the need to consider sufficient exercise dosing with therapeutic specificity; additional proprioceptive and https://doi.org/10.1016/j.jphys.2022.08.001 1836-9553/Crown Copyright © 2022 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 68 (2022) 269–276 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 Diagnostic labels and advice for rotator cuff disease influence perceived need for shoulder surgery: an online randomised experiment Joshua R Zadro a, Mary O’Keeffe a, Giovanni E Ferreira a, Adrian C Traeger a, Andrew R Gamble b, Richard Page c, Robert D Herbert d, Ian A Harris a,e, Christopher G Maher a aInstitute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia; bSchool of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; cUniversity Hospital Geelong and St. John of God Hospital Geelong, Barwon Centre for Orthopaedic Research and Education (B-CORE), IMPACT, School of Medicine, Deakin University, Geelong, Australia; dNeuroscience Research Australia (NeuRA), University of New South Wales, Australia; eIngham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Australia KEYWORDS ABSTRACT Rotator cuff Question: What are the effects of diagnostic labels and advice, and interactions between labels and advice, Shoulder pain on perceived need for shoulder surgery for rotator cuff disease? Design: 232 factorial online randomised Subacromial impingement experiment. Participants: People with shoulder pain. Intervention: Participants read a scenario describing a Bursitis patient with rotator cuff disease and were randomised to bursitis label plus guideline-based advice, bursitis Labelling label plus treatment recommendation, rotator cuff tear label plus guideline-based advice, and rotator cuff tear Advice label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation stressed that treatment is needed for recovery. Outcome measures: Perceived need for surgery (primary outcome), imaging, an injection, a second opinion and to see a specialist; and perceived seriousness of the condition, recovery expectations, impact on work performance and need to avoid work. Results: A total of 2,024 responses (99.8% of 2,028 randomised) were analysed. Labelling as bursitis (versus rotator cuff tear) decreased perceived need for surgery (mean effect –0.5 on a 0-to-10 scale, 98.3% CI –0.7 to –0.2), imaging and to see a specialist, and perceived seriousness of the condition and need to avoid work. Guideline-based advice (versus treatment recommendation) decreased perceived need for surgery (mean effect –1.0, 98.3% CI –1.3 to –0.7), imaging, an injection, a second opinion and to see a specialist, and perceived seriousness of the condition and recovery expectations. There was little to no evidence of an advice label interaction for any outcome. Conclusion: Labels and advice influenced perceived need for surgery and other secondary outcomes in people with rotator cuff disease, with larger effects for advice. There was evidence of little or no interaction between labels and advice for any outcome, but the additive effect of labels and advice appeared large for some outcomes (eg, perceived need for imaging and perceived seriousness of the condition). Trial registration: ACTRN12621001370897. [Zadro JR, O’Keeffe M, Ferreira GE, Traeger AC, Gamble AR, Page R, Herbert RD, Harris IA, Maher CG (2022) Diag- nostic labels and advice for rotator cuff disease influence perceived need for shoulder surgery: an online randomised experiment. Journal of Physiotherapy 68:269–276] © 2022 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 How rotator cuff disease is labelled influences patients’ manage- ment preferences.5 A recent online randomised experiment Rotator cuff disease has a prevalence ranging from 0.5 to 7.4%1 and is an umbrella diagnosis that captures 85% of shoulder pain cases.2 It (n = 1,308) found that labelling rotator cuff disease as bursitis includes structural diagnoses such as rotator cuff tendinopathy, tear decreased perceived need for shoulder surgery compared with or tendinitis, calcific tendinitis, and subacromial bursitis, but not other causes of shoulder pain such as adhesive capsulitis, gleno- labelling as rotator cuff tear, and decreased perceived need for im- humeral osteoarthritis, fracture, dislocation, instability or tumours aging compared with labelling as rotator cuff tear or subacromial masquerading as shoulder pain.3 While it is often possible to identify impingement syndrome.5 Qualitative data collected in this study rotator cuff disease, it is usually impossible to determine which pa- suggested that people are more likely to associate the labels rotator thology is causing it or whether there is any pathological cause;2 therefore, diagnostic labels are usually speculative or arbitrary.4 cuff tear and subacromial impingement syndrome with feelings of psychological distress, seriousness of the condition, poor prognosis, and the need for diagnostic imaging and surgery compared with other labels (eg, bursitis).6 https://doi.org/10.1016/j.jphys.2022.09.005 1836-9553/© 2022 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/).
270 Zadro et al: Labels and advice for shoulder pain These findings are important because surgery and diagnostic im- digital fingerprinting technology. More detail on Qualtrics’ sampling aging for rotator cuff disease are examples of overuse. Overuse is and recruitment procedures can be found elsewhere.20 For this study, defined as care that, according to the best available evidence, has no Qualtrics targeted market research panels where participants were net benefit or causes harm.7 Evidence has demonstrated that highly likely to be included (eg, ones focused on healthcare surveys) subacromial decompression surgery is not superior to placebo or and aimed for an equal proportion of participants from Australia, New non-surgical management for rotator cuff disease,8 and rotator cuff Zealand, Canada, the United Kingdom and United States, given the repair surgery may not be clinically superior to non-surgical man- overuse of shoulder surgery in several countries.10–13 The survey was agement for full-thickness degenerative rotator cuff tears.9 Yet, use of only available to participants who were emailed by the market these procedures is increasing or remaining high in several countries research panel. No login details or password were required to com- (eg, in Australia, the United States and United Kingdom).10–13 Simi- plete the survey (‘open survey’). Participant data were collected larly, diagnostic imaging is frequently used14,15 even though it is not through the Qualtrics survey platform. useful for identifying a specific nociceptive cause of rotator cuff disease and may not inform management decisions.16 All recruitment and data collection procedures were approved by the University of Sydney Human Research Ethics Committee (refer- A previous study5 investigated the isolated effect of diagnostic ence number: 2021/776). Informed consent to participate was ob- labels. Diagnostic labels are often provided alongside advice from a tained from all participants and the rights of participants were healthcare professional. Although there is a lack of direct evidence on protected. No personal information was provided to the research the benefits of advice for people with shoulder pain, advice to stay team from Qualtrics. See Appendix 3 for how participants were active and positive prognostic information is beneficial for other introduced to the study and how consent was obtained. Qualtrics musculoskeletal conditions (eg, low back pain,17 knee osteoar- pilot tested (‘soft launch’) the experiment with a group of 89 par- thritis18) and is recommended in some shoulder pain guidelines.19 It ticipants prior to recruitment, so data checks could be performed, is also possible that advice from a healthcare professional could typographical errors in the survey be corrected, and survey usability interact with the diagnostic label a patient receives (although it is and technical functionality be evaluated. believed that there is no empirical evidence to support this). For example, guideline-based advice provided alongside a label that de- The survey began with three self-reported screening questions to creases patients’ perceived need for surgery (eg, bursitis) could identify participants who had non-traumatic shoulder pain (Box 1). further reduce overuse via an additive or supra-additive effect. There is no research on how diagnostic labels interact with advice from Eligible participants were asked a series of questions on healthcare professionals or the direct effect of advice for people with demographics (eg, age, gender, education), healthcare use (eg, pre- rotator cuff disease. vious imaging, surgery and injections for their shoulder pain), and shoulder symptoms (eg, duration of shoulder pain, shoulder pain and The primary aim of this study was to examine the effects of disability index (SPADI) questionnaire21) (Appendix 3 on the eAd- diagnostic labels and advice, and interactions between labels and denda). A maximum of 10 questions was asked per page to reduce advice on perceived need for shoulder surgery in people with rotator participant fatigue. A response to every question was required to cuff disease. Secondary outcomes included perceived need for im- progress through the survey. Participants were able to review and aging, an injection, a second opinion, and to see a specialist; and change their responses if necessary, using a ‘back’ button. The survey perceived seriousness of the condition, recovery expectations, impact included 42 questions, including the screening questions. on work performance and need to avoid work. Intervention Therefore, the study question for this randomised experiment was: Participants were then asked to read a vignette and imagine being the person described in the vignette (Box 2). The vignette was taken What are the effects of diagnostic labels and advice, and from a previous study,5 which received input from clinicians who interactions between labels and advice, on perceived commonly manage patients with shoulder pain. One modification need for shoulder surgery for rotator cuff disease? was made to the original vignette: the duration of shoulder pain was changed from 2 months to 6 months, as perceived need for surgery Methods was low in the previous study (w2.5/10) and it was suspected that the short duration of symptoms could have been partially respon- Design sible. A longer duration of symptoms also aligns with current guid- ance around when to consider shoulder surgery.22,23 A 232 factorial online randomised experiment was performed and prospectively registered on the Australia New Zealand Clinical After reading the vignette, participants were randomised (1:1:1:1 Trials Registry (ACTRN12621001370897). The experiment was re- ratio) to be in one of four groups: bursitis label plus guideline-based ported in accordance with the Consolidated Standards of Reporting advice, bursitis label plus treatment recommendation, rotator cuff tear Trials (CONSORT) statement (Appendix 1 on the eAddenda) and label plus guideline-based advice, and rotator cuff tear label plus Checklist for Reporting Results of Internet E-Surveys (CHERRIES) (Appendix 2 on the eAddenda). Box 1. Screening questions to establish eligibility. Participants, therapists, centres 1. Do you currently have shoulder pain? [people who select Participants with non-traumatic shoulder pain (based on self- ‘No’ will be excluded] report) were recruited through Qualtrics (market research com- pany; www.qualtrics.com) in January 2022. Qualtrics uses panels of ☐ Yes individuals who have previously agreed to complete online surveys (‘market research panels’) and has partnered with over 20 panel ☐ No providers globally to recruit research participants across various fields (eg, technology, travel, healthcare, retail). Qualtrics uses 2. On average, how much shoulder pain have you had over the random sampling and provides incentives for participants to com- plete surveys (eg, gift cards, airline miles or cash). Participation is past week? [people who select ‘0’ will be excluded] voluntary and participants must be 18 years or older and able to read and write in English. To avoid duplication and ensure that responses 0 1 2 3 4 5 6 7 8 9 10 are valid, Qualtrics checks every IP address and utilises sophisticated No pain at all Worst pain imaginable 3. Is your shoulder pain the result of a serious injury (ie, resulted in a dislocation or fracture)? [people who select ‘Yes’ will be excluded] ☐ Yes ☐ No
Research 271 Box 2. Vignette. You have shoulder pain This next section describes a person with shoulder pain who goes to a healthcare provider. We want you to put yourself into this scenario and do your best to imagine that you are the person having this shoulder pain. After reading it, you will be asked a number of questions. Please do your best to answer them based on this imagined scenario. Your shoulder pain Imagine you are suffering from pain in your right shoulder It started 6 months ago There was no specific incident/injury/trauma that caused your pain You think the pain was triggered by reaching for a plate in a high cupboard, but you are not sure You have no pain or other unusual sensations past your shoulder (eg, pins and needles, numbness) The pain is at the front, side and back of your right shoulder and right upper arm, as shown by the red circles on the picture of the body chart below You find it hard to move your shoulder normally. In particular, you find it very hard to lift your right arm past horizontal (‘eye level’) and reach up to high cupboards You cannot lie on your right side in bed as this increases your pain You have used heat and over the counter pain relievers, and have been avoiding using your right shoulder to reach for objects or carry heavy shopping You visit a healthcare provider (eg, general practitioner or physiotherapist) Your healthcare provider asks you questions about your shoulder pain, and some health questions to rule out any worrying causes Your healthcare provider does a detailed physical examination. It involves: looking at your shoulder checking if you can move your shoulder in certain directions, and whether this causes pain checking if they can move your shoulder in certain directions, and whether this causes pain checking if movement of your shoulder against resistance causes pain After this, your healthcare provider tells you: You have [‘bursitis’ or a ‘rotator cuff tear’] [Message #1 or #2] [Video of label and advice] treatment recommendation. Randomisation was performed using The two types of advice were: Qualtrics survey software. In the previous study, participants labelled with bursitis perceived a lower need for surgery and imaging Guideline-based advice: ‘I am not worried that there is anything compared with those labelled with a rotator cuff tear, and this com- serious going on here because your pain is not related to a parison had the largest effect size of all label comparisons for these significant injury. I am also not worried that you have arthritis in outcomes.5 Both labels were accompanied by a brief explanation of your shoulder or a specific condition called frozen shoulder that the label as per the previous study: causes severe pain and stiffness. Your pain should gradually improve over time by itself. It is recommended that you avoid Bursitis: ‘Bursitis is inflammation of a fluid-filled sac called a activities that aggravate your pain but continue to use your arm bursa in the shoulder.’ so your shoulder does not stiffen up.’ Rotator cuff tear: ‘A rotator cuff tear is a tear in one of the Treatment recommendation: ‘Most people with your symptoms shoulder tendons.’ respond to treatment within 4 to 6 weeks, especially if an
272 Zadro et al: Labels and advice for shoulder pain Assessed for eligibility Excluded (n = 7,489) (n = 10,043) • did not consent (n = 429) • no shoulder pain (n = 4,053) Baseline assessment • shoulder pain from traumatic injury (n = 1,637) (n = 2,554) • consented and eligible but provided no data (n = 27) • data quality issues (n = 1,343) Eligible but withdrew before randomisation (n = 515) Randomised (n = 2,039) Allocated to bursitis label Allocated to bursitis label Allocated to rotator cuff tear label Allocated to rotator cuff tear label and guideline-based advice and treatment recommendation and guideline-based advice and treatment recommendation (n = 523) (n = 495) (n = 508) (n = 513) Did not finish survey Did not finish survey Did not finish survey Did not finish survey (n = 2) (n = 1) (n = 1) (n = 0) Analysed for primary outcome Analysed for primary outcome Analysed for primary outcome Analysed for primary outcome (n = 493) (n = 507) (n = 522) (n = 513) Figure 1. Flow of participants through the study. injection is part of the treatment. Without proper treatment, information for shoulder surgery.24 Reputable sources (eg, govern- your symptoms can persist for months or years, and usually ment, university) that presented contrasting advice to the guideline- become worse over time.’ based advice script were prioritised. Treatment recommendation was adapted from a Harvard Medical School webpage titled ‘Rotator Cuff Guideline-based advice was taken from the previous study5 and Injury’ and stressed that treatment is needed for recovery. Any based on recommendations for the management of rotator cuff reference to a diagnosis was removed so the advice could be pre- disease.23 It provided encouragement to stay active and positive sented alongside the bursitis and rotator cuff tear labels. The order of prognostic information. For treatment recommendation, examples of sentences was also edited to start with a more positive message advice were searched for on webpages identified in a content (Appendix 4 on the eAddenda). The labels and advice were delivered analysis that was conducted examining the quality of online by an orthopaedic surgeon (IH) via a pre-recorded video (w30 Table 1 Characteristics of participants. Demographics Total sample Bursitis 1 guideline-based Bursitis 1 treatment Rotator cuff tear 1 guideline- Rotator cuff tear 1 treatment (n = 2,039) advice recommendation based advice recommendation (n = 508) (n = 523) (n = 513) (n = 495) 43.6 (15.2) 45.7 (16.1) Age (y), mean (SD)a 45.1 (15.4) 45.4 (15.6) 45.8 (14.6) 309 (59.1) 287 (56.0) Female, n (%) 1,213 (59.5) 309 (62.4) 308 (60.6) Country, n (%) 91 (17.4) 106 (20.7) 411 (20.2) 104 (21.0) 110 (21.7) 104 (19.9) 104 (20.3) Australia 402 (19.7) 100 (20.2) 94 (18.5) 117 (22.4) 111 (21.6) New Zealand 433 (21.2) 103 (20.8) 102 (20.1) 114 (21.8) 103 (20.1) United States 404 (19.8) 90 (18.2) 97 (19.1) 97 (18.6) 89 (17.4) United Kingdom 389 (19.1) 98 (19.8) 105 (20.7) Canada 48 (9.2) 36 (7.0) Education, n (%) 169 (8.3) 37 (7.5) 48 (9.5) 171 (32.7) 170 (33.1) high school (not completed) 692 (34.0) 180 (36.4) 171 (33.7) 89 (17.0) 93 (18.1) high school (completed) 367 (18.0) 93 (18.8) 92 (18.1) non-university tertiary 215 (41.1) 214 (41.7) 811 (39.8) 185 (37.4) 197 (38.8) education 326 (62.3) 310 (60.4) university 1,231 (60.4) 291 (58.8) 304 (59.8) 125 (23.9) 108 (21.1) Employment, n (%) 456 (22.4) 99 (20.0) 124 (24.4) 22 (4.3) employed 31 (6.3) 17 (3.3) 73 (14.2) unemployed 83 (4.1) 73 (14.8) 13 (2.6) 55 (10.5) student 268 (13.1) 67 (13.2) 0 (0) retired 1 (0.2) 0 (0) 200 (39.0) other (not specified) 1 (0.1) 220 (44.4) 0 (0) 212 (40.5) Private health insurance, n (%) 806 (39.5) 174 (34.3) 52 (10.1) General health, n (%) 50 (10.1) 54 (10.3) 244 (47.6) very good 196 (9.6) 238 (48.1) 40 (7.9) 260 (49.7) 122 (23.8) good 974 (47.8) 146 (29.5) 232 (45.7) 140 (26.8) 86 (16.8) neither good nor poor 561 (27.5) 52 (10.5) 153 (30.1) 59 (11.3) poor 271 (13.3) 74 (14.6) 9 (1.8) very poor 9 (1.8) 10 (1.9) 5.2 (2.9) Anxiety (0 to 10)b, mean (SD) 37 (1.8) 5.2 (2.9) 9 (1.8) 5.4 (2.8) 4.6 (3.1) Depression (0 to 10)b, mean (SD) 5.3 (2.8) 4.6 (3.1) 5.5 (2.8) 4.7 (3.2) 4.6 (3.1) 4.6 (3.1) a Data on age were missing from one participant in the ‘bursitis 1 guideline-based advice’ group. b Higher scores indicate greater symptom severity.
Research 273 Table 2 Total sample Bursitis 1 guideline- Bursitis 1 treatment Rotator cuff tear 1 Rotator cuff tear 1 treatment Characteristics of the participants’ shoulder pain. recommendation guideline-based advice recommendation (n = 2,039) based advice (n = 508) (n = 513) Demographics (n = 523) (n = 495) Previous treatment for shoulder pain, n (%) Previous shoulder surgery, n (%) 1,229 (60.3) 290 (58.6) 307 (60.4) 308 (58.9) 324 (63.2) Previous shoulder imaging, n (%) 104 (5.1) 19 (3.8) 35 (6.9) 22 (4.2) 28 (5.5) Previous shoulder injection, n (%) 843 (41.3) Previous sick leave for shoulder pain, n (%) 444 (21.8) 207 (41.8) 194 (38.2) 222 (42.5) 220 (42.9) Previous shoulder pain diagnosis, n (%) 609 (29.9) 106 (21.4) 114 (22.4) 101 (19.3) 123 (24.0) Shoulder pain over past wk (0 to 10)a, mean (SD) 596 (29.2) 146 (29.5) 143 (28.2) 160 (30.6) 160 (31.2) Duration of shoulder pain 5.1 (1.8) 143 (28.9) 142 (28.0) 163 (31.2) 148 (28.9) 5.1 (1.9) 5.1 (1.8) 5.1 (1.8) 5.0 (1.9) , 1 week 1 week to 3 months 201 (9.9) 51 (10.3) 54 (10.6) 44 (8.4) 52 (10.1) 4 months to 12 months 565 (27.7) 125 (25.3) 152 (29.9) 158 (30.2) 130 (25.3) . 12 months 361 (17.7) 104 (21.0) 82 (16.1) 79 (15.1) 96 (18.7) Total SPADI (0 to 100), mean (SD) 912 (44.7) 215 (43.4) 220 (43.3) 242 (46.3) 235 (45.8) Pain subscore (0 to 100) 48.5 (21.7) 47.8 (21.7) 49.0 (21.3) 48.3 (21.8) 48.8 (22.0) Disability subscore (0 to 100) 55.2 (21.0) 54.8 (20.7) 55.6 (20.4) 55.2 (21.1) 55.3 (21.6) 41.7 (24.6) 40.8 (24.8) 42.4 (24.5) 41.4 (24.5) 42.3 (24.6) SPADI = Shoulder Pain and Disability Index. a Assessed using numeric rating scale. seconds). Participants had access to the script and were able to re- and history of injection(s), respectively. The remaining analyses were watch the video if needed. Participants had to spend at least 90 unadjusted. A Bonferroni correction was used to control for family- seconds on the page with the script and video before proceeding to wise Type I errors, obtaining 98.3% CIs. All analyses were conducted the next part of the survey. using commercial statistical softwarea and performed as per intention to treat. The pool of 1,840 participants provided 80% power to detect an Outcome measures interaction effect between labels and advice of 1.0 point, using a Outcome data were collected immediately after participants had standard deviation of 3, a correlation between previous surgery and outcome of 0.27, and 24% dropout from the previous study.5 Due to read the vignette (Appendix 3). The primary outcome was perceived rapid recruitment and a short delay in stopping recruitment via Qual- need for shoulder surgery, assessed by the following question from trics, this study recruited 206 more participants than planned. previous labelling studies:5,25,26 Based on what your healthcare pro- vider has told you, do you think you need surgery to relieve your Results symptoms? Response options ranged from 0 (‘definitely do not’) to 10 (‘definitely do’). Perceived need for imaging, an injection to relieve Flow of participants, therapists, and centres through the study symptoms, a second opinion and to see a specialist (eg, shoulder surgeon, rheumatologist) were secondary outcomes also adapted The survey was sent to 10,043 individuals and 8,004 (79.7%) were from previous labelling studies5,25,26 and scored from 0 (‘definitely do excluded for various reasons (Figure 1). There were 2,039 participants not’) to 10 (‘definitely do’). Other secondary outcomes included randomised to the four groups. Four participants (0.2%) did not perceived seriousness of the condition (0 = ‘not at all serious’, complete the primary outcome measure (ie, dropped out after ran- 10 = ‘extremely serious’) adapted from Courneya et al,27 perceived domisation), leaving 2,035 (99.8%) for inclusion in the primary recovery expectations (0 = ‘not at all likely’, 10 = ‘very likely), and analysis. The four groups had simliar demographic characteristics perceived impact on work performance (0 = ‘completely agree work (Table 1) and shoulder pain (Table 2). The details of the survey might harm my shoulder’, 6 = ‘completely disagree work might harm completion process are presented in Table 3. my shoulder’) and need to avoid work (0 = ‘completely agree I should not do my normal work’, 6 = ‘completely disagree I should not do my Primary outcome: perceived need for surgery normal work’). Based on the previous trial,5 scores of 0 to 3 were considered as ‘low’ (eg, low perceived need for surgery, low recovery Both labelling as bursitis (versus rotator cuff tear) (estimated mean expectations), scores of 4 to 6 as ‘moderate’, and scores of 7 to 10 as effect –0.5 on a 0-to-10 scale, 98.3% CI –0.7 to –0.2) and guideline- ‘high’ where outcomes were assessed on a 0-to-10 scale. For based advice (versus treatment recommendation) (estimated mean perceived impact work performance and need to avoid work (0 to 6 effect –1.0, 98.3% CI –1.3 to –0.7) decreased perceived need for sur- scale), scores of 0 to 2 were considered as ‘low’, scores of 2 to 4 as gery. There was evidence of little or no interaction effect (estimated ‘moderate’, and scores of 5 to 6 as ‘high’. mean effect 0.3 points, 98.3% CI –0.3 to 0.8). Data analysis Secondary outcomes The main effects of label and advice, and their interaction on an Both labelling as bursitis rather than rotator cuff tear (estimated additive scale, were estimated using 232 (label3advice) multivariable mean effect –0.6 points, 98.3% CI –0.9 to –0.2) and guideline-based linear regression models. To facilitate comparison with the previous advice rather than treatment recommendation (estimated mean effect study,5 analyses for perceived need for surgery, imaging and an injec- –1.4 points, 98.3% CI –1.8 to –1.1) decreased perceived need for im- tion were adjusted for history of shoulder surgery, history of imaging aging. Guideline-based advice rather than treatment recommendation decreased perceived need for an injection (estimated mean effect Table 3 –3.4 points, 98.3% CI –3.7 to –3.1) and a second opinion (estimated Details of survey completion. mean effect –0.5 points, 98.3% CI –0.8 to –0.2). Labelling as bursitis rather than rotator cuff tear had little or no effect on perceived need Duration (minutes) Included in primary analysis Completed the entire survey for an injection (estimated mean effect 0.1 points, 98.3% CI –0.2 to 0.4) or a second opinion (estimated mean effect –0.2 points, 98.3% CI (n = 2,035) (n = 1,976) –0.5 to 0.1) (Table 4). Mean (SD) 16.5 (72.9) 16.6 (74.0) Median (IQR) 10.4 (8.5 to 13.8) 10.4 (8.6 to 13.8)
274 Zadro et al: Labels and advice for shoulder painIntercept (98.3% CI) Both labelling as bursitis rather than rotator cuff tear (estimated2.6 (2.5 to 2.8) mean effect –0.4 points, 98.3% CI –0.7 to –0.1) and guideline-based4.3 (4.1 to 4.5) advice rather than treatment recommendation (estimated mean effect4.8 (4.6 to 5.0) –1.4 points, 98.3% CI –1.7 to –1.1) decreased perceived need to see a4.1 (4.0 to 4.3) specialist. Both labelling as bursitis rather than rotator cuff tear4.3 (4.2 to 4.5) (estimated mean effect –0.6 points, 98.3% CI –0.9 to –0.3) and4.9 (4.7 to 5.0) guideline-based advice rather than treatment recommendation (esti-6.0 (5.9 to 6.2) mated mean effect –1.9 points, 98.3% CI –2.2 to –1.6) decreased the3.4 (3.3 to 3.5) perceived seriousness of the condition (Table 4).3.2 (3.1 to 3.3) Labelling as bursitis rather than rotator cuff tear appeared to have aInteraction negligible effect on recovery expectations (estimated mean effect(98.3% CI) –0.2 points, 98.3% CI –0.5 to 0.1) and impact on work performance0.3 (–0.3 to 0.8) (estimated mean effect –0.2 points, 98.3% CI –0.3 to 0.0), but it–0.2 (–0.8 to 0.5) decreased the perceived need to avoid work (estimated mean effect–0.2 (–0.8 to 0.4) –0.2 points, 98.3% CI –0.4 to 0.0). Guideline-based advice rather than–0.2 (–0.8 to 0.5) treatment recommendation decreased perceived recovery expecta-–0.1 (–0.8 to 0.5) tions (estimated mean effect –0.3 points, 98.3% CI –0.6 to 0.0), but had0.0 (–0.6 to 0.5) little or no effect on perceived impact on work performance (esti-0.2 (–0.3 to 0.8) mated mean effect –0.2 points, 98.3% CI –0.4 to 0.0) and need to avoid–0.1 (–0.5 to 0.3) work (estimated mean effect –0.1 points, 98.3% CI –0.3 to 0.1). There0.0 (–0.4 to 0.4) was evidence of little or no interaction effect for any outcome (Table 4).Effect of guideline- based advice (98.3% CI) Discussion –1.0 (–1.3 to –0.7) Labelling rotator cuff disease as bursitis decreased perceived need–1.4 (–1.8 to –1.1) for surgery, imaging and the need to see a specialist, and perceived–3.4 (–3.7 to –3.1) seriousness of the condition and need to avoid work, compared with–0.5 (–0.8 to –0.2) labelling as rotator cuff tear. Guideline-based advice for rotator cuff–1.4 (–1.7 to –1.1) disease, including encouragement to stay active and positive prog-–1.9 (–2.2 to –1.6) nostic information, decreased perceived need for surgery, imaging, an–0.3 (–0.6 to 0.0) injection, a second opinion and to see a specialist, and perceived–0.2 (–0.4 to 0.0) seriousness of the condition and recovery expectations, compared–0.1 (–0.3 to 0.1) with a treatment recommendation that stresses treatment is needed for recovery. The effect of guideline-based advice was largest forEffect of bursitis perceived need for an injection and perceived seriousness of thelabel (98.3% CI) condition, and around two to three times stronger than the effect of–0.5 (–0.7 to –0.2) labelling as bursitis for most outcomes. Why these effects might be–0.6 (–0.9 to –0.2) clinically important is discussed below. There was evidence of little to0.1 (–0.2 to 0.4) no interaction for any outcome, suggesting labels and advice have, at–0.2 (–0.5 to 0.1) least approximately, an additive effect on management preferences–0.4 (–0.7 to –0.1) for rotator cuff disease.–0.6 (–0.9 to –0.3) –0.2 (–0.5 to 0.1) Advice to stay active and positive prognostic information is–0.2 (–0.3 to 0.0) beneficial for other musculoskeletal conditions (eg, low back pain,17–0.2 (–0.4 to 0.0) knee osteoarthritis18) and has been recommended in some shoul- der pain guidelines for years.23 Yet, before this study there was noRotator cuff tear 1 direct evidence on the benefits of this type of advice for people withtreatment recommendation shoulder pain. This study is the first to evaluate the effect of advice to stay active and positive prognostic information for rotator cuff dis-3.5 (2.8) n = 513 ease, showing that this advice likely decreases perceived need for5.9 (3.0) n = 513 surgery, imaging, an injection, a second opinion and to see a6.7 (2.9) n = 513 specialist, and perceived seriousness of the condition and recovery4.5 (3.1) n = 512 expectations in someone with symptoms for 6 months. The largest5.2 (3.1) n = 512 effects were observed on perceived need for an injection and6.1 (2.5) n = 512 perceived seriousness of the condition. Since some guidelines do not6.3 (2.7) n = 512 recommend advice to stay active and positive prognostic informa-3.5 (1.8) n = 512 tion,19 the results of this study should be considered in all future3.3 (1.7) n = 512 guidelines for the management of rotator cuff disease. Appropriate Table 4 advice could decrease patients perceived need for unnecessary careRotator cuff tear 1recommendation guideline-based advice2.4 (2.6) n = 522 Means (standard deviations), effects (98.3% CI), interaction and intercept for primary and secondary outcomes in each group. and help them choose non-surgical options.4.6 (3.3) n = 521 3.3 (3.0) n = 521 Very limited data on the type of advice healthcare professionals4.0 (3.2) n = 519 provide to patients with rotator cuff disease suggest that there is a3.9 (3.2) n = 519 need to explore this issue further. A systematic review of physio-4.2 (2.8) n = 519 therapists’ treatment choices for musculoskeletal conditions found5.9 (2.8) n = 518 seven studies on rotator cuff disease,28 three of which had data on3.4 (1.8) n = 517 advice provided by physiotherapists.29–31 These studies suggest that3.2 (1.9) n = 517 91% of physiotherapists provide information or advice (type not specified),29 74 to 84% provide advice on posture,30,31 and 10% provideBursitis 1 guideline- Bursitis 1 treatment3.0 (2.8) n = 507 advice to rest or reduce activity.30 An audit of Australian general5.4 (3.0) n = 507 practitioners’ management of shoulder pain found that 10% of6.9 (2.9) n = 506 4.3 (2.9) n = 506 4.9 (3.1) n = 506 5.5 (2.4) n = 504 6.0 (2.6) n = 504 3.4 (1.8) n = 501 3.1 (1.7) n = 501 based advice 2.0 (2.5) n = 493 3.9 (3.1) n = 492 3.4 (2.9) n = 490 3.7 (3.0) n = 489 3.4 (3.1) n = 488 3.6 (2.6) n = 488 5.8 (2.7) n = 488 3.2 (1.8) n = 486 3.0 (1.8) n = 486 Outcome Primary Need for surgery (0 to 10)a, n = 2,035 Secondary Need for imaging (0 to 10)b, n = 2,033 Need for an injection (0 to 10)c, n = 2,030 Need for a second opinion (0 to 10), n = 2,026 Need to see a specialist (0 to 10), n = 2,025 Perceived seriousness (0 to 10), n = 2,023 Recovery expectations (0 to 10), n = 2,022 Impact on work performance (0 to 6), n = 2,016 Need to avoid work (0 to 6), n = 2,016 a Adjusted for previous shoulder surgery. b Adjusted for previous shoulder imaging. c Adjusted for previous shoulder injection.
Research 275 encounters with patients with rotator cuff disease involve advice, the scenario. For example, the larger effect treatment recommenda- education or counseling, whereas 43% involve referral for imaging.32 tion had on percieved need for an injection (versus other outcomes) If future work confirms healthcare professionals commonly aren’t is likely because participants were told that an injection is an providing guideline-based advice, strategies to effectively implement important part of treatment. The main limitation of this study was guidelines into practice would be necessary (eg, guideline dissemi- that it was an online scenario-based experiment; it is possible that nation combined with interactive educational meetings, performance the effects of labels and advice provided during in-person consul- monitoring, or peer assessment33). tations might be different from the effects observed here. It did not exclude participants who previously received diagnostic labels or Advice had a larger effect than labels for most outcomes, but advice for their shoulder pain and did not mention previous labels healthcare professionals should not neglect the potential impor- or advice in the vignette. Such past experience could have interacted tance of avoiding inapproriate labels for rotator cuff disease, such as with the label and advice participants received in this trial. This rotator cuff tear. This is the second study to demonstrate that, in- study only selected two labels from the six evaluated in the previous dependent of advice, labelling rotator cuff disease as a rotator cuff study.5 Although these labels had the largest effect on perceived tear increases perceived need for surgery and imaging compared need for shoulder surgery, they might not be acceptable to all with labelling it as bursitis.5 Although there are no data on how to healthcare professionals. There were no existing data to guide the interpret the effect size for these outcomes, the effect of labelling classification of outcome scores nor how to interpret between- appeared small in both studies (estimated mean effect for current group effect sizes for these outcomes. The classification for versus initial study: surgery 0.5 versus 0.7 and imaging 0.6 versus outcome scores was based on a previous trial the authors con- 1.0 on a 0-to-10 scale). Given the problem of unnecessary sur- ducted.5 Outcomes were immediately assessed after randomisation. gery10–13 for rotator cuff disease in several countries, and that Management preferences may have been different if participants avoiding the label that rotator cuff tear is free of cost, risk and effort, were given more time to reflect. even small effects could be worthwhile on a population level. To illustrate this, there were around 15,500 subacromial decompres- Both labels and advice influenced patients’ preferences regarding sion surgeries and rotator cuff repair surgeries performed in management of their rotator cuff disease. The effect of advice was Australia in 2019, costing over $155 million.10,34 If avoiding the label around two to three times stronger than the effect of labels for most rotator cuff tear only stops one in every 100 patients from having outcomes, although it is uncertain whether these effects are clinically surgery, this would prevent nearly 155 surgeries and save $1.6 important. Labelling rotator cuff disease as bursitis decreased the million per year; money that could be re-directed towards other perceived need for surgery, imaging and the need to see a specialist, areas of need in healthcare. and perceived seriousness of the condition and need to avoid work, compared with labelling as rotator cuff tear. Guideline-based advice for The current findings suggest an additive effect of labels and advice rotator cuff disease, including encouragement to stay active and on management preferences for rotator cuff disease. The combined positive prognostic information, decreased perceived need for sur- effect was largest for perceived need for imaging (2 points on a gery, imaging, an injection, a second opinion and to see a specialist, 0-to-10 scale) and an injection (3.3 points), and perceived seriousness and the perceived seriousness of the condition and recovery expec- of the condition (2.5 points; Table 4). Hence, avoiding the label rotator tations, compared with a treatment recommendation that stresses cuff tear and providing guideline-based advice is likely a simple treatment is needed for recovery. There was evidence of little or no strategy to further reduce patient fear, anxiety and perceived need for interaction between labels and advice for any outcome, but the ad- unnecessary care. ditive effect of labels and advice was large for some outcomes (eg, perceived need for imaging, perceived seriousness of the condition). There will be times when a healthcare professional sees a patient Future research in a clinical setting is needed to confirm the benefits whose shoulder pain has already been given a potentially inappro- of advice, while qualitative research could be used to explain the priate label and we believe that, in these cases, there are things the effect of advice in this study. healthcare professional could do (although these suggestions are not supported by evidence). In these cases, the healthcare professional What was known on this topic: Rotator cuff disease is an could carefully consider whether the benefits of re-labelling umbrella diagnosis that captures most shoulder pain cases. outweigh the potential harms. For example, re-labelling might Diagnostic labels for rotator cuff disease are largely speculative make patients feel that their recall is being challenged or their pre- or arbitrary, and a previous trial found that labelling rotator cuff vious diagnosis is being dismissed. Patients may also lose confidence disease as bursitis decreases patients’ perceived need for in a healthcare professional’s expertise due to conflicting information. shoulder surgery compared with labelling as a rotator cuff tear. Focusing on providing good advice might be more valuable and less This is important because, on average, subacromial decom- likely to create conflict. pression surgery provides little to no benefit over non-surgical management or placebo for rotator cuff disease, and rotator In terms of appropriate labelling, bursitis appears to be the best cuff repair surgery may provide little to no benefit to non- choice for reducing patients’ perceived need for surgery and surgical management for full-thickness degenerative rotator benefiting other outcomes based on our recent studies.5 However, cuff tears. labelling as bursitis attributes a specific nociceptive cause to What this study adds: Guideline-based advice for rotator cuff someone’s shoulder pain. This is potentially inaccurate and disease, including encouragement to stay active and positive misleading, and it is not known whether healthcare professionals prognostic information, decreases perceived need for surgery would be comfortable labelling in such a way. This highlights the compared with a treatment recommendation that stresses importance of future research to investgate the acceptability of treatment is needed for recovery. The effect of labelling was different labels among among healthcare professionals, patients similar to a previous trial where labelling rotator cuff disease as and other key stakeholders (eg, insurance companies and bursitis decreased patients’ perceived need for shoulder surgery compensation systems). compared with labelling it as a rotator cuff tear. The effect of guideline-based advice on perceived need for surgery (and The main strengths of this study included a large sample size several other outcomes) is around two to three times stronger evenly distributed across five countries, use of random allocation, than the effect of labelling as bursitis. concealed allocation, intention-to-treat analysis, a correction for multiple comparisons, and a sample of participants experiencing moderate shoulder pain and disability (mean SPADI score: 49/100). The findings also suggest that participants paid careful attention to
276 Zadro et al: Labels and advice for shoulder pain Footnotes: a Stata Statistical Software Version 17 (Basic Edition), 7. Elshaug AG, Rosenthal MB, Lavis JN, Brownlee S, Schmidt H, Nagpal S, et al. Levers Statacorp, USA. for addressing medical underuse and overuse: achieving high-value health care. Lancet. 2017;390(10090):191–202. eAddenda: Appendices 1-4 can be found online at https://doi. org/10.1016/j.jphys.2022.09.005 8. Karjalainen TV, Jain NB, Page CM, Lähdeoja TA, Johnston RV, Salamh P, et al. Sub- acromial decompression surgery for rotator cuff disease. Cochrane Database Syst Ethics approval: The University of Sydney Human Research Ethics Rev. 2019;1:CD005619. Committee (Reference number: 2021/776) approved this study. All participants gave written informed consent before data collection 9. Karjalainen TV, Jain NB, Heikkinen J, Johnston RV, Page CM, Buchbinder R. Surgery began. for rotator cuff tears. Cochrane Database Syst Rev. 2019;12:CD013502. Competing interest: All other authors declare no support from any 10. Medicare Item Reports 2000/2001 to 2019/20. http://medicarestatistics.human organisation for the submitted work; no financial relationships with services.gov.au/statistics/mbs_item.jsp. Accessed February 9, 2022. any organisations that might have an interest in the submitted work; no other relationships or activities that could appear to have influ- 11. Judge A, Murphy RJ, Maxwell R, Arden NK, Carr AJ. Temporal trends and enced the submitted work. geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England. Bone Joint J. 2014;96-b:70–74. Source of support: This study was funded from JRZ’s National Health and Medical Research Council (NHMRC) Investigator Grant 12. Paloneva J, Lepola V, Äärimaa V, Joukainen A, Ylinen J, Mattila VM. Increasing (APP1194105). incidence of rotator cuff repairs—A nationwide registry study in Finland. BMC Musculoskelet Disord. 2015;16:189. Acknowledgements: Nil. Contributors: All authors critically revised the manuscript for 13. Zhang AL, Montgomery SR, Ngo SS, Hame SL, Wang JC, Gamradt SC. Analysis of important intellectual content and approved the final manuscript. rotator cuff repair trends in a large private insurance population. Arthroscopy. Please find below a detailed description of the role of each author: 2013;29:623–629. JRZ: conception and design, analysis and interpretation of data, drafting and revision of the manuscript, and final approval of the 14. Buchbinder R, Staples MP, Shanahan EM, Roos JF. General practitioner management version to be published. MO’K: conception and design, interpretation of shoulder pain in comparison with rheumatologist expectation of care and best of data, drafting and revision of the manuscript and final approval of evidence: an Australian national survey. PLoS One. 2013;8:e61243. the version to be published. GEF: conception and design, interpre- tation of data, drafting and revision of the manuscript and final 15. Artus M, van der Windt DA, Afolabi EK, Buchbinder R, Chesterton LS, Hall A, et al. approval of the version to be published. ACT: conception and design, Management of shoulder pain by UK general practitioners (GPs): a national survey. interpretation of data, drafting and revision of the manuscript and BMJ Open. 2017;7:e015711. final approval of the version to be published. AG: conception and design, interpretation of data, drafting and revision of the manuscript 16. Tran G, Cowling P, Smith T, Bury J, Lucas A, Barr A, et al. What imaging-detected and final approval of the version to be published. RP: conception and pathologies are associated with shoulder symptoms and their persistence? A design, interpretation of data, drafting and revision of the manuscript systematic literature review. Arthritis Care Res. 2018;70:1169–1184. and final approval of the version to be published. RDH: conception and design, interpretation of data, drafting and revision of the 17. Hagen KB, Hilde G, Jamtvedt G, Winnem MF. The Cochrane review of advice to stay manuscript and final approval of the version to be published. IAH: active as a single treatment for low back pain and sciatica. Spine. 2002;27:1736– conception and design, interpretation of data, drafting and revision of 1741. the manuscript and final approval of the version to be published. CGM: conception and design, interpretation of data, drafting and 18. Goff AJ, De Oliveira Silva D, Merolli M, Bell EC, Crossley KM, Barton CJ. Patient revision of the manuscript and final approval of the version to be education improves pain and function in people with knee osteoarthritis with published. The corresponding author (JZ) attests that all listed au- better effects when combined with exercise therapy: a systematic review. thors meet authorship criteria and that no others meeting the criteria J Physiother. 2021;67:177–189. have been omitted. Data sharing: All data relevant to the study are available upon 19. Doiron-Cadrin P, Lafrance S, Saulnier M, Cournoyer É, Roy JS, Dyer JO, et al. reasonable request to the corresponding author. Shoulder rotator cuff disorders: a systematic review of clinical practice guidelines Provenance: Not invited. Peer reviewed. and semantic analyses of recommendations. Arch Phys Med Rehabil. Correspondence: Joshua Zadro, Institute for Musculoskeletal 2020;101:1233–1242. Health, The University of Sydney and Sydney Local Health District, Sydney, Australia. Email: [email protected] 20. Qualtrics. ESOMAR 28. 28 questions to help research buyers of online samples. 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Journal of Physiotherapy 68 (2022) 220 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 Announcement Expressions of interest for the Journal of Physiotherapy Editorial Fellowship Expressions of interest are now invited for the next Editorial Fellowship term, which will run for two years from January 2023 to December 2024. The Editorial Fellowship (one post available) will enable an emerging Australian physiotherapy researcher to gain important exposure to an international Editorial Board. This Fellowship will allow an early career researcher to develop skills in the key Journal of Physiotherapy portfolios, including Critically Appraised Papers and Clinimetrics. By rotating through each portfolio, there will be opportunities to receive mentoring from the Scientific Editor and Editorial Board members across all stages of the publication process. The position will also have a communications focus, contributing to our social media presence. A tangible outcome of the Fellowship will be a co-authored editorial or appraisal paper in the Journal. The successful applicant will be expected to attend quarterly Editorial Board meetings during the appointed term (as a non-voting member) and to prepare a brief report at the end of the Fellowship. Please note that this is an unpaid Fellowship. To be eligible to apply, applicants must: 1. be within 5 years of PhD award (taking career disruption into account) 2. be a financial member of the Australian Physiotherapy Association at the time of application. To be considered, applicants must submit: 1. a cover letter (maximum 2 pages) summarising: (a) what they hope to gain from the Editorial Fellowship; (b) what they would uniquely bring to the Journal of Physiotherapy; and (c) their specific areas of interest with respect to Editorial Fellowship rotations 2. a brief CV (maximum 3 pages) that also addresses the eligibility criteria above Expressions of interest are assessed by the Editorial Board, with a focus on what the applicant will gain from the Editorial Fellowship, what the applicant will bring to the role, and their research and dissemination track record (relative to opportunity), with attention given to diversity and equity considerations. Short-listed applicants will be asked to share their idea(s) for broadening journal reach and enhancing reader engagement; for example, through the preparation of a sample tweet, infographic, podcast outline or plain language research summary. Short-listed applicants may be interviewed. Expressions of interest close Friday, 4 November 2022 and should be directed to Melissa Mitchell at [email protected] https://doi.org/10.1016/j.jphys.2022.10.001 1836-9553/
Journal of Physiotherapy 68 (2022) 255–261 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 Injury prevention programs that include plyometric exercises reduce the incidence of anterior cruciate ligament injury: a systematic review of cluster randomised trials Wesam Saleh A Al Attar a,b,c, Jumana M Bakhsh a, Ehdaa H Khaledi a,d, Hussain Ghulam e, Ross H Sanders b aDepartment of Physical Therapy, Faculty of Applied Medical Sciences, Umm Al Qura University, Makkah, Saudi Arabia; bDiscipline of Exercise and Sport Science, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, Australia; cDepartment of Sport, Exercise and Health, Faculty of Medicine, University of Basel, Basel, Switzerland; dDepartment of Physical Therapy, King Abdullah Medical City, Makkah, Saudi Arabia; eDepartment of Physical Therapy, Faculty of Applied Medical Sciences, Najran University, Najran, Saudi Arabia KEYWORDS ABSTRACT Injury risk reduction Question: Do injury prevention programs that include plyometric exercises reduce the incidence of anterior Sporting injuries cruciate ligament (ACL) injuries in sport? Design: Systematic review of (cluster) randomised trials with Knee injury meta-analysis. Participants: Sporting participants of any age, sex or competition level. Interventions: The ACL injury experimental intervention was an injury prevention program that included plyometric exercises. The control Physical therapy intervention was the usual warm-up program, which did not include plyometric exercises. Outcome measures: Exposure-based ACL injury rates. Results: The initial search yielded 7,302 articles, of which nine met the inclusion criteria. All nine articles reported cluster randomised trials, providing data on 14,394 participants. The pooled results showed that injury prevention programs that include plyometric exercises reduce the risk of ACL injury by 60% per 1,000 hours of exposure compared with the control group, with an injury risk ratio (IRR) of 0.40 (95% CI 0.26 to 0.63). Data from subgroups of these trials estimated that this preventative effect may be stronger in males (IRR 0.21, 95% CI 0.07 to 0.62) and weaker in females (IRR 0.51, 95% CI 0.30 to 0.87), albeit with less precise estimates. Subgroup analysis also suggested a stronger effect on non-contact ACL injuries (IRR 0.34, 95% CI 0.18 to 0.65), whereas the effect on contact ACL injuries remained uncertain (IRR 0.59, 95% CI 0.15 to 2.30). Conclusions: Injury prevention programs that incorporate plyo- metric exercises substantially decrease the risk of ACL injuries more than warm-up programs that do not include plyometric exercises. The preventive effect appears to be stronger among males and in the pre- vention of ACL injuries that do not involve contact with another player. PROSPERO CRD42020196982. [Al Attar WSA, Bakhsh JM, Khaledi EH, Ghulam H, Sanders RH (2022) Injury prevention programs that include plyometric exercises reduce the incidence of anterior cruciate ligament injury: a systematic review of cluster randomised trials. Journal of Physiotherapy 68:255–261] © 2022 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 ACL injuries are common in a very wide range of sports. In soccer, Anterior cruciate ligament (ACL) tears are estimated to number for example, the high incidence of ACL injuries is believed to relate to 250,000 each year in the USA, with an average annual cost exceeding two billion dollars.1 In young sporting participants, up to 96% of ACL tasks such as landing from attempts to head the ball and forceful injuries are reported to be non-contact in nature,2 occurring without cutting manoeuvres to get around other players.9,10 In the USA, bil- any direct physical contact by other players with the athlete’s body. These types of injuries can occur under any conditions that cause the lions of dollars each year are spent on imaging, surgery, bracing and stress on the ACL to increase beyond its capacity. These conditions rehabilitation of these injuries.1 In response, the Fédération Inter- include performing actions such as cutting when running or landing after jumping.3 About 79% of ACL injuries occur during sports activ- nationale de Football Association (FIFA) programs for injury preven- ities when participants land on one leg (with their whole body tion have been promoted and deployed worldwide.11 weight) in a position where the knee is at a minimal degree of flexion.2 ACL injuries may result in long-term clinical sequelae such as Strategies for the prevention of ACL injuries include a wide variety posttraumatic knee osteoarthritis.4–8 of interventions, such as neuromuscular training, proprioceptive training, stretching, plyometrics, movement training, core strength- ening, balance training, resistance training and speed training.12 Plyometric exercises comprise a very popular form of physical inter- vention that involve performing loaded jumping-type exercises using the stretch-shortening cycle muscle action.13,14 Although plyometrics https://doi.org/10.1016/j.jphys.2022.09.001 1836-9553/© 2022 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/).
256 Al Attar et al: Plyometric exercises to prevent cruciate ligament injury training is widely used to increase the power of subsequent move- Box 1. Inclusion criteria. ments,14 it has also been examined as a preventative intervention for ACL injuries. Design (Cluster) randomised controlled trials Within the last 5 years, five reviews have been conducted that in Published in English some way evaluated the effectiveness of plyometric exercises on reducing the rate of ACL injuries.15–19 Stevenson et al16 concluded that Participants neuromuscular training programs including plyometric exercises are Sports players the most effective for ACL injury prevention; non-randomised studies No restriction by age, sex or skill level were included in that review so the conclusions may be open to some bias. Nessler et al17 evaluated programs to prevent ACL injuries and Intervention sought to identify risk factors that are linked with such injuries. Injury prevention programs that included plyometric training Although they concluded that plyometrics can help to reduce ACL exercises, such as the FIFA 111 injury prevention program injuries, only two of the included studies used plyometric exercises; furthermore, the review did not have a formal search strategy. Outcome measures Neither of these reviews conducted any meta-analysis. The remaining Reported at least two of: number of ACL injuries, ACL injury three reviews used robust searches and meta-analysis.15,18,19 Two of rate and exposure hours the reviews examined the effect of multicomponent neuromuscular training in female athletes only, so they cannot guide management of Comparisons males.15,18 Moreover, there was considerable variability in the An injury prevention program that included plyometric training experimental interventions that they pooled together and the com- exercises versus usual/standard warm-up program that did not ponents of the control intervention were not stated.15,18 The final include plyometric training exercises systematic review meta-analysed eight (cluster) randomised trials involving 13,562 male and female athletes.19 The included programs Inclusion procedure incorporated components such as strengthening, plyometrics and Two researchers (WSA and JB) working independently completed agility exercises along with training in the proper landing technique using feedback. However, key factors related to the delivery of the the search process, including the removal of duplicates and assessment injury prevention program and the specific exercises included in each of each remaining article’s title and abstract against the eligibility program were highly variable. For example, trials that delivered ex- criteria. Articles that did not meet the eligibility criterion were excluded. ercise components for strength, plyometrics, agility and flexibility but A third researcher (EK) assisted the group to reach a consensus in any not balance were meta-analysed together with a trial that delivered cases of disagreement. Articles that appeared potentially eligible from balance training and none of the other components, making it very their title and abstract were retrieved in full text and assessed to deter- difficult to know what components should be incorporated in an mine eligibility. All articles included in the review and any relevant injury prevention program to achieve the pooled effects calculated in literature reviews identified during the searches underwent reference the meta-analyses. tracking to identify further potentially eligible studies. Since those five reviews were conducted, additional relevant trials Assessment of characteristics of studies have been published, so an updated systematic review is required to assess the effectiveness of injury prevention programs that include Methodological quality plyometric exercises in reducing the incidence of ACL injuries in The quality of the randomised trials included was assessed using sport. the PEDro scale,21 which is a useful tool and a valid measure of the Therefore, the study question for this systematic review was: methodological quality of clinical trials.22 Although the scale consists of 11 items, the first item (eligibility criteria and source) is not used in Do injury prevention programs that include plyometric exercises calculating the score.23 PEDro scores therefore range from 0 to 10 and reduce the incidence of anterior cruciate ligament injuries in reflect risk of bias and completeness of reporting. sport? Participants Methods The age and sex of the participants and their compliance with This systematic review was prospectively registered and reported the study interventions were extracted for each included trial to according to the Preferred Reporting Items for Systematic Reviews characterise the experimental and control groups. The sport and Meta-Analysis (PRISMA) guidelines.20 undertaken and the skill level of the participants were also extracted. Identification and selection of studies Intervention Search strategy The components of the injury prevention program were extracted The literature search strategy involved structured searches of from each included trial, along with the prescribed frequency of use PubMed, Medline, Web of Science, Cochrane Library and the Phys- and the total duration of the intervention period. The corresponding iotherapy Evidence Database (PEDro) for relevant articles published information was extracted from the control group of each study. in 1985 or later. The searches were based around the following Where necessary, the original authors were contacted to obtain these keywords: anterior cruciate ligament injury, ACL, injury prevention details. program, plyometrics training, injury rates, FIFA, knee injuries and athlete. See Appendix 1 on the eAddenda for a detailed search Outcome measures strategy. Data were extracted to calculate injury rate, which could be the number of ACL injuries and exposure hours, or ACL injury rates. Follow-up duration and compliance rate were also extracted from the included trials. Data analysis Eligibility criteria Commercial reference management softwarea was used for stor- Cluster-randomised trials or randomised trials were eligible for age, collation and screening of studies. Primary outcome results from inclusion in the review if they met the inclusion criteria listed in Box 1. Studies were excluded if they did not report player exposure hours or individual studies were extracted and collated in commercial used protective equipment as part of the intervention. spreadsheet softwareb prior to preparation and transfer into com- mercial meta-analysis softwarec.
Research 257 Meta-analysis Records identified through Records identified through The number of incident injuries was divided by the total time at database searching (n = 7,302) other sources (n = 0) risk and multiplied by 1,000 to refer to the injury incidence rate (IRR). Records after duplicates removed (n = 4,724) The IRR was calculated as injury incidence rate in the experimental group divided by the injury rate in the control group. An IRR , 1 Titles and abstracts screened (n = 4,724) indicates that the experimental intervention has a protective effect. Based on the assumption that the studies had diverse populations Excluded based on title and abstract (n = 4,656) and different doses of exercise, we used the invariance random- effects model to assume that the data being analysed were drawn Full-text articles assessed for eligibility (n = 68) from a hierarchy of different populations whose differences related to that hierarchy. Commercial meta-analysis softwarec was used to Excluded after evaluation of full text (n = 59) calculate the overall sample size, the confidence interval for each • did not use plyometric exercises (n = 46) study and the pooled results. • author did not respond with data necessary for Publication bias inclusion of the study (n = 8) If 10 studies were available, it was intended to create a funnel plot • ACL inury rates and exposure times not to assess publication bias. The Egger’s test24 and Begg’s test25 would reported (n = 4) then be applied to establish the degree of asymmetry and the ‘trim • non-English language (n = 1) and fill’ method26 would be used to estimate missing studies due to publication bias in the funnel plot. Definitions of injury and workload ACL injury Studies included in qualitative synthesis (n = 9) Figure 1. Flow of trials through the review. An ACL injury was defined as a partial or complete rupture of the ligament that occurs for the first time or as a recurrence. The ligament injury could occur in isolation or in combination with other knee joint injuries.27 Workload stretching, strengthening, plyometrics, agility activities and avoid- The workload of the participants was described as the number of ance of high-risk positions three times a week. LaBella et al32 used a active hours spent during the study in either training or competitive 20-minute neuromuscular warm-up (strength, balance, plyometric play.28 and agility) twice a week. Waldén et al27 used a 15-minute neuro- Results muscular warm-up program (one-legged knee squat, a pelvic lift, a Flow of studies through the review two-legged knee squat, the bench, the lunge and jump/landing technique) twice a week. Achenbach et al34 used neuromusclar The initial database searches yielded 7,302 articles. After eliminating duplicates, 4,724 articles remained and were screened training (strength exercises, plyometric exercises, jump and landing based on their titles and abstracts. Of these, 68 were considered potentially eligible and retrieved as full-text articles and further exercises, and proprioceptive exercises) two to three times a week. Al assessed for eligibility. Of these, 59 were excluded because they Attar et al35 used the pre-training and post-training FIFA 111 pro- did not meet the eligibility criteria. Thus, nine articles were gram two to three times a week. included in the quantitative analysis of this review. Figure 1 shows the flow of articles through the search, screening and in- For the control group, participants’ usual warm-up program was clusion processes. used in seven studies.27,29–34 Al Attar et al35 used the pre-training FIFA 111 program and Zarei et al36 used a standard warm-up pro- Characteristics of studies gram in the control groups, and the 111 Kids program used by the intervention group. Table 1 illustrates the characteristics of the nine included studies and Table 2 shows the injury rates and hours of exposure of the Methodological quality intervention and control groups. All nine studies were cluster- randomised trials.27,29–36 Three studies were conducted in the The internal validity of the included studies was assessed using the USA,30,32,33 two studies were conducted in Norway,29,31 and single PEDro scale (Table 3).21 The method of randomisation generation was studies were conducted in Iran,36 Sweden,27 Germany34 and defined in all included studies.27,29–36 The intervention allocation was Australia.35 Four studies included only female participants,27,30–32 concealed in five included studies,27,31,33,35,36 but not clarified in four three studies included only male participants,33,35,36 and two studies.29,30,32,34 Seven studies had sufficient information about the studies included female and male participants.29,34 The duration of groups’ characteristics and similarity at baseline,27,29,30,32,33,35,36 while programs ranged from 3 months to one season. two studies did not.31,34 None of the studies were administered with blinding of the subjects and therapists,27,29–36 while assessors were blinded in two studies.27,31 Participant follow-up was sufficient in four of nine studies.29,31–33 Intention-to-treat analysis was applied in six studies,27,29,31,32,35,36 while it was not in three studies.30,33,34 Proper point and variability measures of the study outcome and appropriate statistical comparisons were reported in all studies.27,29–36 Experimental and control intervention components Effect of the intervention One of the Norwegian studies used the FIFA 11 for 15 consecutive Pooled injury estimates sessions and thereafter once a week during the rest of the season.31 The pooled data of 14,394 participants, 985,938 exposure hours, One study used FIFA 111 three times a week,33 and another study used FIFA 111 kids twice a week.36 Olsen et al29 used a structured and 103 ACL injuries were collected from the included studies (Table 2). warm-up program to improve running, cutting and landing tech- Overall reduction in ACL injuries based on total exposure hours Overall, the pooled results showed 60% greater reduction in ACL niques, neuromuscular control, balance and strength at every training injuries per 1,000 hours of exposure among those who received the session for 15 consecutive sessions and then once a week. Gilchrist et al30 used a warm-up program including basic components in
258 Al Attar et al: Plyometric exercises to prevent cruciate ligament injury Table 1 Characteristics of the included studies (n = 9). Study Participants Intervention Outcome measures Design Exp Con ACL injury Country N = 279 ACL injury Achenbach 2017 34 Age (y) = 13 to18 Neuromuscular training Standard warm-up ACL injury Cluster RCT Gender = F, M (included plyometric exercises) 2 to 3/week 3 one season ACL injury Germany Compliance (%) = NA 2 to 3/week 3 one season ACL injury Adolescent handball ACL injury Al Attar 2017 35 FIFA 111 IPP performed before FIFA 111 IPP performed before ACL injury Cluster RCT N = 280 and after training (included training only ACL injury Australia Age (y) = 14 to 35 plyometric exercises) 2 to 3/week 3 6 months ACL injury Gender = M 2 to 3/week 3 6 months Gilchrist 2008 30 Compliance (%) = 83 Standard warm-up Cluster RCT Amateur soccer PEP program (included 3/week 3 3 months USA plyometric exercises) N = 1,435 3/week 3 3 months LaBella 2011 32 Age (y) = 19 to 20 Cluster RCT Gender = F Neuromuscular training Standard warm-up USA Compliance (%) = 72 (included plyometric exercises) 2/week 3 one season Collegiate (Division 1) soccer 2/week 3 6 months (one season) Olsen 2005 29 Cluster RCT N = 1,492 Structured warm-up program Standard warm-up Norway Age (y) = 14 to 18 (included plyometric exercises) 1 to 5 /week 3 8 months Gender = F 1 to 5 /week 3 8 months Silvers-Granelli 2015 33 Compliance (%) = 80 Cluster RCT Youth soccer and basketball FIFA 111 IPP (included Aerobic warm up 3/week 3 6 USA plyometric exercises) months N = 1,837 3/week 3 6 months Steffen 2008 31 Age (y) = 15 to 17 Cluster RCT Gender = F, M FIFA 11 IPP (included plyometric Standard warm-up Norway Compliance (%) = 87 exercises) 1 to 5/week 3 8 months Youth handball 1 to 5/week 3 8 months Waldén 2012 27 Cluster RCT N = 1,525 Neuromuscular training Standard warm-up Sweden Age (y) = 18 to 25 (included plyometric exercises) 2/week 3 7 months Gender = M 2/week 3 7 months Zarei 2019 36 Compliance (%) = 73 Cluster RCT Collegiate soccer FIFA 111 Kids IPP (included Standard warm-up Iran plyometric exercises) 2/week 3 9 months N = 2,020 2/week 3 9 months Age (y) = 13 to17 Gender = F Compliance (%) = 52 Youth soccer N = 4,564 Age (y) = 12 to 17 Gender = F Compliance (%) = NA Youth soccer N = 962 Age (y) = 7 to 14 Gender = M Compliance (%) = 50 to 100 Children soccer Con = control group, Exp = experimental group, F = female, FIFA 111 IPP = Fédération Internationale de Football Association Medical and Research Centre (F-MARC) injury prevention program, M = male, NA = not assessed, RCT = randomised controlled trial, PEP = Prevent injury and Enhance Performance program. injury prevention programs that included plyometric exercise Reduction of ACL injuries in subgroups compared with the control group (IRR 0.40, 95% CI 0.26 to 0.63). The In the studies where data for contact and non-contact injuries inconsistency statistic indicated no heterogeneity between studies (I2 = 0%) (Figure 2); see Figure 3 on the eAddenda for a detailed forest were pooled, injury prevention progams that included plyometric plot. exercises showed a 59% injury reduction per 1,000 hours of exposure (IRR 0.41, 95% CI 0.24 to 0.70). In studies where only contact ACL Table 2 Injury rates per 1,000 hours of exposure in the experimental and control groups of the included studies. Study N ACL injuries Exp Injuries/1,000 hours N ACL injuries Con Injuries/1,000 hours Achenbach 201734 168 1 Exposure hours 0.038 111 2 Exposure hours 0.112 Al Attar 201735 144 0 0.000 136 3 0.095 Gilchrist 200830 583 7 26,278 0.199 852 18 17,929 0.340 LaBella 201132 737 2 35,802 0.071 755 6 31,616 0.262 Olsen 200529 958 3 35,220 0.032 879 10 52,919 0.114 Silvers-Granelli 201533 675 3 28,023 0.085 850 16 22,925 0.362 Steffen 200831 1,073 4 93,812 0.060 947 5 87,483 0.076 Waldén 201227 2,479 7 35,226 0.047 2,085 14 44,212 0.108 Zarei 202036 443 0 66,423 0.000 519 2 65,725 0.062 Pooled data 7,260 27 149,214 7,134 76 129,084 31,934 32,113 501,932 484,006
Research 259 Table 3 PEDro scores for the included trials (n = 9). Study Random Concealed Groups similar Participant Therapist Assessor , 15% loss to Intention- Between-group Point estimate Total allocation allocation at baseline blinding blinding blinding follow-up to-treat difference and variability (0 to 10) analysis reported reported Achenbach 201734 Y N N N NN N N Y Y3 Y6 Al Attar 201735 YY Y N NN N Y Y Y4 Y6 Gilchrist 200830 YN Y N NN N N Y Y6 Y6 LaBella 201132 YN Y N NN Y Y Y Y7 Y7 Olsen 200529 YN Y N NN Y Y Y Y6 Silvers-Granelli 201533 Y Y Y N NN Y N Y Steffen 200831 YY N N NY Y Y Y Waldén 201227 YY Y N NY N Y Y Zarei 202036 YY Y N NN N Y Y N = no, Y = yes. injuries were examined, there was a 41% injury reduction due to the The mean reductions in risk observed in this review were large: injury prevention programs that included plyometric exercises (IRR 60% overall and ranging from 41 to 79% in the various subgroups. 0.59, 95% CI 0.15 to 2.30). Among the studies where only non-contact These effects are certainly large enough to make it worthwhile to ACL injuries were examined, there was a 66% injury reduction (IRR change the components of sporting participants’ usual injury pre- 0.34, 95% CI 0.18 to 0.65). The inconsistency statistic showed mod- vention program to include plyometric exercises. Implementing this erate heterogeneity among the studies of contact ACL injuries (I2 = change in clinical practice involves so little effort that even much 33%), while contact and non-contact injury studies along with non- weaker effects would make adopting plyometric exercises for injury contact injury studies were homogeneous (I2 = 0%) (Figure 4); see prevention worthwhile. Therefore, even the weakest estimated re- Figure 5 on the eAddenda for a detailed forest plot. ductions in risk (shown by the upper limit of the confidence intervals) of 37% overall and ranging from 9 to 38% in most of the various sub- The studies that reported data for males only showed that injury groups are also arguably worthwhile. The exception was the effect on prevention programs that included plyometric exercises caused a 79% injuries that involved contact with another player, where the confi- ACL injury reduction per 1,000 hours of exposure in males (IRR 0.21, dence interval showed that the effect of incorportating plyometric 95% CI 0.07 to 0.62), whereas the value was a 50% reduction in the exercises into an injury prevention program remains very uncertain. studies of females (IRR 0.51, 95% CI 0.30 to 0.87). There was a 71% reduction (IRR 0.29, 95% CI 0.09 to 0.91) in the studies that pooled The subgroup analysis by mechanism of injury (contact versus data for both males and females. The inconsistency statistic indicated non-contact) was an important analysis because most ACL injuries homogeneity between the results from the studies of males only and are caused by non-contact mechanisms.2,37,38 The pooled results females only (I2 = 0%) (Figure 6); see Figure 7 on the eAddenda for a detailed forest plot. Publication bias a Rate Ratio (95% CI) Because there were fewer than 10 studies included in any of the Study meta-analysies, the planned analyses of Egger’s test24 and Begg’s Gilchrist³º test25 were not undertaken. LaBella³² Silvers-Granelli³³ Discussion Waldén²⁷ Total 0.1 1 10 100 100 This systematic review and meta-analysis of nine cluster rando- 0.01 Favours exp Favours con mised controlled trials27,29–36 provided very clear evidence that injury prevention programs that include plyometric exercises have a sig- b Rate Ratio (95% CI) nificant effect in reducing ACL injuries among sporting participants. The meta-analysis revealed that injury prevention programs that Study included plyometric exercises reduced ACL injury rate by 60% per Gilchrist³º 1,000 hours of exposure. Silvers-Granelli³³ Study Rate Ratio (95% CI) Total 0.1 1 10 Achenbach³⁴ 0.01 Favours exp Favours con Al Attar³⁵ Gilchrist³º c LaBella³² Olsen²⁹ Study Rate Ratio (95% CI) Silvers-Granelli³³ Steffen³¹ Gilchrist³º 0.1 1 10 100 Waldén²⁷ LaBella³² Zarei³⁶ Silvers-Granelli³³ Waldén²⁷ Total Total 0.01 0.01 0.1 1 10 100 Favours exp Favours con Favours exp Favours con Figure 2. Forest plot of the effect of injury prevention programs that included plyo- Figure 4. Forest plot of the effect of injury prevention programs that included plyo- metric exercises versus control on anterior cruciate ligament injury risk ratio. Con = metric exercises versus control on anterior cruciate ligament injury risk ratio, sub- control group, Exp = experimental group. grouped by studies of (a) pooled contact and non-contact injuries, (b) contact injuries, and (c) non-contact injuries. Con = control group, Exp = experimental group.
260 Al Attar et al: Plyometric exercises to prevent cruciate ligament injury a Rate Ratio (95% CI) causative factors in ACL injuries, such as by decreasing landing force, knee flexion and knee valgus moments during landing, as well as Study 0.1 1 10 100 increasing muscle activation and proprioception.10,40–42 However, not Achenbach³⁴ all studies support this proposed mechanistic pathway;43,44 for Olsen²⁹ Favours exp Favours con example, female athletes who completed a neuromuscular training program that included plyometric training did not experience all the Total changes in the biomechanical performance that had been anticipated from the theory of how plyometric exercises are protective.44 While it 0.01 would be good to more accurately understand the mechanism behind the preventive effect, the estimates of the magnitude of the effects are b large enough and precise enough for clinicians to implement injury prevention programs that include plyometric exercises as evidence- Study Rate Ratio (95% CI) based injury prevention management. Al Attar³⁵ Silvers-Granelli³³ 0.1 1 10 100 Although the ACL injury rate reduction was clearly worthwhile in Zarei³⁶ 100 both males (IRR 0.21, 95% CI 0.07 to 0.62) and females (IRR 0.51, 95% CI Favours exp Favours con 0.30 to 0.87), the reduction seems greater among males than females. Total Nevertheless, the estimated effect in females is still clearly worthwhile. Rate Ratio (95% CI) This is consistent with another published analysis that concluded that 0.01 female athletes who performed plyometric exercises within their pre- 0.1 1 10 ventive program had a lower ACL injury risk than those who did not,45 c albeit with some non-randomised studies included in that analysis. Study Three of nine included studies reported the data of players with a Gilchrist³º previous ACL injury.27,30,32 However, the number of players who LaBella³² received ACL injuries and the injury rate for players with and without Steffen³¹ a history of a previous ACL injury was provided in one of those Waldén²⁷ studies,30 whereas only the total number of players with previous ACL injury for both intervention and control groups was reported in the Total other two studies.27,32 Therefore, subgroup analysis based on the history of ACL injury could not be conducted due to the heterogeneity 0.01 of the available data. We recommend further cluster-randomised controlled trials on this topic could report a subgroup analysis of Favours exp Favours con participants with and without previous history of an ACL injury. Figure 6. Forest plot of the effect of injury prevention programs that included plyo- Further research is needed to evaluate the effect of injury pre- metric exercises versus control on anterior cruciate ligament injury risk ratio, sub- vention programs that include plyometric exercises on ACL injury grouped by studies of (a) pooled males and females, (b) males, and (c) females. Con = risk. Such research could also investigate the best training parameters control group, Exp = experimental group. of plyometric-based training, and evaluate its effectiveness in reducing ACL injuries among specific sport populations. provided evidence that injury prevention programs that include plyometric training reduce non-contact ACL injuries by around 66% This systematic review and meta-analysis employed subgroup an- (IRR 0.34, 95% CI 0.18 to 0.65) but the estimate that they reduce alyses based on the mechanism of injury and sex, as well as reporting contact injuries by 41% was very uncertain (IRR 0.59, 95% CI 0.15 to the exposure hours. These procedures minimised the heterogeneity 2.30). If plyometric injury prevention programs are truly less effective between included studies and provided knowledge of potential con- (or even ineffective) on contact ACL injuries, this may be because the tributors to ACL injury risk. Although the review was able to include mechanism of injury involves external forces that are beyond what data on a variety of sports and training elements in the prevention can be countered by the additional balance and agility arising from programs, further clinical trials could examine the effect of plyometric the incorporation of plyometrics. The wide confidence interval for exercise on the incidence of ACL injuries in other sport populations. this subgroup is partly due to there being only two studies of contact injuries compared with four studies of non-contact injuries. Thus, the In conclusion, this systematic review and meta-analysis indicates 41% reduction in contact injuries is not a precise enough estimate to that injury prevention programs that include plyometric exercises guide decision-making about prevention of contact injuries. Given have a significant preventive effect against ACL injuries among both that the overall decrease in injury risk when data for contact and male and female sporting participants. The results suggest that ACL non-contact injuries were pooled confirms a worthwhile effect, the injury rates reduce by 60% in teams that perform injury prevention clinical implication remains firmly that plyometrics should be programs that include plyometric exercises compared with teams incorporated in injury prevention, despite the uncertainty about the that do not. Accordingly, these findings may encourage the physio- effect on contact injuries specifically. therapists, coaches and players to include plyometrics exercises within players’ prevention programs. These findings provide valuable evidence to support the position statement of the American National Athletic Trainers’ Association, What was already known on this topic: Anterior cruciate which advises that non-contact and indirect contact ACL injuries are ligament injuries are common in competitive sport and may have reduced by multicomponent injury prevention programs that include long-term sequelae such as posttraumatic knee osteoarthritis. at least three of: plyometrics, balance, flexibility, agility and strength- Multicomponent injury prevention programs seem to reduce the ening.39 However, the recommendation in that position statement is risk of anterior cruciate ligament injury but it is unclear which based on Level B evidence because it partly relies on non-randomised components need to be present. studies; with the current review, that recommendation can now What this study adds: Injury prevention programs that incor- change to level A evidence. Also, it could be modified to indicate that porate plyometric exercises substantially decrease the risk of plyometrics should be one of the components present. The literature anterior cruciate ligament injuries more than warm-up programs emphasises that the inclusion of plyometric exercises in injury pre- that do not include plyometric exercises. The preventive effect vention programs reduces non-contact ACL injuries by mitigating appears to be stronger among males and in the prevention of those injuries that do not involve contact with another player.
Research 261 Footnotes: a Endnote version X8, Thomson Reuters, Philadelphia, ligament injuries in female athletes: a systematic review. Am J Sports Med. USA. 2015;43:482–490. https://doi.org/10.1177/0363546514523388 17. Nessler T, Denney L, Sampley J. ACL Injury Prevention: What Does Research Tell b Microsoft Excel for Mac 2011, Microsoft Corporation, Redmond, Us? Curr Rev Musculoskelet Med. 2017;10:281–288. https://doi.org/10.1007/s12178- USA. 017-9416-5 18. Crossley KM, Patterson BE, Culvenor AG, Bruder AM, Mosler AB, Mentiplay BF. c Comprehensive Meta-Analysis software V.3, Biostat Inc, Engle- Making football safer for women: a systematic review and meta-analysis of injury wood, USA. prevention programmes in 11 773 female football (soccer) players. Br J Sports Med. 2020. https://doi.org/10.1136/bjsports-2019-101587 eAddenda: Appendix 1 and Figures 3, 5 and 7 can be found online 19. Huang YL, Jung J, Mulligan CMS, Oh J, Norcross MF. A majority of anterior cruciate at https://doi.org/10.1016/j.jphys.2022.09.001 ligament injuries can be prevented by injury prevention programs: a systematic review of randomized controlled trials and cluster-randomized controlled trials Ethics approval: Nil. with meta-analysis. Am J Sports Med. 2020;48:1505–1515. https://doi.org/10.1177/ Competing interests: The author(s) declare that they have no 0363546519870175 competing interests. 20. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for Source(s) of support: The authors would like to thank the Dean- systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6: ship of Scientific Research at Umm Al-Qura University for supporting e1000097. this work by Grant Code: 22UQU4350385DSR02. 21. Moseley AM, Elkins MR, Van der Wees PJ, Pinheiro MB. Using research to guide Acknowledgements: The authors would like to acknowledge practice: The physiotherapy evidence database (PEDro). 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Sports Med. 2008;42:394–412. https://doi.org/10.1136/bjsm.2008.048934 43. Pfeiffer RP, Shea KG, Roberts D, Grandstrand S, Bond L. Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior 13. Markovic G, Mikulic P. Neuro-musculoskeletal and performance adaptations to cruciate ligament injury. J Bone Joint Surg Am. 2006;88:1769–1774. lower-extremity plyometric training. Sports Med. 2010;40:859–895. https://doi. 44. Chappell JD, Limpisvasti O. Effect of a neuromuscular training program on the org/10.2165/11318370-000000000-00000 kinetics and kinematics of jumping tasks. Am J Sports Med. 2008;36:1081–1086. 45. Hewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries in female ath- 14. Meylan C, Malatesta D. Effects of in-season plyometric training within soccer letes: Part 2, a meta-analysis of neuromuscular interventions aimed at injury practice on explosive actions of young players. J Strength Cond Res. 2009;23:2605– prevention. Am J Sports Med. 2006;34:490–498. 2613. https://doi.org/10.1519/JSC.0b013e3181b1f330 15. Petushek EJ, Sugimoto D, Stoolmiller M, Smith G, Myer GD. Evidence-based best- practice guidelines for preventing anterior cruciate ligament injuries in young female athletes: a systematic review and meta-analysis. Am J Sports Med. 2019;47:1744–1753. 16. Stevenson JH, Beattie CS, Schwartz JB, Busconi BD. Assessing the effectiveness of neuromuscular training programs in reducing the incidence of anterior cruciate
Journal of Physiotherapy 68 (2022) 238–243 KEYWORDS 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 Breast cancer Research Lymphoedema Physical therapy Measurement of breast cancer-related lymphoedema Measurement Elizabeth Dylke Discipline of Physiotherapy, Sydney School of Health Sciences, The University of Sydney, Sydney, Australia [Dylke E (2022) Measurement of breast cancer-related lymphoedema. Journal of Physiotherapy 68:238– 243] © 2022 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 and the mechanisms that support the movement of fluid into the lymphatic system continue to be investigated.4 Once fluid enters the This Invited Topical Review is the first in a series of three that lymphatic system, it is propelled by a combination of mechanisms, relate to physiotherapy management of breast cancer and its including local contractions of lymphatic muscle cells through sequelae. This first review explains what breast cancer-related lym- repeated cycles of contraction and relaxation.4 phoedema is and addresses the complexities involved in its mea- surement. The second review will address the management of breast Treatment of breast cancer can, for some patients, decrease the cancer-related lymphoedema and the third review will address transport capacity of the lymphatic system, or increase the lymphatic physiotherapy management of other sequelae of breast cancer and its fluid, or a combination of both, beyond the capacity of the lymphatic various treatments. system.1 This results in a greater accumulation of ECF in the tissues, resulting in swelling. While the majority of patients will develop What is breast cancer-related lymphoedema? lymphoedema within the first 2 years after surgery for breast cancer, its development may be delayed until significantly later for others.2 Breast cancer-related lymphoedema (BCRL) refers to a chronic While BCRL is associated with increasing limb size, it also pro- accumulation of extracellular fluid (ECF) in the tissues of the hand, gresses through stages that result in changes in skin texture, upper limb, breast and/or trunk, ipsilateral to the side of treatment abnormal fat deposition and tissue fibrosis.5 The severity or size of for breast cancer. BCRL presents as a progressive swelling of the the swelling and the development of tissue changes may not appear affected body region, resulting from disruption of the lymphatic uniformly along a limb with lymphoedema and they do not appear to system caused by surgical and radiotherapeutic treatment for breast be related to length of time that BCRL has been present.6 The com- cancer, as well as from increased ECF caused by some forms of plexities of the presentation of this condition require careful mea- chemotherapy.1 The incidence of BCRL is unclear due to the variety of surement and assessment of the limb during screening, diagnosis and measurement tools and diagnostic thresholds used in the literature as ongoing monitoring. well as changes in treatment protocols for breast cancer;2 however, it is generally accepted that the incidence of arm lymphoedema is Measurement of breast cancer-related lymphoedema approximately 20% after axillary lymph node dissection and 5% after sentinel node biopsy.2 BCRL can cause considerable physical and This section summarises the most common clinically used psychological morbidity.1 methods of measurement for BCRL in the arm, touching on the pro- tocols used for each measurement method, the known clinimetric Aetiology of breast cancer-related lymphoedema properties and the advantages and disadvantages of the method. Imaging-based assessments will not be covered as they are not The lymphatic system is primarily responsible for maintenance of widely available. Reviews on the measurement tools used for BCRL in fluid levels within the tissues, using its network of superficial and the hand has been published recently.7 deep lymph vessels.3 The lymphatic system captures ECF—which comprises water, macromolecules, cellular waste and immune cells— Breast cancer-related lymphoedema most typically presents from the space between the cells (extracellular space). Once ECF unilaterally, as only the side of treatment for cancer is at risk for enters the lymphatic system, it is referred to as lymph or lymphatic developing swelling. Measurements are often undertaken bilaterally, fluid. The physiology of the lymphatic system is not well understood as the unaffected side is then used as a comparator for the at-risk or affected side, either as an inter-limb difference or an inter-limb ratio, depending on the measurement tools used. https://doi.org/10.1016/j.jphys.2022.09.008 1836-9553/© 2022 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/).
Table 1 Comparison of methods of measurement of breast cancer-related lymphoedema. Characteristic Circumference measurements Whole limb volume Equipment Low-stretch tape measure Water volumeter or Perometer® (optical volumetry Equipment Low Variable cost Water volumeter: dependent on volumeter used Time Variable dependent on number of measurements Optical volumetry: high undertaken Variable dependent on tool used Clinimetrics Excellent inter-rater and intra-rater reliability Water volumetry: high Optical volumetry: low Excellent inter-rater and intra-rater reliability Advantages Provides insight into location of swelling Water volumetry: able to measure irregular shapes Can be completed by patients considered the reference standard for limb volume measurements Disadvantages Error can be introduced if protocols not followed Optical volumetry: quick to use carefully Water volumetry: infection concerns; heavy lifting Measurement of whole arm changes dependent on type of volumeter; specialised equip Time-consuming recording outcomes broad range of protocols used; measurement of wh Broad range of protocols and diagnostic changes thresholds used Optical volumetry: equipment is large BCRL = breast cancer-related lymphoedema, ECF = extracellular fluid. Table 2 Summary of detection thresholds for upper limb lymphoedema. Source of threshold Circumference measurements Whole lim Commonly used 2 cm single inter-limb circumference difference 100 to 200 mL inter-limb vo Normatively determined 2 cm adjacent inter-limb circumference differences 3 to 10% inter-limb volume d 5 cm inter-limb sum of arm circumference difference Mean 1 3 SD inter-arm circumference difference10 arm volume increase) Perometer® equipment:10 = Dom arm affected: Mean 1 3 SD inter-arm volu wrist: 1.3 cm Dom arm affected: 372 mL 10 cm: 2.4 cm Non-dom arm affected: 209 20 cm: 2.5 cm 30 cm: 2.7 cm 40 cm: 3.1cm = Non-dom arm affected: wrist: 1.2 cm 10 cm: 1.9 cm 20 cm: 1.9 cm 30 cm: 2.7 cm 40 cm: 2.7 cm Dom = dominant, Non-dom = non-dominant
Bioimpedance Tissue dielectric constant y) Bioimpedance spectrometer (Impedimed® or InBody® MoistureMeter-D/LymphScanner devices most commonly used) High Moderate Low Variable dependent on the number of measurements undertaken, each measurement time is low Good to excellent inter-rater and intra-rater reliability Moderate to excellent inter-rater and intra-rater reliability s; often Measurement of ECF changes (fluid that is changing in Provides localised measurements of tissue water BCRL) Device used to measure is small of water; Fewer protocols and detection based on normative Detection of BCRL based on normative values pment; thresholds hole arm Unclear utility in progressed BCRL Unclear reliability Cannot be used in patients with pacemaker Multiple measurements recommended Unclear sensitivity Only assesses superficial tissue mb volume Bioimpedance Tissue dielectric constant Research 239 olume difference 1:1.200 inter-arm ratio70 difference (absolute or relative – Mean 1 3 SD ume difference Impedimed® equipment53 = 1.160 inter-arm ratio70 mL Mean 1 3 SD inter-arm ratio (corresponding to an Mean 1 3 SD L-Dex of 10) = 1.270 inter-arm ratio71 = Dom arm affected: 1:1.137 = Non-dom arm affected: 1:1.066 Mean 1 2 SD inter-arm ratio (corresponding to an L-dex of 7) = Dom arm affected: 1:1.103 = Non-dom arm affected: 1:1.032 InBody 720® equipment55 Mean 1 3 SD inter-arm ratio = Dom arm affected: 1:1.014 = Non-dom arm affected: 1:1.018 Mean 1 2 SD inter-arm ratio = Dom arm affected: 1.009 = Non-dom arm affected: 1.012
240 Dylke: Measurement of lymphoedema Box 1. Formulas for calculating limb volumes from circum- BCRL or when clinical appointments cannot be held in a face-to-face ference measurements. manner. Cylinder ! Truncated cone (frustum) Circumference measurements have four main disadvantages. First, ! while a very high reliability has been found for these measurements, P hðC 2 Þ P hðC12 1C1 C2 1C22 Þ this may reduce if protocols are not followed (eg, differences in Vollimb ¼ 4p Vollimb ¼ 12p amount of tension applied to the tape measure can, especially in an arm with soft swelling, greatly change the measured circumference of C is a circumference measurement and h is the height of the segment (ie, distance a limb).31 However, both training and clinician experience improve between circumference measurements). intra-rater and inter-rater reliability.2 Second, recording circumfer- ence measurement and, particularly, conversion to volumes can be The following four sections of text outline four methods of mea- burdensome for busy clinicians.27 Third, the range of measurement surement of breast cancer-related lymphoedema. The characteristics protocols results in difficulties comparing outcomes between studies of each method of measurement of breast cancer-related lymphoe- and potentially between clinicians. The Australasian Lymphology dema are summarised in Table 1. The diagnostic thresholds for each Association has measurement guidelines, which are suggested to be method of measurement of breast cancer-related lymphoedema are used to reduce the impact of the latter concern.32 Fourth, a wide summarised in Table 2. range of inter-limb circumference differences are considered to represent an abnormal inter-limb difference.8 The most commonly Circumference measurements used 2-cm inter-limb threshold was originally arbitrarily chosen;31 however, normatively determined inter-limb differences have been Circumference measurements are reported as the most clinically determined to assist with the detection of abnormal inter-limb used method to measure and monitor for changes in the limb with or differences.10,33 at-risk of lymphoedema.8 This method involves passing a low-stretch tape measure around the limb, in direct contact with the skin, Whole limb volume allowing assessment of changes in the overall girth of the limb. Varying measurement protocols exist, including undertaking the Whole limb volume measurements provide an assessment of measurements either at regular intervals starting from a standardised changes in the overall size of the limb, similar to circumference location such as the fingertips or ulnar styloid,9–11 or at a variety of measurements. Many methods are used to measure whole limb vol- differing distances from anatomical landmarks.12–14 When intervals ume, but their clinical use is limited in some countries such as are used, there is a lack of agreement regarding the appropriate size Australia. Two primary methods of whole limb measurements are of intervals, with 4-cm, 5-cm and 10-cm intervals all regularly used. It used: water displacement and optical volumetry (perometry). A has been shown that 10-cm intervals provide comparable estimates number of measurement protocols for water displacement assess- of limb volume to those found with 4-cm or 5-cm segments, while ments exist;34 water displacement assessments involve submerging taking less time.15,16 the limb in a container with water, with the water that gets displaced within or from the container being equal to the volume of the The measurements collected may be used as an absolute (eg, inter- limb.35,36 Water displacement is often used as the reference standard limb circumference difference at each measured location) or con- for comparing the assessment of limb size by other tools.8 In contrast, verted in a limb volume using the geometric formula for a truncated optical volumetry uses light to measure the circumference of the limb cone (frustum) or cylinder (Box 1).17 Support can be found in the at small intervals, which is then converted to a volume using algo- literature for using the formula for the frustum/truncated cone17–20 rithms specific to the equipment. The Perometer® is the most or the cylinder/disk model.21–23 However, it is suggested that the commonly reported optical volumetry tool. volume calculated by either formula may overestimate the limb volume in comparison with other measures of whole limb volume.8 The review by Hidding et al and clinical practice guidelines led by Levenhagen also looked at the clinimetrics for water displacement Two reviews of studies investigating the clinimetric properties of and optical volumetry whole limb measurements.8,24 For water circumference measurements found that this measurement tool had displacement measurements, from 10 studies, the overall inter-rater excellent inter-rater and intra-rater reliability.8,24 For example, in and intra-rater reliability were reported to be excellent at 0.99 their review, Hidding et al found a pooled inter-rater reliability of (0.97 to 0.99).8,24 The weighted SEM was 0.7% (s = 0.8%) and the 0.98 (95% CI 0.98 to 0.98) and pooled intra-rater reliability of 0.99 weight smallest detectable change was 3.6% (s = 2.7%).24 Similarly for (95% CI 0.99 to 0.99), assessed using data from 10 studies.24 Similarly, optical volumetry, excellent inter-reliability and intra-reliability were Levenhagen found the inter-rater and intra-rater reliability to be found across three studies at 0.99, with a slightly higher weighted between 0.93 and 0.99.8 Furthermore, circumference measurements mean SEM of 2.1% (s = 2.6%).8,24 Studies not included in these review were found to have a weighted standard error of measurements and guideline documents have also found excellent inter-rater reli- (SEM) of 2.8% (s = 3.2%) and a weighted mean smallest detectable ability for both water displacement and optical volumetry.26,35 change of 6.6% (s = 2.6%).24 The concurrent validity of circumference measurements, when compared with water displacement measure- While each measurement of whole limb volume has been found to ments of the whole limb, showed a good correlation of 0.80 to 0.99 be reliable, the results found with each measurement tool are not from nine studies.24 Subsequent to these reviews being completed, interchangeable with those from other tools or calculated from further research has confirmed excellent reliability for circumference circumference measurements.9,17,20,37–39 Therefore, the same mea- measurements, including when they are converted to a volume.25,26 surement tool should be used for all visits in order to determine whether there are true changes in the size of the limb. The key advantages of circumference measurements are their simplicity and low cost to undertake, as they require no special Each approach to whole limb volume measurements also has equipment to complete. Dependent on the number of circumference advantages and disadvantages.9,40,41 The key advantage of water measurements completed, they can also be relatively quick to displacement is its good reliability and ability to measure the volume perform. Clinicians also find them useful for determining the location of irregularly shaped objects such as the arm.35 Disadvantages of swelling more specifically along the limb.27 Finally, studies have include infection control risks, health and safety risks from carrying also shown that patients are able to accurately complete their own large containers of water, the time required to undertake the mea- circumference measurements, often with the help of a friend or surement and that it requires specialised equipment to under- family member.28–30 This can be useful for screening for developing take.1,8,26,42 Optical volumetry has the primary advantage of being very quick to use26 and highly reliable if arm positioning is carefully undertaken.10 Its disadvantages include the cost of equipment and the space required for the equipment.8 As with circumference mea- surements, an overall disadvantage of whole limb volume
Research 241 assessments includes the range of measurement protocols and A disadvantage of this measurement technique is reliability of the diagnostic thresholds that are used in the literature, limiting com- assessment found between studies. To overcome this, measures are parisons between trials. Normative whole limb volumes determined recommended to be taken at least twice, and often three times, in by water displacement measurement43 and optical volumetry10 are each location.72 However, this may not be necessary for all locations, available. Alternative whole limb volume assessment tools, such as particularly in the forearm.72 Finally, this assessment is only able to three-dimensional laser scanning, may become more prominent in measure a short distance into the tissues (0.5 to 5 mm).70 This may the future, as initial studies suggest good reliability and validity.8,44–46 fail to capture the extent of local tissue water in a limb with signifi- cant skin thickening caused by established lymphoedema. Bioimpedance spectroscopy Future directions for research and practice Bioimpedance spectroscopy (BIS) is still considered by some as a newer tool in the measurement of lymphoedema, although its use for As a complex, progressive and multifaceted condition, the this purpose was proposed in the early 1990s.47 Bioimpedance has measurement of a limb with and at-risk for BCRL represents an gained acceptance predominantly in the area of screening and early important aspect of the screening, diagnosis and ongoing monitoring detection of BCRL.48 BIS measures the volume of ECF in a body region of the condition. However, while there are a range of tools with through the measurement of the impedance faced by a harmless low- strong reliability, there is a lack of standardisation of the approach to level current that is passed through the tissues.49 To complete the BCRL assessment and little guidance on how to incorporate other measurement, electrodes are placed at either end of the segment, or clinical findings into the screening, diagnosis and monitoring of the the hands and feet are placed on electrode plates. The inter-limb ratio condition.73 This leads to varied patient management between sites of the ECF volume is reported as is or converted to an L-Dex score, and heterogenous findings in the literature. Within a research setting, depending on the equipment used. The L-Dex measurement sim- there is often a need to dichotomise whether lymphoedema is plifies the inter-limb ratio into a scaled and linearised model, which present or not, which may reduce the assessment and determination may be easier to interpret.49 of BCRL presence to use of a single tool or threshold. However, as not all tools are likely capable of detecting the same or all aspects of Evidence from clinimetrics studies suggests that BIS measure- lymphoedema presentation, or are available in all locations, it is likely ments have good to excellent reliability, with higher reliability when impractical to determine an agreed upon single approach to the tool is used to measure limbs with lymphoedema (ICC . lymphoedema assessment. 0.95)9,50,51 than those without (ICC . 0.81).9,50 The inter-limb BIS ratio SEM is low at 0.05.9 A more holistic approach to assessment is undertaken in clinical practice, where lymphoedema practitioners combine multiple mea- BIS has several advantages as a measurement tool. First, it pro- surement methods with patient history, self-report of symptoms and vides a direct measurement of ECF volume and can detect small symptom behaviour, and a clinical assessment, particularly of palpa- changes in ECF volume in developing BCRL.48,52 Second, the measure tion of the limb, to diagnose and monitor BCRL.27 Pre-surgical mea- is quick to perform.1 Third, for the most commonly used bio- surements of a patient’s limb, regardless of the tools used, should be impedance tools, screening and detection thresholds based on strongly encouraged as they improve early detection of BCRL by normative limb ECF volumes have been determined and are widely providing clearer insight into a patient’s normal inter-limb difference, used.53–58 However, similar to whole limb volume assessments, the size and fluid levels. When they cannot be undertaken or are unavai- measurements taken by different bioimpedance spectroscopy tools lable, comparison with normatively determined inter-limb differences are not interchangeable.59–61 should be used.74 Evidence supports that combining multiple objective and/or subjective assessments increases the certainty of a BCRL diag- BIS also has a number of disadvantages to be considered. It is nosis.74,75 Many of the components of assessment have strong evidence costly and may be difficult for clinicians to afford. Furthermore, the to support them (eg, numerous patient-reported outcomes have utility of BIS for the measurement of limbs where fatty tissue and demonstrated utility with reasonable or developing construct validity fibrosis are now present in place or alongside the fluid is unclear, and reliability).76–79 Furthermore, patient-reported symptoms, although there is growing evidence to support its use with all BCRL particularly a feeling of swelling, appear to be an important component presentations.6,62BIS measurements also cannot be undertaken in of screening for developing BCRL.75,80 However, the evidence is more those with a pacemaker.49 Finally, while this measurement method varied on the validity and reliability of the clinical assessment of lym- has been found to have high specificity across all studies, the sensi- phoedematous tissue using palpation tests such as a pitting or pinch tivity has been found to be more variable.49 This may be due to the test, with particularly variable inter-rater reliability found for the variety of reference standards that BIS has been compared with; pitting test.69,81,82 A standardised assessment protocol of the limb tis- however, this requires further investigation. sues has been developed and appears to have promising reliability and validity.83 What is lacking, however, is clear guidance on how to apply Tissue dielectric constant assessment these assessments from screening to diagnosis and ongoing monitoring.73 Tissue dielectric constant (TDC) is a measurement of the amount of water present in immediate underlying tissues.63 It is assessed Future research focused on determining which test (or combination using a probe-like device that passes an ultra-high-frequency elec- of tests) and diagnostic threshold(s) provide the best certainty of ac- tromagnetic wave perpendicularly into tissues;63 this contrasts with curacy for clinicians and patients will support both academic and BIS, which passes the electrical current longitudinally along a limb.49 clinical assessment of BCRL. Because the goals of assessment change When assessing TDC, multiple locations are usually measured along between screening, diagnosis and ongoing monitoring, the optimal the arm, with variability in the number and location of measurements tool(s) may as well (eg, during screening for developing BCRL, the undertaken.64–68 approach to measurement should be simple, time-efficient and sensi- tive, allowing confidence in ruling out the development of BCRL with a Evidence from clinimetric studies suggests that this method has negative test result).84 During the diagnosis process, assessment can be highly variable reliability ranging from moderate to excellent across more complicated, as accuracy of the outcome is critical. Finally, during studies and measurement locations (both inter-rater and intra-rater ongoing monitoring for patients who have developed BCRL, the tools reliability: 0.65 to 0.98).66,68,69 should be responsive and reliable, with low measurement error to ensure that changes are a result of the treatment or progression of the There are a number of advantages to using TDC as part of the condition and not reflecting only the measurement itself.9 The differ- measurement of BCRL. TDC assessments are localised, providing ences in approach to assessment further highlight the complexity of insight into the tissue water at whichever location is of interest. BCRL assessment. Devices used to assess TDC are small and portable,8 as well as quick and easy to use, with results visible immediately. Finally, measured TDC values in patients can be compared with normative values.70,71
242 Dylke: Measurement of lymphoedema BCRL is poorly understood and recognised in the medical com- 17. Sander AP, Hajer NM, Hemenway K, Miller AC. Upper-extremity volume mea- munity, with little attention paid to lymphatic disorders in educa- surements in women with lymphedema: A comparison of measurements obtained tional curricula, leading to delayed diagnosis and treatment.85 via water displacement with geometrically determined volume. Phys Ther. Referral to allied health and medical practitioners who have under- 2002;82:1201–1212. taken further training in lymphoedema should, therefore, be encouraged. Furthermore it has been identified that a lack of appro- 18. Casley-Smith JR. Measuring and representing peripheral oedema and its alter- priately trained therapists is a current barrier for patients receiving ations. Lymphology. 1994;27:56–70. optimal care;86 allied healthcare providers interested in supporting those treated for cancer may consider further professional develop- 19. Sitzia J. Volume measurement in lymphoedema treatment: examination of ment in this space. With increasing numbers of cancer survivors, due formulae. Eur J Cancer Care. 1995;4:11–16. to improving cancer detection and treatment methods, the number of patients with and at-risk of both BCRL and other cancer-related 20. Karges JR, Mark BE, Stikeleather SJ, Worrell TW. Concurrent validity of upper-ex- lymphoedemas will continue to grow.87 Allied healthcare providers, tremity volume estimates: Comparison of calculated volume derived from girth including physiotherapists, are well placed to continue leading this measurements and water displacement volume. Phys Ther. 2003;83:134–145. field in filling current gaps in both knowledge and the workforce. 21. Bunce IH, Mirolo BR, Hennessy JM, Ward LC, Jones LC. Postmastectomy lymphe- Footnotes: Nil. dema treatment and measurement. Med J Aust. 1994;161:125–128. eAddenda: Nil. Ethics approval: Nil. 22. Farncombe M, Daniels G, Cross L. Lymphedema- the seemingly forgotten compli- Competing interests: Elizabeth Dylke is the President of the cation. J Pain Symptom Manage. 1994;9:269–276. Australasian Lymphology Association, which is the national profes- sional association in Australia and New Zealand that accredits lym- 23. Tierney S, Aslam M, Rennie K, Grace P. Infrared optoelectronic volumetry, the ideal phoedema training providers and lymphoedema practitioners. way to measure limb volume. Eur J Vasc Endovasc Surg. 1996;12:412–417. Source(s) of support: Nil. Acknowledgements: Thank you to my research team, the Cancer 24. Hidding JT, Viehoff PB, Beurskens CH, van Laarhoven HW, Nijhuis-van der Rehabilitation and lymphatic disorders (CaReLym) research group, for Sanden MW, van der Wees PJ. Measurement Properties of Instruments for their support and advice. Measuring of Lymphedema: Systematic Review. Phys Ther. 2016;96:1965–1981. Provenance: Invited. Peer reviewed. 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Journal of Physiotherapy 68 (2022) 218–219 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 Perioperative physiotherapy Fairuz Boujibar a, Mark R Elkins b,c a Department of Thoracic Surgery, Rouen University Hospital, Rouen, France; b Editor, Journal of Physiotherapy; c Faculty of Medicine and Health, University of Sydney, Sydney, Australia This editorial introduces another of Journal of Physiotherapy’s Preoperative physiotherapy is highly likely to be cost-effective article collections.1,2 These are collections of papers on a particular from the hospital’s perspective. Boden et al10 published the first topic, published in the Journal of Physiotherapy within the past decade multicentre randomised trial investigating the effect of preoperative and compiled to: facilitate access to important recent findings on the physiotherapy on postoperative pulmonary complications, with a topic; highlight trends in the research designs, methods, populations comprehensive analysis of postoperative hospital use and a robust and interventions; and suggest avenues for further research. The integrated health economic analysis. They concluded that for patients studies in this article collection relate to perioperative management undergoing major abdominal surgery, carrying out a single physio- of surgical patients by physiotherapists. Two seminal articles about therapy session involving education and training markedly reduces perioperative physiotherapy were published a decade ago.3,4 These the incidence of postoperative pulmonary complications and is cost- highlighted some gaps in the evidence and called for more rando- effective in doing so. mised trials and systematic reviews on the topic. The important advances that have subsequently been published in Journal of Phys- For people undergoing cardiac surgery, preoperative interventions iotherapy are summarised below and are collated as free full-text (education, inspiratory muscle training and exercise training) reduce articles in the online article collection. the risk of postoperative pulmonary complications and reduce hos- pital length of stay in older patients.11 All major surgeries (thoracic, cardiac, abdominal) are associated with significant morbidity and mortality.5 Fortunately, most major Restrictive precautions — such as limiting use of the arms — after surgeries are scheduled in advance, allowing perioperative optimi- cardiac surgery via sternotomy, are often prescribed to prevent ster- sation of the patients. This is a growing field of practice that can nal complications. Katijjahbe et al12 compared participants receiving minimise the physical and psychological decline often associated modified sternal precautions with participants receiving commonly with cancer and chronic diseases. used, more restrictive precautions. They found no significant differ- ences in physical function after surgery. These results are to be Reeve and colleagues6 investigated whether a physiotherapy ex- confirmed by other, larger cohort studies, but they promote post- ercise program improves pain and shoulder function in patients after operative motion, keeping pain as a limitation. open thoracotomy. All participants (n = 76) received standard man- agement and the experimental group also received daily supervised In addition to early mobilisation, respiratory physiotherapy can exercises and a self-exercise booklet on discharge. The experimental also be an important postoperative patient management tool. Zhang group had less shoulder pain and total pain at discharge and better et al13 compared, after thoracic or upper abdominal surgery, patients function at 3 months. When used in conjunction with prehabilitation using an oscillating PEP device, and patients receiving only standard and early mobilisation, these minimally invasive techniques reduce management. The use of an oscillating PEP device resulted in fewer complications and postoperative pain. These results have yet to be cases of fever and a shorter hospital stay. These results should be demonstrated in patients who undergo video-assisted surgery, which considered in relation to the standard management given to both is currently the preferred approach to thoracotomy or laparotomy.7 groups in this study; although this included ‘early mobilisation’ protocols, the study does not detail these protocols nor the level of In addition to rehabilitating patients who undergo lung surgery, physical activity of the patients postoperatively. the physiotherapist also has an important role assessing their risk of complications. Boujibar et al8 recently reported a prospective study Preoperatively and postoperatively, in addition to rehabilitation, assessing the ability of the 6-Minute Stepper Test and the Sit To Stand the role of the physiotherapist includes the detection and evaluation Test to predict postoperative complications after pulmonary resection of possible respiratory complications. In order to make appropriate via minimally invasive surgery. Before surgery, a patient achieving treatment selections, physiotherapists must be able to differentially 20 lifts during the Sit To Stand Test or 140 steps during the diagnose relevant pathologies such as atelectasis or pleural effusion. 6-Minute Stepper Test is at risk of postoperative complications. These are the main complications in thoracic, abdominal and cardiac surgery. Chest radiography and lung auscultation are commonly used Prehabilitation is usually indicated within 3 to 5 weeks before in making these diagnoses but these methods have their limitations. surgery; however, clinicians need to find the right balance between An alternative method is bedside lung ultrasound. A systematic re- the urgency of surgery and the need to provide a sufficient training view with meta-analysis from Hansell et al14 was conducted to assess load to obtain physiological benefits. This balancing act will be easier the diagnostic accuracy of lung ultrasound for pleural effusion, lung if preoperative training can be modified to achieve the same physi- consolidation and collapse. This meta-analysis demonstrated high ological benefits in a shorter period. Gravier et al9 investigated the sensitivity of lung ultrasound compared with chest radiograph. effect of condensing 15 prehabilitation sessions into a 3-week regimen compared with a 5-week regimen. They found that Associate Professor Catherine Granger15 reviewed the scope of condensing sessions led to similar or better improvement in cardio- practice of physiotherapy in lung cancer, from diagnosis to curative or respiratory fitness and did not increase adverse events. palliative treatment, whether the patient is treated by surgery, chemo-radiotherapy or molecular targeted agents. For patients https://doi.org/10.1016/j.jphys.2022.09.009 1836-9553/© 2022 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 219 treated surgically, prehabilitation can be used to maximise their prone to exercise deconditioning and muscular weakness, and possibly physical status prior to surgery and reduce postoperative morbidity; stands to benefit more from pre- and post-surgical rehabilitation. or to improve inoperable patients’ physical status enough for them to become operable. Postoperative physiotherapy starts on the day of In recent years there has been an acceleration of research, with surgery with early mobilisation and the start of physical activity. studies of better methodological quality (randomised controlled tri- Respiratory physiotherapy is also used but there is still a lack of ev- als, meta-analysis). However, cohorts are still small and physio- idence for its routine application. The author emphasises the rapid therapy regimens are yet to be standardised. growth of evidence supporting exercise-based rehabilitation after surgery and prehabilitation, but there are differences in timing and Ethics approval: Not applicable. type of rehabilitation. The lack of a standardised definition of post- Competing interest: Nil. operative complications may lead to a misinterpretation of the Source of support: Nil. effectiveness of some treatments between studies. Acknowledgement: Nil. Provenance: Invited. Not peer reviewed. Thoracic surgery is the main curative treatment for lung cancer, the Correspondence: Mark Elkins, Centre for Education & Workforce origin of which, is in the majority of cases, is smoking. The context of Development, Sydney Local Health District, Sydney, Australia. Email: surgical stress and diagnosis of the disease is an important time to [email protected] initiate behavioural change and smoking cessation. Physiotherapists are in a good position to implement smoking cessation guidelines. Dr Nia References Luxton16 discusses how a simple three-step brief intervention model (Ask – Advise – Help) can help physiotherapists to more routinely embed 1. Dale M, et al. J Physiother. 2021;67:84–86. evidence-based smoking cessation into their clinical practice. 2. Dennett A, et al. J Physiother. 2020;66:70–72. 3. Ambrosino N, et al. Best Prac Res Clin Anaesthesiol. 2010;24:283–289. Duarte et al17 did not look at the value of preoperative physio- 4. Patel BK, et al. Curr Opin Anaesthesiol. 2013;26:152–156. therapy in preventing complications, but rather on the effect of 5. Bernard A, et al. PLoS ONE. 2019;14:67–72. adding perioperative muscle training to pelvic organ prolapse sur- 6. Reeve J, et al. J Physiother. 2019;56:245–252. gery, with pelvic symptoms as the outcome. The results did not 7. Agostini P, et al. Interact Cardiovasc Thorac Surg. 2017;24:931–937. demonstrate any clear benefit from the perioperative muscle training. 8. Boujibar F, et al. J Physiother. 2022;68:130–135. 9. Gravier F-E, et al. J Physiother. 2022;68:43–50. This article collection focuses on perioperative physiotherapy, 10. Boden I, et al. J Physiother. 2020;66:180–187. whether in the assessment, prevention or treatment of complications 11. Snowdon D, et al. J Physiother. 2014;60:66–77. from various major or minimally invasive surgeries. Research into peri- 12. Katijjahbe MA, et al. J Physiother. 2018;64:97–106. operative physiotherapy seems for the moment to be mainly focused on 13. Zhang X, et al. J Physiother. 2015;61:16–20. patients undergoing major surgery, who often suffer from cancer, 14. Hansell L, et al. J Physiother. 2021;67:41–48. cachexia or cardiovascular disease. This is a patient profile that is more 15. Granger CL. J Physiother. 2016;62:60–67. 16. Luxton N, et al. J Physiother. 2020;66:207–210. 17. Duarte TB, et al. J Physiother. 2020;66:27–32.
Journal of Physiotherapy 68 (2022) 221–237 KEYWORDS 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 Achilles tendinopathy Research Physical therapy Biopsychosocial Physiotherapy management of Achilles tendinopathy Stretch-shorten cycle Peter Malliaras Department of Physiotherapy Monash University, Melbourne, Australia [Malliaras P (2022) Physiotherapy management of Achilles tendinopathy. Journal of Physiotherapy 68:221–237] © 2022 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 shorter distances, 24% for athletes in general and 6% for the general population.3 Between two and three patients per 1,000 in Dutch This review focuses on two distinct but related conditions: mid- portion Achilles tendinopathy and insertional Achilles tendinopathy. general practice have Achilles tendinopathy, and two-thirds are not They are characterised by localised pain (Figure 1) and impaired lo- classified as athletes.4 comotor function, including walking, running and jumping. The in- formation mainly pertains to midportion tendinopathy, which A large database study (20 million records) found that men and dominates the literature, but evidence about insertional Achilles tendinopathy is highlighted. Although discussed briefly within dif- women are equally affected by Achilles tendinopathy and the peak age ferential diagnosis, Achilles tendon rupture and partial tears are not for incidence is from 40 to 59 years.5 Midportion Achilles tendinopathy the focus. Exercise is a primary recommended treatment, along with education and advice; therefore, physiotherapists have an important is reported to be more common than insertional Achilles tendinop- role in managing Achilles tendinopathy. After outlining the epide- athy6,7 and about one in three people report bilateral symptoms.8,9 miology, burden and clinical course of Achilles tendinopathy, this review focuses on current considerations in its diagnosis, assessment Achilles tendinopathy is considered an overuse injury, meaning and management from a physiotherapy perspective. A theme throughout the review is a shift from a reductionist biomedical view that activity (and thereby tendon load) is an important extrinsic towards a biopsychosocial view of Achilles tendinopathy, emphasis- causative factor.10 Walking, running and jumping are implicated ing how this shapes current clinical care. because they involve a rapid stretch-shorten cycle of the muscle- Terminology tendon unit and repetitive high Achilles tendon force and strain (eg, Participants in a recent international symposium about the con- dition agreed that the term Achilles tendinopathy is most appro- five to seven times body weight per stride and up to 6% strain during priate.1 Labels such as tendinitis and tendinosis are discouraged running).11-15 A sudden change in stretch-shorten cycle activities (eg, because: they imply specific biological processes that are currently debated and unclear; they may erroneously imply that certain rapid increase in weekly running mileage or introduction of hill treatments like rest may be sufficient for recovery; and the use of multiple terms among clinicians, the literature and other sources (eg, running or higher intensity track sessions) that exceeds physiological the internet) contributes to confusion and mistrust among patients.1 adaptive capacity is implicated in most cases16-18 and this is likely related to slow adaptation of tendon compared with muscle.19-21 Epidemiology Compression of the insertion of the Achilles tendon against the Achilles tendinopathy is very common among people involved in running and running sports but can impact people who are less calcaneum may occur in extreme ranges of ankle dorsiflexion and is active. Between 6 and 10% of runners are affected by Achilles ten- considered a risk factor for development of insertional tendinop- dinopathy at any one time.2 The lifetime prevalence is 52% for athy.22 Compression in dorsiflexion during the stretch-shorten cycle middle-distance and long-distance runners, 36% for runners of (as may occur when running up a hill) seems to be a particular issue. It is rare for a tendinopathy to manifest from compression alone (eg, stretching into ankle dorsiflexion). Consideration should be given to sporting or daily movement patterns that involve excessive ranges of dorsiflexion during the stretch-shorten cycle (eg, running backwards and changing direction as is common in some football codes). Intrinsic factors moderate the risk profile and are more common among less active people who develop tendinopathy.23 Evidence- based prospective predictive factors include prior lower limb ten- dinopathy or fracture, use of fluroquinolone antibiotics, moderate alcohol use, training in cold weather, and decreased isokinetic plantar flexor strength.24 Pathology precedes and is a weak predictive factor for the onset of pain.25 This adds complexity because some factors may contribute to pathology but not pain, or vice versa, explaining https://doi.org/10.1016/j.jphys.2022.09.010 1836-9553/© 2022 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/).
222 Malliaras: Physiotherapy management of Achilles tendinopathy Figure 1. Site of pain in Achilles tendinopathy. about the location of pain, patients either pinch the midportion of the tendon with two fingers (2 to 6 cm above the calcaneum) or point to a why pain manifests differently in individuals with seemingly similar localised area at the posterior calcaneum (Figure 1). Most can recall a risk profiles. Clinically, it is helpful to consider factors that may in- change in loading activity coinciding with the onset of pain. Increase fluence tissue load (eg, activity, body weight), tissue homeostasis and in pain severity and impact on function are typically gradual. Initially adaptive potential (eg, age) and other biopsychosocial factors that people report minor symptoms (pain or stiffness) upon weight- may influence pain onset. bearing after prolonged rest or sleep (referred to as ‘morning stiff- ness’ or ‘arising pain’) or pain upon commencing walking or running Burden of Achilles tendinopathy that improves after a few minutes (referred to as the ‘warm-up’ phenomenon). As severity progresses, symptoms are reported for People with Achilles tendinopathy can experience a profound several hours or even days following bouts of activity and ultimately impact on their quality of life that seems to be rooted in a loss of they persist throughout active periods and severely limit them. identity because they are unable to undertake social and sporting Diagnosis is aided by appreciating that activities that provoke Achilles activities that are important to them.26-29 Consistent with this, a tendon pain will most likely be stretch-shorten cycle loads such as recent cohort study found that most participants with Achilles ten- walking, running and sports involving running and jumping. dinopathy reported quality of life impacts in relation to mobility (66%), usual activity (50%) and pain/discomfort (89%) impairments.30 Clinical tests have unknown value for diagnosing painful Achilles In contrast, only 1% and 20% reported impact on self-care and anxi- tendinopathy, as imaging pathology (which is commonly asymp- ety/depression, respectively.30 There was reduced work productivity tomatic45) is used as the reference standard, and intra-rater and inter- among 38% of participants (comparable with moderately severe knee rater reliability are variable.46-48 The issue with imaging used as a osteoarthritis) and direct treatment and lost productivity costs were reference standard is that people with asymptomatic pathology will estimated to be AUD $1,396.30 Reduced mobility related to Achilles be positive on this reference standard even though they do not have a tendinopathy is likely to result in adverse consequential effects on painful variant of the condition (so will test negative on other tests). general health, especially among older people.31 Reproducing localised midportion or insertional Achilles pain with loading tests such as the calf raise or hop tasks on one leg is a hall- Clinical course and natural history mark of Achilles tendinopathy diagnosis. The issue is that load tests may be negative in less severe presentations.49 More progressive load Based on one trial, only 24% of participants exposed to a wait-and- test options are shown in Figure 2. Pain into compression (eg, see intervention for midportion Achilles tendinopathy were classified extreme dorsiflexion position during calf raise/drop over a step) is as recovered.32 Exercise interventions resulted in an average improve- often more painful than submaximal hopping for insertional Achilles ment of 20 points in composite pain and disability (clinically mean- tendinopathy (vice versa for midportion). Localised tendon thick- ingful benefit is 14 points) over 12 weeks33 but there are reports that ening or swelling with palpation are surrogates of (potentially between 44%34 and 75% of people35 may not respond. Further im- asymptomatic45) pathology and therefore only helpful in the pres- provements in symptoms are likely between 12 and 52 weeks but not ence of other clinical features. Tenderness on palpation is of limited beyond this time.36,37 Mild symptoms may persist among 60% and 25% value (palpation may be tender in people with and without tendon at 5 and 10 years, respectively.38,39 pain50) but raises suspicion of a differential diagnosis when absent. The Arc sign and London Hospital test are disease-specific tests but Persistence of symptoms is also an issue with athletes, as well as have limited diagnostic utility.46-48 recurrence and reduced performance. Among a cohort of 1,929 run- ners, 5% developed Achilles pain training for a running event and 32% Achilles tendon imaging pathology is common in people without had persisting symptoms at 52 weeks.36 Among elite soccer players, any symptoms.41,51 For example, up to 45% of people without pain time-loss related to Achilles tendinopathy is low (median of 10 days) have intratendinous abnormalities and up to 51% have thickening, but recurrence is high (27%) and more likely if sport cessation is , 10 with substantial variation between cohorts that is partially explained days.40 Time loss fails to capture performance impact, which is a by age, physical activity and body mass index.41 The prevalence of larger issue because many athletes with Achilles tendinopathy asymptomatic pathology means that a diagnosis based on imaging continue to compete.41 alone may be incorrect and lead to unnecessary healthcare in- terventions,52 and confirming symptomatic Achilles tendinopathy Diagnosis with imaging is unnecessary.44 Imaging may, however, be indicated after non-response to initial recommended treatments and to Achilles tendinopathy is primarily diagnosed based on a detailed confirm suspected differential diagnoses. patient history and clinical assessment.10,42-44 When questioned Figure 3 describes common differential diagnoses.42,53 Pathology features such as Haglund’s deformity and retrocalcaneal bursitis are encompassed within insertional Achilles tendinopathy and have overlapping symptoms. They are managed with non-tissue-specific (often imaging has not been performed so the tissue features are unknown) primary treatments for Achilles tendinopathy based on the clinical presentation (outlined below). Other conditions have a distinct symptom presentation and some of these can overlap with Achilles tendinopathy and others are separate (Figure 3). Their presence is appreciated based on clinical history and examination (eg, paratenonitis often presents as diffuse midportion tendon pain and tendon movement may evoke crepitus).48 In some instances, imaging may be indicated to confirm a differential diagnosis if it will help to implement appropriate treatment (eg, anti-inflammatory approaches in the case of paratenonitis). In the presence of symptoms following sudden high Achilles load (eg, sprinting across the road), it is crucial to be alert to red flags such as tendon rupture (characterised by plantarflexor dysfunction and a positive Thompson test48) or a substantial acute tear (characterised by severe pain and plantarflexor dysfunction).42 People with painful Achilles tendinopathy rarely progress to a frank tendon tear or rupture,5 but asymptomatic Achilles tendinopathy is a prerequisite
Research 223 STEP 1: Assess pain intensity and STEP 2: Assess time to STEP 3: Assess pain behaviour with usual activities recover if the patient intensity and experiences flare-up with usual activities apprehension with loading tasks (progression shown below) 5 to 10 x body weight Achilles load 3 to 8 x body weight Achilles load Single-leg hop Single-leg hop forwards 1 to 3 x body weight Achilles load Double-leg jumps Single-leg hop backwards Walking Single-leg pogo hop Double-leg calf raise Walking faster Single-leg calf raise Walking incline + over step Running + knee bent Running faster + external load Running incline + speed Figure 2. Steps in assessment of load tolerance. Force values based on unpublished data from Sancho et al. for these conditions.54 Identifying tears on imaging is a current during a progressive loading task. These are the same load tests used to reproduce localised pain for diagnostic purposes. For load tolerance enigma, probably because a range of pathologies can occur in the purposes pain intensity is also assessed to guide activity modification absence of pain45 so imaging cannot be relied on to confirm recent and exercise prescription. Numerical rating scales are commonly structural tendon changes. Clinicians need to be alert to the possi- used, with pain rated up to 5 out of 10 suggested to be acceptable.9,56 bility of inflammatory arthropathy.42 Suspicion of inflammatory This scale is not universally acceptable so a graded chronic pain scale arthropathy is increased when there are sudden bilateral and severe (eg, mild, moderate, severe) may be more patient-centred.57 Achilles tendinopathy pain is thought to be load-dependent4,58 and the pain symptoms following no obvious change in activity or very poor response is generally proportional to load; however, pain is not a surrogate for load because of other biopsychosocial influences on response or aggravation with low-intensity exercise interventions. pain.59,60 MayAssessment Self-reported impairments coexist Load tolerance Considering biopsychosicial factors in assessment (Table 1), guided by current evidence,24 helps to identify impairments and potential Examination of pain severity and response with Achilles tendon contributors and guides patient-centred management. In the tendin- loading (or load tolerance) is an important part of assessment; it opathy literature, physical (eg, strength and biomechanics) impair- guides activity modification and exercise prescription and progres- ments have been extensively investigated,61-64 with greater attention sion advice in tendinopathy.10,55 Load tolerance assessment involves more recently on psychological factors65-67 and the lived experi- three components (Figure 2): assess self-reported pain intensity ence.26-29 Given that Achilles tendinopathy presentation is heteroge- during Achilles tendon loading activities; if the pain increases after neous, biopsychosocial impairments are only seen in some people.65 these activities, assess how long it takes to return to pre-loading pain levels; and assess self-reported pain intensity on a pain rating scale An appreciation of hallmark impacts of Achilles tendinopathy can be gained by assessing key outcome domains. This includes pain and Plantaris tendinopathya disability, or combinations of these, as in the validated and disease- Sural nerve neuropathya specific Victorian Institute of Sport Assessment-Achilles (VISA-A).68 Participation can be assessed clinically by asking about modification Midportion Insertional of usual daily, leisure or sports activities that involve walking and Achilles Achilles running, and appreciating whether these modifications are justified given the pain and disability levels, or indicating maladaptive coping tendinopathy tendinopathy (ie, activity endurance or fear-avoidance).69 Quality of life can be explored with open questions about overall impact (cueing for May Paratenonitis Retrocalcaneal bursitis emotional, mobility and social aspects) that can be explored further coexist Acute tear/ruptureb Haglund’s deformity with formal assessment or questioning (Table 1). Pre-Achilles bursitis Sever’s disease A careful history may reveal relevant features that may contribute to the condition or prolong recovery. Long symptom duration is often Often Accessory soleus Posterior impingement associated with multiple failed treatments and conflicting advice separate Fascia cruris tear Calcaneal bone stress from multiple clinicians, and this can lead to frustration and reduced Lumbar radiculopathy Lumbar radiculopathy outcome expectation. It is particularly important to consider how prior imaging has been perceived and may influence beliefs and be- Figure 3. Differential diagnoses for midportion and insertional Achilles tendinopathy. haviours. General health (eg, elevated low-density lipoprotein a Plantaris and sural nerve presentations are not site specific. cholesterol) and lifestyle factors (eg, diet, sleep, and general exercise b Acute tear/rupture occurs on background of asymptomatic Achilles tendinopathy. and physical activity) may be relevant.
224 Malliaras: Physiotherapy management of Achilles tendinopathy Table 1 Biopsychosocial aspects of assessment. Assessment considerations Link to Achilles Further context about the assessment or evidence linking to tendinopathy Achilles tendinopathy Domain Key Outcome Domains Pain with calf raise or hop tests 81,153 Most common pain assessment in Achilles tendinopathy 81,153 Distinct information to disability49 Pain with activity/loadinga Pain over last 7 days 81,153 MCID 10 points155,b Pain over a specific timea Victorian Institute of Sport Assessment Pain and disabilitya 59,81,153 Most common disability assessment in Achilles Participationa Participation in running, sport or usual 81,153 tendinopathy Quality of life impacta walking Biological and Physical MCID 14 points156 Demographic, general health Open questions about impact on Less relevant for non-athletic people68,157,158 mobility, social life, emotions History Low participation despite low pain or high participation despite high pain may indicate maladaptive coping Medications Pain mechanisms May indicate need for more detailed assessment of Physical function capacitya certain domains such as emotions Range of motion Obesity (body mass index . 30) 24 Not a risk factor but conflicting cross-sectional association Older age and female gender 24 Elevated triglycerides or LDL choles- 159-161 Conflicting evidence they are risk factors terol or lowered HDH cholesterol 162 Cross-sectional association with Achilles tendinopathy Hypertension 162 Hormone replacement 162 Cross-sectional association with Achilles tendinopathy Contraceptive pill use 164 Cross-sectional association with Achilles tendinopathy. Perimenopausal status or amenorrhea HRT may help musculoskeletal pain in menopause163 so None association may be because people with more severe History of severe mental health illness menopause opt for HRT 165 Other tendinopathies/pain conditions 23,26,28,29 Indirect basic science evidence that loss of oestrogen Long duration of symptoms negatively effects tendon metabolism Multiple failed treatments 166 Multiple clinicians (with inconsistent No direct evidence 167 May require multidisciplinary team input advice) Imaging pathology perceived as severe 24 Prior lower-limb tendinopathy is a risk factor 168 Family history of Achilles 77,79 Evidence from qualitative studies tendinopathy 61,62 Consider outcome expectations and secondary impair- 153 Fluoroquinolone antibiotics 70 ments (eg, frustration, physical impairments, pain PainDETECT questionnaire 24,61,62 mechanism) Diffuse mechanical hyperalgesia 74 Standing calf raise test No direct evidence 73,74 May relate to fear of movement Seated calf raise 6 repetition 74 maximum Possible genetic predisposition 74 Hip abduction and extension 74 Risk factor dynamometry 62,64 Cross-sectional association Knee extension 6 repetition maximum Conflicting cross-sectional association 74 Submaximal hop height or plyometric 169,170 Cross-sectional association quotient Most common PFC assessment in Achilles tendinopathy 24 Normative data among healthy people Submaximal hop duration Single or triple hop for distance Reduced maximal strength is a risk factor Weight-bearing ankle dorsiflexion Reliability among recreational runners with Achilles range of motion tendinopathy Conflicting cross-sectional association Reliability among recreational runners with Achilles tendinopathy Cross-sectional association Reliability among recreational runners with Achilles tendinopathy Cross-sectional association Contact or jump mat required Cross-sectional association Cross-sectional association Conflicting risk factor evidence for increased and decreased range
Research 225 Table 1 (Continued) Domain Assessment considerations Link to Achilles Further context about the assessment or evidence linking to tendinopathy Achilles tendinopathy Psychological Tampa Scale of Kinesiophobia-11 37,153,171,172 Conflicting evidence that kinesiophobia predicts out- (TSK-11) 155 comes, and no direct evidence for catastrophising (rele- Fear of movement and 155 vant for some subgroups) catastrophisinga Pain catastrophising scale 155 Convergent validity TSK-11 Apprehension/unwilling to complete 155 11 to 22 (minimal), 23 to 28 (low), 29 to 35 (moderate), load tests 36 to 44 (high) High expected pain during hops and calf raise Kinesiophobia associated with unwillingness to complete load tests Kinesiophobia associated with higher expected load test pain Belief that activity may lead to damage 27-29 Evidence from qualitative studies or rupture 28,29 Evidence from qualitative studies Belief need to rest/protect the tendon Outcome expectations How much do you expect your Achilles 82,84,173 Preliminary evidence that may predict outcome from a problem to change as a result of the feasibility study treatment? (Likert scale) Self-efficacya Belief may not overcome the problem 29 Evidence from qualitative studies Emotiona Belief that exercise may be damaging 28 Evidence from qualitative studies Pain self-efficacy questionnaire 153,171 No direct evidence (relevant for some subgroups) Feeling not in control of symptoms 29 Evidence from qualitative studies Hospital anxiety and depression scale 153,171 No direct evidence (relevant for some subgroups) Negative emotions from loss of 29 Evidence from qualitative studies mobility Social and Lifestyle Consider social circumstances and 27 Evidence from qualitative studies Social support lifestyle in developing treatment plan 27-29 Evidence from qualitative studies Social wellbeing Consider how mobility may impact on 24 social participation and wellbeing Not a risk factor but conflicting cross-sectional Activity levels associations Quantify current walking (eg, steps/ day) sports or running (frequency and volume) Other lifestyle Moderate alcohol use 165 Risk factor Sleep and diet None No direct evidence HDL = high-density lipoprotein, HRT = hormone-replacement therapy, LDL = low-density lipoprotein, MCID = minimum clinically important difference, PFC = physical function capacity, TSK-11 = Tampa Scale of Kinesiophobia-11. Validated outcomes measures are shaded blue. a Recommended outcomes by ICON consensus.81 b Calculated from cross-sectional data rather than prospectively from actual change in pain data. Fear of movement can be identified via apprehension or unwill- is preferable to use normative data as a target. Demonstration of ingness to undertake tasks that are perceived as threatening or pro- objective strength impairments compared to normative data (avail- vocative, or via the validated Tampa Scale of Kinesiophobia. Beliefs able for calf raise endurance test70) or population-specific data among that can drive fear of movement and poor outcome expectations health comparator groups (Table 1) can motivate patients to engage should be considered. Some patients will benefit from formal with exercise interventions. The soleus has the largest physiological assessment of pain self-efficacy or emotional aspects if open ques- cross-sectional area of all the calf muscles (three times greater than tions suggest that these impairments may be present. Social impact medial and six times larger than lateral gastrocnemii71) so consid- may include a loss of self and social relationships stemming from an eration should also be given to assessment of calf capacity in knee- inability to engage in self-defining and social pursuits involving straight positions (soleus and gastrocnemius are activated equally) walking and running. This highlights the importance of a patient- and knee-bent positions (biased towards soleus activation).72 Global centred approach to understand and address these impacts within lower-limb strength impairments should be considered73,74 guided the treatment process. by history of prior lower-limb injury. Physical examination of impairments Power impairments are common and can be assessed objectively in a clinical setting via: hop height or plyometric quotient (using a Physical examination (Table 1) should include multidimensional contact or jump mat) during submaximal cyclical hopping; or single calf muscle capacity, including endurance tests such as the standing or triple hop for distance.62 To minimise the risk of pain flare up, calf raise, which is clinically accessible, but also strength under load power assessment should be undertaken when pain is acceptable. For (which is more closely related to maximal strength).61,62 This is some people, obvious strategies to reduce Achilles load can be important because maximal strength appears to be more impaired observed, including landing with the foot flat rather than on the toes (16 to 44%) than endurance (8%) (note that this literature either uses or landing on the toes but with minimal ankle absorption through the unaffected or healthy controls as a comparator).62 The opposite or dorsiflexion. Clinicians should note apprehension with power as- less affected side is often stronger but may still be impaired61,62 so it sessments, as this can guide rehabilitation progression (see graded exposure approach below).
226 Malliaras: Physiotherapy management of Achilles tendinopathy Screen Primary management Secondary management Medical triage Education and advice Musculoskeletal or • metabolic • including activity modification as necessary sports physician • hormonal • imaging • inflammatory Exercise • medication • rupture • graded exposure • injection • address specific capacity impairments • GTN patches • pain management ± ± 3 to 6 months Adjunct options 6 to 12 mothsMulti disciplinary • Ice/heata careh • Footwear adviceb • exercise • heel liftsc • acupunctured physiology or • radial shockwave dietetics (weight therapye,f management) • manual therapyg • psychology Recovery ~20 point improvement in composite pain and function at 12 weeks BUT up to 60% still have some symptoms at 5 years Figure 4. Achilles tendinopathy management process informed by evidence and clinical reasoning. a No direct evidence but possible short-term effects on pain/comfort. b No direct evidence but advice about appropriate shoes often helpful (see text). c Evidence (conflicting) as an alternative treatment for midportion Achilles tendinopathy. d Evidence as an alternative treatment for midportion Achilles tendinopathy. e Evidence (conflicting) as an alternative treatment for insertional Achilles tendinopathy. f Evidence (conflicting) as an adjunct treatment for midportion Achilles tendinopathy. g Evidence (conflicting) for adding instrumented manual therapy to exercise for insertional Achilles tendinopathy. h Based on biopsychosocial factors that may impact on Achilles tendinopathy. Note: conflicting evidence treatments made it onto this figure if a majority of outcomes at a given timepoint showed a positive effect. Restricted calf muscle flexibility or restricted or hypermobile ankle via their general practitioner or onward referral to specialist care. dorsiflexion range should be considered in weight-bearing. Slow Primary physiotherapy management should include education, ex- eccentric phase isotonic calf exercise can be prescribed to target calf ercise and activity advice. The goal is to empower the patient to flexibility impairment.75 Although dynamic ankle eversion does not develop understanding of their condition and its unique bio- appear to be related to Achilles tendinopathy,64 running analysis (on a psychosocial contributors, and to develop confidence to self-manage treadmill or outside based on patient preference) may detect reduced via load modification and exercise strategies. The success of this ankle dorsiflexion in midstance (possibly an adaptive response to approach is reliant on an effective alliance between the health pro- reduce load),64 or other impairments (eg, running with low cadence, fessional and patient with Achilles tendinopathy, which enables which may increase ankle dorsiflexion excursion). Increased running shared decisions about treatment and goals, as well as understanding cadence (5% above preferred) may reduce Achilles stress.76 individual barriers and enablers.82 The pain mechanisms should be considered (Table 1). Consistent Although they are not all evidence-based, some relatively safe and with local nociceptive pain, quantitative sensation testing suggests an accessible physiotherapy adjuncts to help pain include advice about absence of diffuse mechanical hyperalgesia77 and spreading pain is ice or heat, rigid taping to reduce ankle range of motion (eg, uncommon. Nevertheless, central features may be present among augmented low dye tape), heel wedges (0.8 to 1.2 cm generally based some people,78,79 which can be appreciated with questionnaires on comfort), and advice to wear shoes with a pitch of . 8 mm and (painDETECT) or clinical proxies (such as diffuse mechanical hyper- avoid walking barefoot or with flat shoes. Heel wedges, appropriate algesia and spreading pain) and may then indicate the need for shoes and avoiding stretching also reduce compression loads for appropriate mechanism-based treatment.80 people with insertional Achilles tendinopathy. Consideration may also be given to advice about non-steroidal anti-inflammatories (for Outcome measures sudden onset or new symptoms) or pain medication (longer term presentations). Other physiotherapy adjuncts targeting bio- Outcome measurement is guided by recent international expert and psychosocial factors may involve a multidisciplinary team (such as patient consensus on core outcome domains for tendinopathy.81 This dietetics and exercise physiology input to manage weight or psy- should include pain with loading and over specific time, as well as pain chology to manage severe mood issues) (Figure 4). Knowledge of and disability outcomes (Table 1); global rating of change is also rec- prognostic factors is incomplete but they may include obesity, body ommended because it is simple and acceptable to patients.81 Other mass index and psychological factors,83,84 which may be addressed psychological outcomes (eg, fear of movement, pain self-efficacy and with primary treatments and some of the outlined adjuncts. Some emotion) can also be assessed over time if found to be impaired. patients may not want to undertake exercise, or exercise may not be an option due to some other condition (eg, severe forefoot pain Management limiting calf raise exercise); in these instances, it is helpful for healthcare professionals to have alternative evidence-based treat- Considerations for physiotherapy management of a person with ments that may be offered (Figure 4). Achilles tendinopathy are outlined in Figure 4. Screening and assessment will identify people who may need medical management Where low adherence to recommendations is a potential reason for inadequate response, a shared decision to extend the primary
Research 227 Table 2a Evidence summary for midportion Achilles tendinopathy: exercise, adjunct and education interventions. Categories of Specific Short term ( 8 weeks) Medium term (. 8 to 16 weeks) Longer term (. 16 weeks) interventions interventions compared Neutral compared Pain/disability and pain Education/advice Pain science versus Neutral Neutral versus other other education Pain/disability, pain and global change Pain/disability and global change education/ advice Advice to continue Neutral Neutral or stop Achilles loads Pain/disability and pain Pain/disability and pain Exercise versus Exercise versus Favours exercise control wait-and-see Pain/disability, pain, global change Favours exercise Disability (social activities and running) Neutral Disability (home, recreation, other activities) Exercise versus Eccentric versus Favours alternative Favours alternative other exercises alternative exercise Global change Global change Neutral Exercise 1 Eccentric versus Neutral Favours alternativea Pain/disability adjunct versus concentric exercise Pain/disability Pain/disability Neutral exercise Neutral Pain Eccentric versus Favours Pain stretching alternative Neutralb Favours eccentric Global change Eccentric versus Pain Global change eccentric 1 isometric Favours eccentric Neutralb Favours intervention Global change Pain/disability, pain Adding radial ESWT Pain Neutral to exercise Neutralb Neutral Pain/disability, global Pain, global change Adding radial ESWT Pain/disability, global Favours ESWT or placebo to exercise Neutral Favours intervention Pain/disability, pain, global change Pain, disability, pain/disability, global Adding radial/focused Pain/disability, pain or placebo ESWT Favours ESWT Neutral to exercise Neutral Pain Global change Pain Adding focused ESWT Neutral Neutral or placebo to exercise Neutralb Pain, disability, pain/disability, global Pain/disability Pain, global change Adding night splint Neutral Neutral to exercise Neutral Global change Pain/disability Pain, disability Adding orthotics or Neutral Neutral placebo to exercise Neutral Pain/disability Pain/disability, pain Global change Neutral Neutral Neutral Disability Pain/disability, global change Pain/disability Favours AirHeel Adding AirHeel to Painc exercise Neutral Paind Adding pressure Neutral Neutral massage Pain Pain/disability to exercise Neutral Neutral Adding LLLT or Pain/disability Pain/disability, pain placebo to exercise Neutral Neutral Pain/disability, pain Pain/disability, global change Adding needling 1 stimulation or Neutral Neutral placebo to exercise Pain/disability, global change Pain Adding dry needling Neutral to exercise Pain
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