Appraisal Critically Appraised Papers Aerobic exercise enhances executive function and academic achievement in sedentary, overweight children aged 7–11 years Synopsis day unsupervised sedentary activities including board games, drawing, and card games. The average duration of Summary of: Davis CL et al (2011) Exercise improves the program was 13 ± 1.6 weeks. The control group did executive function and achievement and alters brain not receive any after school program or transportation. activation in overweight children: a randomized controlled Outcome measures: The primary outcome was the trial. Health Pscyh 30: 91–98. [Prepared by Nora Shields, Cognitive Assessment System taken at baseline and post- CAP Editor.] intervention. This measure tests four cognitive processes: planning (or executive function), attention, simultaneous, Question: Does aerobic exercise improve cognition and and successive tasks with each process yielding a standard academic achievement in overweight children aged 7–11 score with a mean of 100 and a SD of 15. Secondary years? Design: Randomised, controlled trial with concealed outcome measures were the broad reading and mathematics allocation and blinded outcome assessment. Setting: clusters of the Woodcock-Johnson Tests of Achievement III. After school program in the United States. Participants: Results: 164 participants completed the study. At the end of Overweight, inactive children aged 7–11 years with no the intervention period, there was a dose-response benefit medical contraindication to exercise. Randomisation of 171 of exercise on executive function (linear trend p = 0.013) participants allocated 56 to a high dose exercise group, 55 and mathematics achievement (linear trend p = 0.045); to a low dose exercise group, and 60 to a control group. ie, the post-intervention group scores for these outcomes Interventions: Both exercise groups were transported increased with the intensity of exercise. Compared to the to an after school exercise program each school day control group, exposure to either exercise program resulted and participated in aerobic activities including running in higher executive function scores (mean difference = –2.8, games, jump rope, and modified basketball and soccer. 95% CI –5.3 to –0.2 points) but not in higher mathematics The emphasis was on intensity, enjoyment, and safety, not achievement scores. The groups did not differ significantly competition or skill enhancement. The student-instructor on any of the other outcomes. There were no differences ratio was 9:1. Heart rate monitors were used to observe the between the two exercise groups. Conclusion: Aerobic exercise intensity. Points were awarded for maintaining an exercise enhances executive function in overweight children. average of > 150 beats per minute and could be redeemed Executive function develops in childhood and is important for weekly prizes. The high dose exercise group received for adaptive behaviour and cognitive development. 40 min/day aerobic exercise and the low dose exercise group received 20 min/day aerobic exercise and 20 min/ Overall the study assists policy makers and clinicians in weighing up the benefit of implementing physical activity Commentary interventions. Given the positive effect, the results may support stakeholders’ efforts to increase exercise time during As the global prevalence of paediatric obesity rises, the school day where curriculum demands can sometimes participation in health-enhancing physical activity is of act as a barrier to such initiatives. Similarly, such school or vital importance for the prevention of chronic diseases community interventions should be appropriately designed such as Type 2 diabetes, cardiovascular disease, coronary to maximise the associated benefits (Baker et al 2011). heart disease, and some cancers (Penedo and Dahn 2005). The reported global prevalence of ‘some but insufficient Grace O’Malley physical activity’ is estimated to be associated with 1.9 Weight Management, Physiotherapy Department, The million deaths, 19 million Daily Adjusted Life Years, and approximately 22% of coronary heart disease prevalence Children’s University Hospital, Dublin, Ireland globally (WHO 2002). References The study by Davis et al highlights the benefit of increasing physical activity in childhood for parameters of health Baker et al (2011) Cochrane Database Syst Rev 13(4): other than weight management alone and provides evidence CD008366. for the positive effect of increasing physical activity on mental functioning. This well-designed study uses robust Biddle SJ et al (2011) Br J Sports Med 45: 886. techniques to explore the dose-response relationship between activity levels and executive function and expands Penedo FJ, Dahn JR (2005) Curr Opin Psychiatry 18: 189. the evidence for the importance of human movement in overall physical and cognitive health in childhood which, at World Health Organization (2002) World Health Report 2002: times, can be lacking (Biddle et al 2011). The authors did not reducing risks, promoting healthy life. collect data relating to the cost associated with achieving such benefit, however, and this information would be very useful for policy makers. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 255
Appraisal Appraisal Index To assist clinicians looking for authoritative assistance with clinical problems, the journal will publish an annual index of content from the most recent two years of Appraisal pages. This inaugural index includes content from Volumes 56 and 57 of Journal of Physiotherapy. Content is indexed under the PEDro codes: subdiscipline, intervention, problem, and body part, and identified by Appraisal section and Volume and page number. Some content is indexed under more than one code. SUBDISCIPLINE Musculoskeletal CAPs Cardiothoracics High intensity resistance training Vol 56 No 2, p 133 restored lean body mass and physical Vol 57 No 3, p 195 CAPs function in patients with rheumatoid Vol 56 No 2, p 135 arthritis Vol 57 No 4, p 257 Breathing training improves subjective Vol 56 No 1, p 60 health status but not pathophysiology Vol 57 No 4, p 256 Lateral wedge insoles worn for 12 Vol 56 No 1, p 57 in asthmatic adults months provided no symptomatic or Vol 57 No 2, p 125 structural benefit for people with medial Questioning the role of targeted knee osteoarthritis respiratory physiotherapy over and above a standard clinical pathway in the McKenzie treatment for acute back pain postoperative management of patients added to first line care does not result in following open thoracotomy appreciable clinical improvements Clinical Practice Guidelines Surgery with disc prosthesis may produce better outcomes than Bronchiectasis Vol 57 No 3, p 198 multidisciplinary rehabilitation for The COPD-X plan Vol 56 No 3, p 205 patients with chronic low back pain Venous thromboembolism Vol 56 No 4, p 281 Tai Chi reduces pain and improves $POUJOFODF8PNFOT)FBMUI physical function for people with knee OA CAPs Telephone-based patient self- Early physiotherapy after surgery for Vol 56 No 2, p 134 management program might be effective breast cancer can reduce the incidence Vol 57 No 4, p 258 in reducing osteoarthritis-related pain of lymphoedema in the following 12 Vol 56 No 4, p 276 months Clinical Practice Guidelines Manual lymph drainage when added Achilles pain, stiffness, and muscle Vol 57 No 1, p 62 to advice and exercise may not be power deficits effective in preventing lymphoedema Arthroscopic shoulder surgery Vo 57 No 4, p 261 after surgery for breast cancer Hip and knee osteoarthritis Vol 56 No 2, p 139 Knee pain Vol 57 No 2, p 130 Pelvic floor muscle training can improve Management of rheumatoid arthritis symptoms in women with pelvic organ Tension-type headache Vol 56 No 1, p 64 prolapse and may help to reverse Vol 57 No 4, p 261 prolapse Clinimetrics Vol 57 No 4, p 260 Clinimetrics The Neer sign and Hawkins-Kennedy test for shoulder impingement 2D real time ultrasound for pelvic floor Vol 57 No 1, p 59 /FVSPMPHZ muscle assessment &SHPOPNJDT0DDVQBUJPOBM)FBMUI Clinical Practice Guidelines Clinical Practice Guidelines Vol 56 No 1, p 64 Early Parkinson’s disease Vol 57 No 3, p 198 Stroke Vol 56 No 4, p 281 Occupational aspects of upper limb Tension-type headache Vol 57 No 4, p 261 disorders Gerontology Clinimetrics CAPs International standards for the Vol 57 No 2, p 129 neurological classification of spinal Additional physiotherapy during acute Vol 56 No 3, p 201 cord injury care reduces falls in the first 12 months Vol 56 No 3, p 200 after hip fracture Orthopaedics Vol 57 No 2, p 130 Twelve months of resistance training CAPs Vol 56 No 1, p 59 can improve the cognitive functioning of older women living in the community The Canadian C-spine rule safely reduces imaging rates for cervical Clinical Practice Guidelines spine injuries Prevention of falls in older persons Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 267
Appraisal Annual Index Paediatrics Education CAPs Vol 57 No 4, p 255 CAPs Vol 56 No 1, p 60 Vol 56 No 2, p 132 Vol 56 No 2, p 133 Aerobic exercise enhances executive Vol 56 No 4, p 277 Breathing training improves subjective function and academic achievement in health status but not pathophysiology in sedentary, overweight children aged Vol 56 No 3, p 205 asthmatic adults 7–11 years Vol 57 No 2, p128 An internet-based computer-tailored High intensity resistance training physical activity intervention has short Vol 56 No 3, p 202 restored lean body mass and physical term positive effects on physical activity function in patients with rheumatoid levels among adolescents Vol 56 No 1, p 63 arthritis A preventive care program for very Vol 56 No 3, p 204 preterm infants improves infant Vol 56 No 4, p 280 &MFDUSPUIFSBQZ )FBUBOE$PME behavioural outcomes and decreases Vol 56 No 3, p 203 anxiety and depression in caregivers Vol 56 No 4, p 279 CAPs Vol 56 No 3, p 202 Vol 56 No 2, p 137 Clinical Practice Guidelines Ankle exercises in combination with intermittent ice and compression Juvenile idiopathic arthritis following an ankle sprain improves function in the short term Clinimetrics Fitness Training The six-minute walk test in paediatric populations CAPs Sports Aerobic exercise enhances executive Vol 57 No 4, p 255 function and academic achievement in CAPs sedentary, overweight children aged 7–11 years Ankle exercises in combination with intermittent ice and compression Supervised aerobic and resistance Vol 57 No 2, p 126 following an ankle sprain improves exercise improves glycaemic control function in the short term and modifiable cardiovascular risk factors in people with Type 2 diabetes mellitus Other Orthoses, Taping, Splinting Clinimetrics CAPs Vol 57 No 3, p 193 The Coping Strategy Questionnaire Vol 57 No 3, p 195 The Depression Anxiety Stress Foot orthoses can reduce lower limb Scale (DASS) overuse injury rate The Illness Perceptions Questionnaire -Revised (IPQ-R) Lateral wedge insoles worn for Impact of Event Scale-Revised 12 months provided no symptomatic Pain Attitudes and Beliefs Scale or structural benefit for people with The Pain Catastrophising Scale medial knee osteoarthritis Respiratory Therapy INTERVENTION Clinical Practice Guidelines Vol 57 No 3, p 198 Vol 56 No 3, p 205 Bronchiectasis The COPD-X plan Acupuncture Strength Training CAPs Vol 57 No 1, p 56 CAPs Vol 56 No 3, p 200 Traditional Chinese Acupuncture was Vol 56 No 2, p 132 Twelve months of resistance training not superior to sham acupuncture for Vol 57 No 2, p 125 can improve the cognitive functioning knee osteoarthritis but delivering of older women living in the community treatment with high expectations of improvement was superior to delivering Stretching, Mobilisation, Manipulation, treatment with neutral expectations Massage Behaviour Modification CAPs Vol 56 No 2, p 135 CAPs McKenzie treatment for acute back pain added to first line care does not result in An internet-based computer-tailored appreciable clinical improvements physical activity intervention has short term positive effects on physical activity levels among adolescents Telephone-based patient self-management program might be effective in reducing osteoarthritis-related pain 268 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Appraisal Annual Index PROBLEM Reduced Exercise Tolerance Difficulty with Sputum Clearance Clinimetrics Vol 56 No 2, p 136 Vol 57 No 2, p128 Clinical Practice Guidelines 10-metre Shuttle Run Test The six-minute walk test in paediatric Bronchiectasis populations The COPD-X plan Vol 57 No 3, p 198 Other Vol 56 No 3, p 205 Clinimetrics Impaired Ventilation The Coping Strategy Questionnaire CAPs The Depression Anxiety Stress Scale Vol 56 No 1, p 63 (DASS) Vol 56 No 3, p 204 Patients with chronic obstructive Vol 57 No 2, p 127 The Illness Perceptions pulmonary disease (COPD) who are Impact of Event Scale-Revised Vol 56 No 4, p 280 not hypoxaemic at rest do not benefit Questionnaire-Revised (IPQ-R) Vol 56 No 3, p 203 from home oxygen BODY PART Resistance training preserves skeletal Vol 57 No 3, p 194 muscle function in patients with COPD who are hospitalised with an acute exacerbation Using titrated oxygen instead of high Vol 57 No 1, p 55 )FBE/FDL flow oxygen during an acute exacerbation of chronic obstructive pulmonary disease CAPs (COPD) saves lives The Canadian C-spine rule safely Clinical Practice Guidelines reduces imaging rates for cervical Vol 56 No 1, p 59 spine injuries Bronchiectasis Vol 57 No 3, p 198 The COPD-X plan Vol 56 No 3, p 205 Upper Arm, Shoulder or Shoulder Girdle Clinimetrics CAPs The BODE Index Vol 56 No 1, p 62 Exercise therapy alone and exercise Vol 56 No 4, p 278 therapy after corticosteroid injection are Vol 56 No 1, p 5 Incontinence equally effective after 12 weeks for moderate to severe shoulder pain Vo 57 No 4, p 261 Clinimetrics Vol 57 No 1, p 59 Vol 57 No 4, p 260 Supervised exercises are more effective Vol 57 No 3, p 197 2D real time ultrasound for pelvic floor for subacromial pain than extracorporeal muscle assessment shockwave treatment Muscle Weakness Clinical Practice Guidelines Clinimetrics Vol 57 No 3, p 196 Arthroscopic shoulder surgery Rehabilitative ultrasound imaging Clinimetrics Pain The Neer sign and Hawkins-Kennedy test for shoulder impingement CAPs Vol 57 No 2, p 125 Shoulder Pain and Disability Index Telephone-based patient Vol 56 No 2, p 139 (SPADI) self-management program might Vol 56 No 2, p 139 be effective in reducing Vol 56 No 3, p 205 Chest osteoarthritis-related pain Vol 56 No 1, p 64 CAPs Vol 56 No 1, p 60 Clinical Practice Guidelines Vol 56 No 1, p 63 Breathing training improves subjective Acute pain management Vol 56 No 4, p 279 health status but not pathophysiology Hip and knee osteoarthritis Vol 56 No 2, p 137 in asthmatic adults Juvenile idiopathic arthritis Vol 57 No 1, p 58 Thoracic Spine Management of rheumatoid arthritis Clinimetrics Vol 57 No 2, p 129 Clinimetrics International standards for the The Coping Strategy Questionnaire neurological classification of spinal Pain Attitudes and Beliefs Scale cord injury The Pain Catastrophising Scale (Thermal) Quantitative Sensory Lumbar Spine, SIJ or Pelvis Testing–tQST CAPs Vol 57 No 4, p 257 Surgery with disc prosthesis may produce better outcomes than multidisciplinary rehabilitation for patients with chronic low back pain Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 269
Appraisal Annual Index Clinimetrics Foot or Ankle International standards for the Vol 57 No 2, p 129 CAPs neurological classification of spinal cord injury Achilles pain, stiffness, and muscle Vol 57 No 1, p 62 power deficits McKenzie treatment for acute back Vol 56 No 2, p 135 pain added to first line care does not Ankle exercises in combination with Vol 56 No 3, p 202 intermittent ice and compression result in appreciable clinical improvements following an ankle sprain improves function in the short term Perineum or Genito-Urinary System Clinimetrics Foot orthoses can reduce lower limb Vol 57 No 3, p 193 overuse injury rate 2D real time ultrasound for pelvic floor muscle assessment Vol 57 No 1, p 59 Lateral wedge insoles worn for 12 months Vol 57 No 3, p 195 provided no symptomatic or structural 5IJHIPS)JQ benefit for people with medial knee osteoarthritis Clinical Practice Guidelines 8IPMF#PEZ0UIFS Hip and knee osteoarthritis Vol 56 No 2, p 139 CAPs Lower Leg or Knee An internet-based computer-tailored Vol 56 No 2, p 132 physical activity intervention has Vol 57 No 2, p 125 CAPs short term positive effects on physical activity levels among adolescents Achilles pain, stiffness, and muscle Vol 57 No 1, p 62 power deficits Telephone-based patient self-management program might be Lateral wedge insoles worn for 12 months Vol 57 No 3, p 195 effective in reducing osteoarthritis-related provided no symptomatic or structural pain benefit for people with medial knee osteoarthritis Clinical Practice Guidelines Tai Chi reduces pain and improves Vol 56 No 1, p 57 The Coping Strategy Questionnaire Vol 56 No 1, p 63 physical function for people with Vol 56 No 3, p 204 knee OA The Depression Anxiety Stress Scale (DASS) Vol 57 No 4, p 259 Clinical Practice Guidelines Vol 56 No 2, p 139 Vol 57 No 2, p 130 General Health Questionnaire – Vol 56 No 4, p 280 Hip and knee osteoarthritis 28 (GHQ-28) Knee pain Vol 56 No 1, p 64 The Illness Perceptions Vol 56 No 3, p 203 Questionnaire-Revised (IPQ-R) Vol 56 No 3, p 205 Management of rheumatoid arthritis Impact of Event Scale-Revised Juvenile idiopathic arthritis 270 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Appraisal Clinical Practice Guidelines Tension-type headache Tension-type headache Description: These guidelines present evidence for the acute and prophylactic treatment of tension-type Latest update: 2010. Next update: Within 5 years. Patient headache using drug and non-drug interventions. It begins group: Adults with a tension-type headache as defined by by outlining the known epidemiology of tension-type the International Headache Society. Intended audience: headache, common clinical characteristics, and diagnostic Clinicians managing patients with tension-type headaches. criteria. Evidence for drug treatment of acute tension-type Additional versions: Nil. Expert working group: A task headache is then presented, covering simple analgesics, force of 6 representatives from the European Federation non-steroidal anti-inflammatory drugs, combination of Neurological Societies (EFNS), associated with analgesics, triptans, muscle relaxants and opioids. Next, Neurology Departments in Denmark, Germany, Sweden, evidence for prophylactic pharmacotherapy is presented, Norway, Greece, Italy and Belgium.Funded by: European discussing interventions including amitriptyline, other Federation of Neurological Societies. Consultation with: antidepressants and other agents such as muscle relaxants or Representatives of over 20 British and American medical botulinum toxin. The final section details evidence for non- societies, including the APTA and the Chartered Society pharmacological interventions including EMG biofeedback, of Physiotherapists. Approved by: EFNS. Location: The cognitive-behavioural therapy, relaxation training, physical guidelines were published as: Bendtsen L et al (2010) therapy, acupuncture, and nerve blocks. Physical therapy in EFNS guideline on the treatment of tension-type headache this guideline encompassed a variety of treatment options, – report of an EFNS task force. European Journal of such as exercise, manipulation, massage, and electrotherapy Neurology 17: 1318–1325. They are also available at: and was investigated in 13 articles. Overall, the guidelines h t t p: // w w w.ef n s.o r g / f i le a d m i n / u s e r_ u plo a d /g u id l i n e _ are supported by 129 references. p a p e r s / E F NS _ g u id el i n e _ 2 010 _ t r e a t m e nt _ of _ t e n sio n - type_headache.pdf Sandra Brauer The University of Queensland, Australia Arthroscopic shoulder surgery Arthroscopic Anterior Capsulolabral Repair of the Shoulder Latest update: 2010. Next update: Not indicated. Patient Description: These guidelines relate specifically to patients group: Adults who have undergone an arthroscopic who have undergone arthroscopic anterior capsulolabral anterior capsulolabral repair of the shoulder to restore repair in which the detached labrum has been anchored stability. Intended audience: Therapists involved with the back to the glenoid rim and/or capsular tension has been rehabilitation of patients who have undergone this surgical restored through suture tightening of the plicated capsule. procedure. Additional versions: Nil. Expert working They are based on the best available evidence, along with group: Six representatives from the American Society of ASSET member expertise and clinical opinion. The article Shoulder and Elbow Therapists (ASSET) including physical begins by providing detailed information about this surgical therapists, an orthopaedic surgeon, and an athletic trainer. procedure, the likely anatomical structures affected, tissue Funded by: Not indicated. Consultation with: Guidelines healing, and factors including mechanical stress that could were sent to all members of ASSET for comment. This influence the progression of healing such as exercise and included American and international physical therapists, immobilisation. The second half of the document outlines athletic trainers, and occupational therapists, in addition rehabilitation guidelines across three phases: weeks 0 to 6, to orthopaedic surgeons. Approved by: ASSET and the 6 to 12, and 12 to 24. The guidelines are presented in detail American Shoulder and Elbow Surgeons Society. Location: at the end of the document and include goals, interventions The guidelines were published as: Gaunt BW et al (2010) to avoid, specific interventions such as techniques to gain The American Society of Shoulder and Elbow Therapists’ range, neuromuscular re-education, strength, endurance, consensus rehabilitation guideline for arthroscopic anterior and pain management. capsulolabral repair of the shoulder. Journal of Orthopaedic and Sports Physical Therapy 40: 155–168 and are available Sandra Brauer at: http://www.asset-usa.org/Rehab_Guidelines.html The University of Queensland, Australia Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 261
Appraisal Media A self management toolkit for people in pain 5IF1BJO5PPMLJUIUUQXXXQBJOUPPMLJUPSH with health care professionals emphasise partnership, team work, and shared decision making. The toolkit does a great Education is rightly seen as an important part of pain job of integrating engagement with health care providers management. There is evidence that education produces within the self-management paradigm. better health outcomes if it is engaging (Fox 2009), and data suggest that people with chronic back pain are helped more This is a great resource for any clinician working with if education is intensive (Engers et al 2008), and accurately people who suffer from chronic pain. The website has reflects current understanding of pain problems (Burton useful links to additional resources for patients and health et al 1999). The internet seems ideally placed to address care professionals. These include patient advocate groups, the first two issues, allowing people with pain problems to professional organisations, and clinical service providers. access resources at any time as well as utilising a variety of There is understandably a strong UK emphasis, though media to engage the learner (Fox 2009). Indeed Chiauzzi I found it very informative to see what resources are et al (2010) provide some evidence that an internet-based available outside the local health care setting. The amount educational package produces more favourable outcomes of additional information would be impossible to review than text-based material in people with chronic back pain. here in any detail. Importantly, though, it appears that the additional links largely support the self-management With the internet it is the issue of information quality that is message of the Toolkit, so when navigating around the site far more problematic. The amount of data available means the user isn’t confronted with conflicting and contradictory it is almost inevitable that people searching for help and messages. advice about their pain will access information that is a hindrance rather than helpful to the resolution of their In summary the authors have put together a fabulous resource problem. As clinicians, it is important to direct patients for clinicians and health care consumers. The information towards resources that are likely to lead to better outcomes, reflects current thinking regarding the management of and in this regard The Pain Toolkit (http://www.paintoolkit. chronic pain and is presented in an easily accessible way. org/site/) is highly recommended. I highly recommend its use. The main thrust of the site is the Toolkit itself, a twelve- Benedict Wand step program to support patients in gradually returning University of Notre Dame, Australia to usual activities and self-managing their pain. The Toolkit can be accessed directly online or downloaded as References a single document. The downloaded version also contains additional information, examples, and links. Put together Burton AK et al (1999) Spine 24: 2484. in the United Kingdom by patient advocate Pete Moore and GP Frances Cole, the information is clearly delivered, Chiauzzi E et al (2010) Pain Med 11: 1044. practical and easily accessible. The tools introduce the user to important concepts such as acceptance, goal setting, Engers A et al (2008) Cochrane Database Syst Rev. 1: pacing, and dealing with setbacks. In keeping with the CD004057. self-management approach, the steps that involve liaising Fox MP (2009) Patient Educ Couns 77: 6. 262 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Editorial 2 Engagement of physiotherapists in cardiology research Julie Redfern1,2 and Lee Nedkoff3 1The George Institute for International Health, 2Faculty of Medicine, The University of Sydney, 3School of Population Health, University of Western Australia Australia Each year cardiovascular disease is the leading cause of Cardiorespiratory Physiotherapy Australia is a clinical death globally (WHO 2011). An estimated 17.1 million group of the Australian Physiotherapy Association that aims deaths were attributed to cardiovascular disease in 2004, to promote the role of physiotherapy in the management of representing 29% of all deaths worldwide. Of these deaths, both acute and chronic cardiorespiratory conditions (APA an estimated 7.2 million were due to coronary heart disease 2011). ‘Cardiorespiratory physiotherapists’ manage diverse and 5.7 million due to stroke. Cardiovascular disease is cardiac and respiratory conditions in a range of inpatient and projected to remain the single leading cause of death in the outpatient clinical areas, from intensive care to outpatient future (WHO 2011) and is a priority health area for research pulmonary and cardiac rehabilitation (APA 2011). These and for evidence translation. clinicians may work in acute adult and paediatric hospitals, rehabilitation and community health centres, private The greatest proportion of the burden of cardiovascular practice, and academic environments. disease in Australia is attributable to cardiac conditions, predominantly coronary heart disease and heart failure The physiotherapy management of cardiac disease (AIHW 2011). Myocardial infarctions are a common is largely focussed on therapeutic exercise. Reviews manifestation of these conditions. People who survive an examining the benefit of therapeutic exercise have found acute myocardial infarction and those with chronic cardiac high-level evidence that therapeutic exercise is beneficial disease are at high absolute risk of recurrence and death for patients across broad areas of physiotherapy practice, (Fox et al 2010, Krempf et al 2010). Options for reducing including people with coronary heart disease (Taylor et al this risk include medications, revascularisation procedures, 2007). Furthermore, individualised exercise programs may and secondary prevention and rehabilitation programs be more beneficial than standardised programs (Taylor (Briffa et al 2009). et al 2007). However, whilst the role of physiotherapy in therapeutic exercise and assessment is widely accepted, The reduction of modifiable cardiovascular risk is an the capacity of physiotherapists to participate in and co- important aim in the management of cardiac patients. ordinate other behavioural strategies for cardiac disease Behavioural risk factors such as unhealthy diet, physical management is also of key importance. Recent studies inactivity, and tobacco use are responsible for the majority relating to physiotherapy strategies for people with diabetes of coronary heart disease, and may contribute to increased (Ng et al 2010, Irvine et al 2009), chronic heart failure blood pressure, raised blood glucose levels, dyslipidaemia, (Hwang et al 2010), and coronary disease (Redfern et al and overweight and obesity (WHO 2011). Despite this, 2009) have also been documented. In addition, other studies in a recent examination of 18 809 patients after an acute highlight the integration of musculoskeletal training with coronary event, only 30% were adhering to diet and exercise strategies aimed to relieve shoulder (Reeve et al 2010) and recommendations and only 70% had quit smoking (Chow et sternal pain after thoracotomy (El-Ansary et al 2007). al 2010). This highlights the vast scope for physiotherapists to join other researchers, clinicians, and policy-makers in Overall, physiotherapists are highly trained health improving management of cardiovascular disease. professionals, are comfortable working as part of a multidisciplinary team and have extensive training in Clinical role of physiotherapy in cardiac disease behaviour modification. This makes physiotherapists management well placed to supervise individual health management programs that focus on risk factors for coronary disease and The potential role for physiotherapists in the clinical to be involved in and lead high-quality scientific research in management of people with cardiac conditions is extensive cardiac disease. and diverse. Interventions span acute and chronic care, involvement in primary and secondary prevention Cardiac disease research and physiotherapists programs, and implementation of strategies aimed at reducing modifiable risk factors (Pryor and Prasad 2008). Despite the extensive burden of cardiac disease on the Physiotherapists are not only skilled in the assessment of health of people across the globe and the ideal training of physical activity, activities of daily living, musculoskeletal physiotherapists in the area of prevention and management, integrity, and quality of life, but they can also assess other our impression is that little Australian cardiology cardiovascular risk factors such as blood pressure and body research is being led by physiotherapists. To investigate mass index, as well as absolute cardiovascular risk. In this more objectively, we examined the engagement of addition, physiotherapists’ understanding of multiple body physiotherapists in cardiology research in terms of outputs systems allows them to account for the impact of co-morbid such as peer-reviewed publication, conference presentation conditions when developing cardiovascular management and participation, and level of physiotherapist membership plans, eg, physical activity management plans for patients of relevant Australian professional organisations. We who have co-existing musculoskeletal conditions or reviewed recent abstracts at national meetings and contacted breathlessness. professional organisations to determine membership by physiotherapists. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 209
Editorial 2 Publications: To obtain a snapshot of physiotherapist journal. In comparison, 107 (38%) abstracts were engagement in peer-reviewed publications, we obtained authored and presented (six subsequent peer-reviewed full a random sample of 100 cardiac-related published trials manuscripts) by registered nurses. registered on the PEDro database. We examined each paper in detail to determine the profession of the authors. Where The biennial Cardiorespiratory Physiotherapy Australia relevant information was not obtained on the paper itself, meeting is part of APA Conference and is the major meeting we searched the Internet or contacted the corresponding that specifically targets Australian physiotherapists. author for clarification. Through this process we found that, Therefore, the conference proceedings for the of the 100 trials reviewed, only one included an author who Cardiorespiratory Stream at the conferences in 2007, 2009, was identified as having a qualification in physiotherapy. We and 2011 were reviewed. Of the abstracts presented at the also reviewed all papers in Australian cardiology journals three conferences, only 8% (SD 4%) were related to cardiac over the period 2006–2010. During that five-year period, conditions. In comparison, 60% (SD 13%) were related to only three papers listed a physiotherapist as an author: one respiratory disease. The difference between cardiac and in Heart Lung and Circulation and two in the Medical respiratory abstracts was much less extreme at the recent Journal of Australia. World Physical Therapy meeting. In this forum, 31 abstracts related specifically to cardiac disease (among a much larger Professional membership: Another way to assess the cohort of abstracts on lifestyle disease prevention generally), engagement of physiotherapists in cardiovascular research compared to 42 abstracts related specifically to respiratory is by the number of physiotherapists who are members of disease. professional organisations specialising in cardiology and cardiovascular disease management. We contacted the two It is possible that physiotherapy research is being conducted major professional organisations of this kind in Australia: and published outside traditional physiotherapy journals the Cardiac Society of Australia and New Zealand (CSANZ) and conferences, or that physiotherapists working in and the Australia Cardiovascular Health and Rehabilitation non-clinical roles do not identify physiotherapy as their Association (ACRA). CSANZ is the professional society for profession when joining professional organisations. cardiologists and those working in the area of cardiology However, this does not appear to provide a solid explanation including researchers, scientists, cardiovascular nurses, for the lack of physiotherapy-led presentations at national allied health professionals, and other healthcare workers. conferences identified in recent years. It also fails to explain ACRA is a peak body that provides support and advocacy for the imbalance between representation of physiotherapists multidisciplinary health professionals to deliver evidence- and other health professionals in this arena. based best practice across the continuum of cardiovascular care. While both actively promote membership by allied What can we do health professionals, including physiotherapists, and both provide numerous benefits, membership in both Physiotherapy organisations, academic institutions, organisations by physiotherapists is typically very low. and therapists could develop strategies to increase the engagement of physiotherapists in cardiology research. There are currently 1965 members of CSANZ of which Some simple strategies could include the implementation of 702 (36%) are affiliate or non-cardiologist members. a mentoring system designed to link physiotherapists with Surprisingly, only 8 (1% of affiliate members) of these established research backgrounds and clinicians working in identify themselves as physiotherapists. In contrast, 384 the management or prevention of cardiac disease. Greater (55% of affiliate members) identify as registered nurses. mentorship of postgraduate physiotherapy research on There are currently 460 members of ACRA, with only 43 cardiac topics is also needed in physiotherapy schools. The (9%) identifying themselves as physiotherapists. These data establishment of more frequent communication between are somewhat disturbing given that most hospitals employ clinical and research physiotherapists, via bodies such as physiotherapists to work on cardiology wards, most cardiac Cardiorespiratory Physiotherapy Australia, CSANZ, and rehabilitation programs include a physiotherapist as an ACRA may also inspire clinicians to consider research integral member of the multidisciplinary team, and many in this area. Funding and academic opportunities in the physiotherapists working in the community would manage area of cardiovascular disease management are extensive. patients on a daily basis with, or at risk of, cardiac disease. Exploration of these opportunities by physiotherapists would be fruitful for individual physiotherapists, the profession Conference participation: The respective national annual and, ultimately and most importantly, for patients. Research scientific meetings of CSANZ and ACRA provide for opportunities are widely available and physiotherapists are participation and presentation by a variety of health ideally positioned to take a leadership role in the future professionals, including physiotherapists. At the CSANZ evolution of cardiac management. conferences in 2009 and 2010 there were a total of 2310 and 2062 registrants respectively and a total of 700 and 655 Conclusions abstracts presented respectively. A review of the registrant database indicates that less than five physiotherapists were In summary, cardiac disease is a leading international health identified as registering for each of the annual conferences. problem. Despite physiotherapists being ideally trained with A review of the ACRA Proceedings for 2003–2007 found relevant clinical experience there appears to be a general a total of 279 abstracts were presented over the five-year lack of engagement with cardiology research. The problem period (Fernandez et al 2011). Detailed analysis of author manifests across a range of domains including professional profession, independent of order listed, found that only 13 membership, active participation in national conferences, (5%) were presented by physiotherapists over the five-year and publication of research in the area of cardiovascular period examined. Of those presented by a physiotherapist, disease. The expertise and capacity of physiotherapists only one was subsequently published in a peer-reviewed coupled with extensive career opportunities in the area of cardiology research presents a range of opportunities for physiotherapists to explore. 210 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Editorial 2 References Irvine C, Taylor NF (2009) Aust J Physiother 55: 237. Australian Institute of Health and Welfare (2011) Cardiovascular Krempf M et al (2010) Am J Cardiol 105: 667. disease: Australian facts 2011. Cardiovascular disease series. Cat. no. CVD 53. Canberra: AIHW. Ng C et al (2010) J Physiother 56: 163. Australian Physiotherapy Association (2011) Cardiorespiratory Pryor JA, Prasad A (2008) Physiotherapy for Respiratory and F^oi_ej^[hWfo 7kijhWb_W$ ^jjf0%%mmm$f^oi_ej^[hWfo$ Cardiac Problems (4th ed). London: Churchill Livingstone. Wid$Wk%]hekfi%Wd_cWb#f^oi_ej^[hWfo%YWhZ_eh[if_hWjeho# physiotherapy) [Accessed 7th September 2011.] Redfern J et al (2009) Heart 95: 468. Briffa T et al (2009) Med J Aust 190: 683. Reeve J et al (2010) J Physiother 56: 245. Chow CK et al (2010) Circulation 121: 750. Taylor NF et al (2007) Aust J Physiother 53: 7. El-Ansary D et al (2007) Aust J Physiother 53: 255. World Health Organisation (2011) Cardiovascular diseases 9L:i <WYji^[[jDe)'-@WdkWho(&'' ^jjf0%%mmm$m^e$_dj% Fernandez R et al (2011) Heart Lung Circ 20: 19. c[Z_WY[djh[%\\WYji^[[ji%\\i)'-%[d%_dZ[n$^jcb Q7YY[ii[Z -th September 2011.] Fox KAA et al (2010) Eur Heart J 31: 2755. Website Hwang CL et al (2010) J Physiother 56: 87. PEDro: www.pedro.org.au Statement regarding registration of clinical trials from the Editorial Board of Journal of Physiotherapy This journal now requires registration of clinical trials. All clinical trials submitted to Journal of Physiotherapy for publication must have been registered in a publicly-accessible trials register. We will accept any register that satisfies the International Committee of Medical Journal Editors requirements. Authors must provide the name and address of the register and the trial registration number on submission. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 211
Appraisal Clinimetrics General Health Questionnaire – 28 (GHQ-28) Description from 0 to 84. Using this method, a total score of 23/24 is the threshold for the presence of distress. Alternatively the The GHQ-28 was developed by Goldberg in 1978 (Goldberg GHQ-28 can be scored with a binary method where Not 1978) and has since been translated into 38 languages. at all, and No more than usual score 0, and Rather more Developed as a screening tool to detect those likely to than usual and Much more than usual score 1. Using this have or to be at risk of developing psychiatric disorders, method any score above 4 indicates the presence of distress the GHQ-28 is a 28-item measure of emotional distress or ‘caseness’. in medical settings. Through factor analysis, the GHQ-28 has been divided into four subscales. These are: somatic Reliability and validity: Numerous studies have investigated symptoms (items 1–7); anxiety/insomnia (items 8–14); reliability and validity of the GHQ-28 in various clinical social dysfunction (items 15–21), and severe depression populations. Test-retest reliability has been reported to (items 22–28) (Goldberg 1978). It takes less than 5 minutes be high (0.78 to 0 0.9) (Robinson and Price 1982) and to complete. The GHQ-28 must be purchased and is interrater and intrarater reliability have both been shown available at the following website: https://shop.psych.acer. to be excellent (Cronbach’s α 0.9–0.95) (Failde and Ramos edu.au/acer-shop/product/ 2000). High internal consistency has also been reported (Failde and Ramos 2000). The GHQ-28 correlates well Instructions to client and scoring: Examples of some of with the Hospital Depression and Anxiety Scale (HADS) the items in use include ‘Have you found everything getting (Sakakibara et al. 2009) and other measures of depression on top of you?’, ‘Have you been getting scared or panicy (Robinson and Price 1982). for no good reason?’, and ‘Have you been getting edgy and bad tempered?’ Each item is accompanied by four possible The GHQ-28 was developed to be a screening tool and for responses: Not at all, No more than usual, Rather more this reason responsiveness in terms of Minimal Detectable than usual, and Much more than usual. There are different Change (MDC) and Minimally Clinically Important methods to score the GHQ-28. It can be scored from 0 to 3 Difference (MCID) have not been established. for each response with a total possible score on the ranging potential for confusion over the different scoring methods, Commentary and this has implications for interpretation of scores derived from the questionnaire. There may also be some Physiotherapists are becoming more aware of the need to concern over the severe depression subscale which includes screen for psychological and psychiatric co-morbidity in some confronting questions for the patient to answer. patients under their care. This may be to adapt or modify Other tools such as the HADS may be less confronting for the physiotherapy approach to management or to institute physiotherapy use. referral to appropriate mental health care providers. Despite these limitations, the GHQ-28 remains one of the The GHQ-28 is one of the most widely used and validated most robust screening tools available to assess psychological questionnaires to screen for emotional distress and possible well-being and detect possible psychiatric morbidity. psychiatric morbidity. It has been tested in numerous populations including people with stroke (Robinson and Michele Sterling Price 1982), spinal cord injury (Sakakibara et al 2009), The University of Queensland, Australia heart disease (Failde and Ramos 2000), and various musculoskeletal conditions including whiplash associated References disorders (Sterling et al 2003) and occupational low back pain (Feyer et al 2000) amongst others. Thus for clinicians Failde I, Ramos R (2000) Europ J Epidem 16: 311. there is a wealth of data with which to relate patient outcomes. Feyer A et al (2000) Occup Environ Med 57: 116. It assesses the client’s current state and asks if that differs Goldberg D (1978) Manual of the General Health Questionnaire. from his or her usual state. It is therefore sensitive to Windsor: NFER-Nelson. short-term distress or psychiatric disorders but not to long- standing attributes of the client. Robinson R, Price T (1982) Stroke 13: 635. There are some disadvantages to use of the GHQ-28 in Sakakibara B et al (2009) Spinal Cord 47: 841. physiotherapy practice. First, the questionnaire is not freely available and must be purchased. Second, there is the Sterling M et al (2003) Pain 106: 481. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 259
Moodie et al: Inspiratory muscle training in mechanically ventilated patients Inspiratory muscle training increases inspiratory muscle strength in patients weaning from mechanical ventilation: a systematic review Lisa Moodie1, Julie Reeve2 and Mark Elkins3 1Auckland District Health Board, New Zealand, 2AUT University, New Zealand, 3The University of Sydney, Australia Question: Does inspiratory muscle training improve inspiratory muscle strength and endurance, facilitate weaning, improve survival, and reduce the rate of reintubation and tracheostomy in adults receiving mechanical ventilation? Design: Systematic review of randomised or quasi-randomised controlled trials. Participants: Adults over 16 years of age receiving mechanical ventilation. Intervention: Inspiratory muscle training versus sham or no inspiratory muscle training. Outcome measures: Data were extracted regarding inspiratory muscle strength and endurance, the duration of unassisted breathing periods, weaning success and duration, reintubation and tracheostomy, survival, adverse effects, and length of stay. Results: Three studies involving 150 participants were included in the review. The studies varied in time to commencement of the training, the device used, the training protocol, and the outcomes measured. Inspiratory muscle training significantly increased inspiratory muscle strength over sham or no training (weighted mean difference 8 cmH2O, 95% CI 6 to 9). There were no statistically significant differences between the groups in weaning success or duration, survival, reintubation, or tracheostomy. Conclusion: Inspiratory muscle training was found to significantly increase inspiratory muscle strength in adults undergoing mechanical ventilation. Despite data from a substantial pooled cohort, it is not yet clear whether the increase in inspiratory muscle strength leads to a shorter duration of mechanical ventilation, improved weaning success, or improved survival. Further large randomised studies are required to clarify the impact of inspiratory muscle training on patients receiving mechanical ventilation. Review registration: PROSPERO CRD42011001132. <.PPEJF- 3FFWF+ &MLJOT. *OTQJSBUPSZNVTDMF USBJOJOHJODSFBTFTJOTQJSBUPSZNVTDMFTUSFOHUIJOQBUJFOUTXFBOJOHGSPNNFDIBOJDBMWFOUJMBUJPOBTZTUFNBUJDSFWJFX Journal of Physiotherapyo> Key words: Systematic review, Respiratory muscle training, Mechanical ventilators, Weaning, Intensive care, Physiotherapy Introduction diaphragmatic structure and function. These alterations, known as ventilator-induced diaphragmatic dysfunction, Mechanical ventilation temporarily replaces or supports involve changes in myofibre length and rapid atrophy spontaneous breathing in critically ill patients in intensive (Petrof et al 2010). Patients who undergo prolonged periods care units. Weaning is the withdrawal of mechanical of ventilation also demonstrate decreases in respiratory ventilation to re-establish spontaneous breathing. Patients muscle endurance (Chang et al 2005). are considered to have successfully weaned from ventilatory support when they can breathe on their own for at least 48 Inspiratory muscle training is a technique that loads the hours (Sprague and Hopkins 2003). Weaning typically diaphragm and accessory inspiratory muscles with the aim comprises 40–50% of the total duration of mechanical of increasing their strength and endurance. Theoretically, ventilation, with almost 70% of patients in intensive care mechanically ventilated patients could undertake inspiratory weaning without difficulty on the first attempt (Boles et al muscle training in several ways: isocapnic/normocapnic 2007). Other patients have a more difficult or prolonged hyperpnoea training, the application of devices that period of weaning, which is associated with a poorer impose resistive or threshold loads, or adjustment of the prognosis (Vallverdu et al 1998, Esteban et al 1999). ventilator sensitivity settings, such that patients need to Failure to wean results in prolonged ventilation with an generate greater negative intrathoracic pressures to initiate increased risk of respiratory muscle weakness, critical inspiratory flow (Hill et al 2010, Caruso et al 2005, Bissett illness weakness syndromes, nosocomial infection, and and Leditschke 2007). Inspiratory muscles respond to airway trauma (Boles et al 2007, Gosselink et al 2008). Despite representing only a small percentage of ICU What is already known on this topic: Inspiratory patients, those who fail to wean from ventilation consume muscle weakness in critically ill patients appears a disproportionate share of healthcare resources (Sprague to contribute to slow or unsuccessful weaning from and Hopkins 2003) with an increase in mortality, morbidity, mechanical ventilation. Several trials of inspiratory and ICU length of stay (Choi et al 2008, Epstein 2009, muscle training to facilitate weaning in intensive care Gosselink et al 2008). have been performed, with inconsistent results. Weakness or fatigue of the diaphragm and the accessory What this review adds: Pooled data from randomised muscles of inspiration is widely recognised as a cause of trials confirm that inspiratory muscle training increases failure to wean from mechanical ventilation (Choi et al inspiratory muscle strength, but it is not yet clear 2008, Petrof et al 2010). There is also some evidence to whether it shortens the mechanical ventilation period, suggest that mechanical ventilation may adversely affect improves weaning success, or improves survival. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 213
Research training in the same way as other skeletal muscles in terms #PY. Inclusion Criteria. of the principles of overload, specificity, and reversibility (Romer and McConnell 2003, McConnell et al 2005). Design In healthy people and in people with chronic obstructive Randomised controlled trial and quasi-randomised pulmonary disease, inspiratory muscle training has been shown to increase inspiratory muscle strength and endurance controlled trials* (McConnell and Romer 2004, Gosselink et al 2011, Geddes Participants et al 2008). Sprague and Hopkins (2003) hypothesised that Patients aged > 16 years who were intubated or inspiratory muscle training may also increase inspiratory muscle strength and endurance in ventilated patients and tracheostomised receiving full or partial mechanical thus potentially assist patients in weaning from ventilation. ventilation In addition, reducing ventilation time may help to reduce Intervention the incidence of ventilator-associated complications and Inspiratory muscle training via any of the following: may decrease length of stay in the intensive care unit and in ¸ _ieYWfd_Y%dehceYWfd_Y^of[hfde[W hospital. In patients who have failed to wean from mechanical – inspiratory resistive training ventilation using conventional weaning techniques, several – threshold pressure training case reports have demonstrated increases in inspiratory – adjustment of ventilator pressure trigger sensitivity muscle strength after inspiratory muscle training, followed Outcome measures by successful weaning (Abelson and Brewer 1987, Aldrich Inspiratory muscle strength and Uhrlass 1987, Aldrich et al 1989, Sprague and Hopkins Inspiratory muscle endurance 2003, Martin et al 2002, Bissett and Leditschke 2007). Duration of unassisted breathing periods Weaning duration As no systematic appraisal of studies investigating the effect Weaning success of inspiratory muscle training on weaning from mechanical Reintubation ventilation has been indexed on the PEDro website or in Tracheostomy PubMed, we undertook such a review, which aimed to Intensive care unit or hospital length of stay answer the following specific research questions: Mortality Adverse effects 1. Does inspiratory muscle training improve inspiratory Comparisons muscle strength and endurance in adults receiving ?dif_hWjehockiYb[jhW_d_d]l[hikii^Wc%dejhW_d_d] mechanical ventilation? * Only the first arm of cross-over trials was included. 2. Does it improve the success and reduce the duration of weaning? Assessment of characteristics of studies 3. Does it improve survival and reduce reintubation and Quality: The methodological quality of the studies tracheostomy? was assessed using the PEDro scale (de Morton 2009). The PEDro scale scores the methodological quality of Method randomised controlled studies out of 10. The score for each included study was determined by a trained assessor (ME). In addition to registration on PROSPERO, a more detailed Scores were based on all information available from both protocol for conducting this review was submitted for the published version and from communication with the peer review and publication (Moodie et al 2011) prior to authors. No study was excluded on the basis of poor quality. commencing the review process. Participants: Studies involving hospitalised patients over Identification and selection of studies 16 years of age who were intubated or tracheostomised receiving full or partial mechanical ventilation, and for Five electronic databases were searched (PEDro, PubMed, whom liberation from mechanical ventilation was a goal of CENTRAL, EMBASE, and CINAHL) from the earliest clinical care, were included in the study. Where available, available date until April 2011. Two authors (LM and JR) the age, gender, height, weight, cause of admission, and independently reviewed all the retrieved studies against severity score of the participants at admission were recorded. the eligibility criteria (Box 1). Studies were not excluded Pre-intervention characteristics including severity score, on the basis of language or publication status. The title and ventilation status, ventilation period and endotracheal tube/ abstract were examined and full text was obtained if there tracheostomy, inspiratory muscle strength and inspiratory was ambiguity regarding eligibility. If the two authors could muscle endurance were also recorded where available. not reach agreement, a third author (ME) made the decision regarding eligibility. The reference lists of any eligible Intervention: The experimental intervention was studies were screened to identify other relevant studies. inspiratory muscle training. The control intervention was We asked the authors of eligible studies and manufacturers sham or no inspiratory muscle training. The device used, the of inspiratory muscle training devices if they were aware ventilation mode while training, training pressure, duration, of any other eligible studies. The following keywords frequency, and progression of training were recorded were included in our search: randomised controlled trial, for the experimental group and for the control group if it inspiratory/respiratory/ventilatory muscle training/ received sham training. The method of inspiratory muscle conditioning, pressure threshold load, incremental training (isocapnic/normocapnic hyperpnoea, inspiratory threshold load, isocapnic/normocapnic hyperpnoea, resistance load, mechanical ventilation, weaning, critically ill, intubated/ventilated/tracheostomy (see Appendix 1 on the eAddenda for the full search strategy). 214 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Moodie et al: Inspiratory muscle training in mechanically ventilated patients Titles and abstracts screened from were reported as weighted mean differences with 95% CIs, electronic search (n = 816) while dichotomous outcomes were reported as risk ratios with 95% CIs. Papers excluded after screening j_jb[i%WXijhWYji d3-/- Results Potentially relevant papers retrieved Flow of studies through the review for evaluation of full text (n = 19) The search retrieved 816 studies. After screening titles and Papers excluded after evaluation abstracts, 797 were excluded and 19 full text articles were of full text (n = 12) identified. After evaluation of the full text, nine studies Participants did not meet were excluded on the basis of participants not meeting the inclusion criteria. A further three were excluded on the inclusion criteria (n = 9) basis of the intervention not meeting the inclusion criteria. Intervention did not meet Therefore seven papers (Cader et al 2010, Caruso et al 2005, Martin et al 2006a, Martin et al 2006b, Martin et al 2007, inclusion criteria (n = 3) Martin et al 2009, Martin 2011) met the inclusion criteria for the review. One trial was reported across five publications Papers included in systematic review (n = 7) (Martin et al 2006a, Martin et al 2006b, Martin et al 2007, Studies included in systematic review (n = 3) Martin et al 2009, Martin et al 2011), so the seven included papers provided data on three trials. No additional studies 'JHVSF Flow of studies through the review. were found by searching the reference lists of the included publications or by contacting manufacturers and authors. resistive training, threshold pressure loading, or adjustment Figure 1 presents the flow of studies through the review. of ventilator pressure trigger sensitivity) was also recorded. Authors of all the included studies were contacted to clarify interpretation and or extraction of data and all authors Outcome measures: Primary outcome measures were responded to the queries. There were no disagreements measures of inspiratory muscle strength at a controlled regarding eligibility or the extracted data, so arbitration by lung volume (eg, maximal inspiratory pressure at residual the third author was not required. volume), inspiratory muscle endurance, the duration of unassisted breathing periods, weaning success (ie, Description of studies proportion of patients successfully weaned, defined as spontaneous breathing without mechanical support for at All of the studies (n = 3) reported the effects of inspiratory least 48 hours), weaning duration (ie, from the identification muscle training on inspiratory muscle strength as measured of readiness to wean, as determined by the authors and/ by maximal inspiratory pressure. Two studies reported data or commencement of inspiratory muscle training, to the about weaning success (Cader et al 2010, Martin et al 2011), discontinuation of mechanical ventilation) and reintubation two studies reported data on weaning duration (Cader (ie, proportion of extubated patients who were reintubated et al 2010, Caruso et al 2005), and three studies reported within the follow-up period of the study). Secondary survival data (Cader et al 2010, Caruso et al 2005, Martin et outcomes were tracheostomy (ie, proportion of extubated al 2011). Therefore, the effect of inspiratory muscle training patients tracheostomised after the commencement of was examined using meta-analysis for four outcomes: training), survival, adverse effects, and length of stay in inspiratory muscle strength, weaning success, weaning hospital or the intensive care unit. duration, and survival. Only one study reported data about reintubation (Caruso et al 2005) and tracheostomy (Cader et Data analysis al 2010) and so these outcomes could not be meta-analysed. The relevant data including study characteristics and No studies reported inspiratory muscle endurance, the outcome data were extracted from the eligible studies by duration of unassisted breathing periods, and length of stay two reviewers (LM and JR) using a standard form and the in the intensive care unit and hospital. The quality of the third author (ME) arbitrated in cases of disagreement. The included studies is outlined in Table 1 and a summary of the reviewers extracted information about the method (design, studies is presented in Table 2. participants, and intervention) and outcome data for the experimental and control groups. Authors were contacted Quality: The mean PEDro score of the included studies was where there was difficulty in interpreting or extracting 6. In all studies, randomisation was carried out correctly and data. The data analysis was performed using Revman 5.1 group data and between-group comparisons were reported (Revman 2011). A fixed-effect model was used unless adequately. No study blinded participants or therapists, but there was substantial heterogeneity (I2 > 50%), when a one study (Martin et al 2011) blinded assessors. random-effects model was used. Continuous outcomes Participants: There were 150 participants across the three studies. The mean age of participants across the three studies ranged from 65 to 83 years, and 50% were male. The reasons for mechanical ventilation included respiratory, surgical, cardiovascular, other medical, trauma, sepsis, and decreased level of consciousness. One study (Cader et al 2010) excluded patients who were tracheostomised, one study (Martin et al 2011) included only tracheostomised patients, and it is unknown whether participants in the other study were ventilated via tracheostomy or endotracheal tube. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 215
Research Total APACHE II scores ranging from 20 to 24 were reported in 216 (0 to 10) two of the studies (Caruso et al 2005, Cader et al 2010) and SAPS II score was reported in one study (Martin et al 2011). 6 In all three studies, the mean duration of ventilation before 4 inspiratory muscle training commenced was reported and 8 varied greatly between 1 (Caruso et al 2005) and 45 days (Martin et al 2011). Prior to initiation of training, the mean Point estimate Cader et al (2010) Y Y Y N N N N Y Y Y Caruso et al (2005) Y N Y N N N N N Y Y Martin et al (2011) Y Y Y N N Y Y Y Y Y maximal inspiratory pressure of the participants, measured and variability at residual volume, ranged from 15 to 51 cmH2O among the included studies. No study reported the maximal reported inspiratory pressures as a percentage of the predicted values. However, because maximal inspiratory pressure < 15% Intention- Between-group difference reported in healthy individuals ranges from 104 to 129 cmH2O for men and 70 to 98 cmH2O for women (ATS/ERS 2002), the dropouts to-treat analysis maximal inspiratory pressures of the participants can be considered extremely low. Participant Therapist Assessor blinding blinding blinding Intervention: A threshold pressure device was used for inspiratory muscle training in two of the studies (Cader et Groups al 2010, Martin et al 2011) and adjustment of the sensitivity similar at of the pressure trigger on the ventilator was used in one baseline study (Caruso et al 2005). Training protocols used starting pressures ranging from 20% of maximal inspiratory 5BCMF PEDro scores for included studies (n = 3) Random Concealed pressure to the highest pressure tolerated. The duration allocation allocation of the training sessions varied from 5 to 30 min and the frequency from 5 to 7 days a week. Two studies reported Study N = No, Y = Yes that physiotherapists or respiratory therapists supervised the training (Cader et al 2010, Caruso et al 2005). One study (Martin et al 2011) provided sham training to the control group with a modified Pflex device, while the other studies provided usual care only to the control group. Outcome measures: In all three studies, inspiratory muscle strength was measured by maximal inspiratory pressure in cmH2O. This was measured after the application of a unidirectional valve for 20 to 25 seconds, which is intended to ensure the measurement is taken from residual volume. Two studies recorded the number of patients successfully weaned as a percentage of the total number of participants, defined as spontaneous breathing without ventilator support for 48 hours (Cader et al 2010) or 72 hours (Martin et al 2011). In two studies weaning duration was recorded in hours (Caruso et al 2005) or days (Cader et al 2010) and results were converted to hours. Effect of intervention Inspiratory muscle strength: Three studies (Cader et al 2010, Caruso et al 2005, Martin et al 2011) with 122 participants provided post-intervention data for pooling with a fixed-effect model to show the effect of inspiratory muscle training on increasing inspiratory muscle strength when compared to control (Figure 2, see also Figure 3 on the eAddenda for a detailed forest plot). Results showed a significant improvement in maximal inspiratory pressure favouring inspiratory muscle training over no or sham training (MD = 8 cmH2O, 95% CI 6 to 9). Weaning success: Two studies (Cader et al 2010, Martin et al 2011) with 110 participants provided post-intervention data about the effect of inspiratory muscle training on the proportion of patients successfully weaned from mechanical ventilation. A random-effects model was used as there was significant heterogeneity (I2 = 60%). The overall effect was not significant but favoured the experimental group (RR = 1.20, 95% CI 0.76 to 1.91) (Figure 4, see also Figure 5 on the eAddenda for a detailed forest plot). Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Moodie et al: Inspiratory muscle training in mechanically ventilated patients 5BCMF Summary of included studies (n = 3). Study Design Participants Intervention Outcome measures Cader et al RCT Intubated via endotracheal tube due Exp: Threshold device at 30% MIP in (2010) to acute respiratory failure supine 45 degrees up MIP Starting PS after a period Weaning of controlled ventilation 5 min duration Exp: n = 21 (9 male) Mortality Twice daily Tracheostomy Age (yr) = 83 (SD 3) Weaning APACHE II = 20 MIP increased 10% of initial MIP success Con: n = 20 (10 male) daily, as tolerated Age (yr) = 82 (SD 7) APACHE II = 20 Stopped if adverse signs Con: No training Caruso et RCT Intubated due to acute respiratory Exp: Adjustment of ventilator trigger MIP al (2005) failure or decreased consciousness sensitivity to 20% of initial MIP Receiving controlled ventilation or PS Weaning Exp: n = 20 5 min duration Completed n = 12 (8 male) Twice daily Mortality Age (yr) = 67 (SD 10) APACHE II = 23 Increased by 5 minutes each Reintubation Con: n = 20 session to 30 minutes Completed n = 13 (9 male) Adverse Increased by 10% of initial MIP to effects maximum 40% MIP Ventilation Con: No training duration Age (yr) = 66 (SD 17) Martin et al RCT APACHE II = 24 Exp: Threshold inspiratory device set at MIP (2011) Intubated and ventilated due to highest pressure tolerated medical and surgical diagnoses Weaning Exp: n = 35 (16 male) Start pressure 7.2 to 12.3 cmH20 success Age (yr) = 66 (SD12) , je'&Xh[Wj^in*i[jin+ZWoi% Mortality SAPS II = 33.5 week Con: n = 34 (15 male) Age (yr) = 65 (SD 11) Until weaned or 28 days SAPS II = 33 Con: Sham: modified Pflex inspiratory resistive device at low load APACHE II = Acute physiology and chronic health evaluation II score, MIP = maximal inspiratory pressure, PS = pressure support, RCT = randomised controlled trial, SAPS II = Simplified Acute Physiology Score Cader 2010 Cader 2010 Caruso 2005 Martin 2011 Martin 2011 –10 –5 0 5 10 0.2 0.5 1 25 Favours control cmH2O Favours training Favours control Favours training Figure 2. Mean difference (95% CI) of the effect of 'JHVSF Risk ratio (95% CI) of the effect of inspiratory muscle training on weaning success (% of patients inspiratory muscle training on inspiratory muscle strength successfully weaned) by pooling data from two studies (n = 110). as measured by maximal inspiratory pressure (in cmH2O) by pooling data from three studies (n = 122). Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 217
Research Cader 2010 Adverse events: One study (Martin et al 2011) reported Caruso 2005 no adverse effects during either the training or the sham training. One study (Cader et al 2010) did not document –100 –50 0 50 100 occurrence of adverse events. One study (Caruso et al Favours control hours Favours training 2005) reported adverse effects in the experimental group including paradoxical breathing, tachypnea, desaturation, 'JHVSFMean difference (95% CI) of the effect of haemodynamic instability, and supraventricular tachycardia. inspiratory muscle training on weaning duration (in hours) However, it is not clear whether the control group underwent an equivalent period of observation for adverse events. by pooling data from two studies (n = 53). Discussion Cader 2010 Caruso 2005 Numerous case reports and case series have described the Martin 2011 use of inspiratory muscle training in mechanically ventilated patients (Martin et al 2002, Bissett and Leditschke 2007, 0.02 0.1 1 25 Sprague and Hopkins 2003, Aldrich et al 1989, Aldrich Favours control Favours training and Uhrlass 1987, Abelson and Brewer 1987). All of these studies observed an increase in maximal inspiratory 'JHVSFRisk ratio (95% CI) of the effect of inspiratory pressure or training pressure and suggested that this may muscle training on survival by pooling data from three have aided weaning from mechanical ventilation. While the data analysed in this review confirm that inspiratory studies (n = 150). muscle training improves maximal inspiratory pressure significantly, it remains unclear whether these benefits Weaning duration: Two studies (Cader et al 2010, Caruso translate to weaning success and a shorter duration of et al 2005) with 53 participants provided post-intervention mechanical ventilation. Although only three randomised data for pooling to examine the effect of inspiratory muscle trials were identified by this review, the total number of training on the duration of weaning from mechanical patients who contributed data was substantial (n = 150). ventilation. A random-effects model was used as there The average rating of the quality of the three studies in was significant heterogeneity (I2 = 73%). The overall effect this review (ie, 6 on the 10-point PEDro scale) is greater was not significant (MD = 21 hours, 95% CI –10 to 53) but than the average score for trials in physiotherapy (Maher favoured the experimental group (Figure 6, see also Figure et al 2008). Therefore this review provides strong evidence 7 on eAddenda for detailed forest plot). that inspiratory muscle training significantly increases inspiratory muscle strength in mechanically ventilated Survival: Three studies (Cader et al 2010, Caruso et al 2005, patients. The non-significant trends on the remaining Martin et al 2011) with 150 participants provided data on outcomes favour inspiratory muscle training over control the effects of inspiratory muscle training on survival (RR and the 95% CIs contain clinically worthwhile benefits, = 1.22, 95% CI 0.54 to 2.77). The overall effect was not strongly suggesting that further research is required. significant but favoured inspiratory muscle training (Figure However, it is not possible to provide a recommendation 8, see also Figure 9 on eAddenda for detailed forest plot). to implement the training to facilitate weaning from mechanical ventilation based on the current evidence. Reintubation: Only one study (Caruso et al 2005) reported the effect of inspiratory muscle training on reintubation, Although individual studies varied in their conclusions providing data on 34 participants. Three of 17 (18%) of the about the effect of inspiratory muscle training on maximal experimental group and five of 17 (29%) of the control group inspiratory pressure, the pooled data show that the training were reintubated. This difference between groups was not significantly increases inspiratory muscle strength. statistically significant (RR = 0.60, 95% CI 0.17 to 2.12). At present there is no established minimum clinically important difference in maximal inspiratory pressure in Tracheostomy: One study (Cader et al 2010) reported the this patient group. The mean pressures recorded at baseline effect of inspiratory muscle training on tracheostomy, in the three included studies ranged from 15 to 51 cmH2O, providing data on 33 participants. Three of 17 (18%) of which is below the predicted normal for healthy individuals the experimental group and 2 of 16 (13%) of the control (ATS/ERS 2002). Even after training in the experimental group received a tracheostomy, which was not a statistically group, the mean maximal inspiratory pressures in all studies significant difference (RR = 1.41, 95% CI 0.27 to 7.38). ranged from 25 to 56 cmH2O, which remain substantially lower than normal values. Sahn and Lakshminaryan (1973) suggested that a low maximal inspiratory pressure was an important predictor of weaning failure, although this finding has not been reproduced consistently in the literature (Bruton et al 2002). These results must be interpreted in the context of the reliability of inspiratory muscle strength measures in ventilated patients. It has been highlighted that maximal inspiratory pressure is difficult to measure reliably in intubated patients (Bruton et al 2002). This has been overcome by the use of a unidirectional valve, which allows maximal inspiratory pressure to be performed easily even 218 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Moodie et al: Inspiratory muscle training in mechanically ventilated patients in unco-operative patients (Caruso et al 1999, Eskandar and Because the confidence intervals around the estimates of Apostolakos 2007). Using a unidirectional valve requires a the effect of inspiratory muscle training on weaning success physiological response demanding less patient co-operation, and weaning duration include values that we consider to be and is more accurate than other methods of measuring clinically worthwhile, we recommend further research to maximal inspiratory pressure (Caruso et al 1999). This refine these estimates. However, using the existing data in technique was used by the authors in all three studies. this review, we calculate that data from 400 patients would Authors have suggested using the maximal value of three be needed to identify a statistically significant effect on manoeuvres to minimise variability (Caruso et al 2008, weaning success. Similarly, 118 patients would be needed Marini et al 1986) however only one included study (Martin to identify an effect on weaning duration. Data from et al 2011) reported undertaking such repetitions. Although additional patients would be needed to determine whether a unidirectional valve was used, measurement variability such effects are clinically worthwhile. Data from cohorts could occur due to the effects of controlled ventilation, as large as this could be accumulated over time through varying levels of consciousness and sedation. However, future meta-analyses. However, intensive care management this technique currently represents the best method for is constantly changing, eg, the implementation of sedation estimating inspiratory muscle strength in mechanically breaks into usual care (Kress et al 2000, Schweickert et al ventilated patients (Caruso et al 1999, Caruso et al 2008). 2004). Such advances in usual care may alter the efficacy of Due to the design of the studies, the experimental group inspiratory muscle training and this may limit the extent to had greater opportunity to practise the maximal inspiratory which it is appropriate to meta-analyse existing and future pressure measurement procedure, eg, during titration of trials of inspiratory muscle training in intensive care. the training load, and to accommodate to the feeling of loaded breathing during training. It is therefore possible If further research is to be conducted to determine the that some or all of the improvement in maximal inspiratory effects of inspiratory muscle training on clinical outcomes, pressure in the experimental group could be attributed to the training regimen and the outcomes should be chosen familiarisation with the technique. carefully. The training protocols in the three studies in this review differed and it is possible that not all were of sufficient This review showed that the overall effect of inspiratory intensity or duration to provide a training effect. The muscle training on weaning success was not significant, training period of participants in our studies ranged from 3 although the best estimate was that it probably increases the to 18 days yet other studies, albeit in different populations, likelihood of weaning success by about 20%. Although this trained people with chronic obstructive pulmonary disease did not reach statistical significance, the 95% CI includes and found significant increases in the proportion of type I some possible clinically worthwhile effects so further and size of type II muscle fibres after five weeks of training research is warranted. Although maximal inspiratory (Ramirez-Sarmiento et al 2002). As the training duration pressure increased, it remained below normative values in the studies we reviewed was short by comparison it is in all three studies and did not translate into statistically possible the changes seen in increased inspiratory muscle significant weaning success in the available data. Apart strength may have been due to the adaptation of neural from its association with inspiratory muscle strength, pathways to improve motor unit recruitment and breathing weaning success has also been shown to be dependent pattern rather than a change in muscle hypertrophy or fibre on cardiovascular stability, sepsis, and nutritional, type. psychological and neurological status (Sprague and Hopkins 2003). It is possible that these factors may have influenced One study included in this review investigated the effect results. of inspiratory muscle training on breathing pattern as measured by the Index of Tobin, which is the ratio of The overall effect of inspiratory muscle training on weaning respiratory frequency (in breaths per min) to tidal volume duration was not statistically significant, although the best (in litres) (Yang and Tobin 1991). This index is a predictor estimate was that the average effect might be to reduce of weaning (Yang and Tobin 1991). Although the Index weaning time by 21 hours. In our opinion, this would be of Tobin was not one of the outcomes we included in our clinically worthwhile because successful withdrawal of review, one study (Cader et al 2010) found a significant mechanical ventilation at any stage is associated with a reduction (ie, improvement) in the Index of Tobin (MD higher survival rate (Eskandar and Apostolakos 2007). = 8, 95% CI 3 to 14) in the participants who underwent The 95% CI suggests that the average effect of inspiratory inspiratory muscle training. The authors suggested this muscle training could, at best, reduce weaning time by indicated a more relaxed breathing pattern, which may be more than two days which has implications in reducing the more compatible with weaning success as hypothesised by risk of ventilator acquired complications and the associated Sprague and Hopkins (2003). health care costs. However, it is equally possible that the improvement in inspiratory muscle strength with training is Other differences in the training protocols may have inadequate to improve weaning duration, because the 95% contributed to the difference in effects seen in the included CI does not exclude neutral and mildly negative effects. studies. The studies report a wide variation in the point of care at which training commenced. Caruso et al (2005) The overall effect of inspiratory muscle training on commenced training after 24 hr of ventilation, whereas mortality was not statistically significant but favoured the Martin et al (2011) commenced after a mean of 45 days. The training group. By strengthening the inspiratory muscles, background mode of ventilation that the participants were the training may decrease the duration of ventilation and receiving also differed between the studies. In the study by associated complications, potentially contributing to a Cader et al (2010) it was pressure support, in the study by reduction in mortality. The outcomes of reintubation Caruso et al (2005) it was pressure- or volume-controlled (Caruso et al 2005) and tracheostomy (Cader et al 2010) ventilation, and in the study by Martin et al (2011) it was were each measured by one study and neither identified a assist-control or synchronised intermittent mandatory statistically significant or clinically worthwhile effect. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 219
Research ventilation or pressure support. Additionally participants in eAddenda: Figures 3, 5, 7, 9 and Appendix 1 available at the study by Caruso et al (2005) remained sedated and had jop.physiotherapy.asn.au only a small increase in maximal inspiratory pressure, from 51 to 56 cmH2O. Thus it is possible that sedation and mode Acknowledgements: We wish to thank Dr Kathy Stiller and of ventilation limited training efficacy. In a later study, Dr Kylie Hill for their insightful comments on the protocol deeper levels of sedation were associated with a decrease in for this systematic review. maximal inspiratory pressure during mechanical ventilation (Caruso et al 2008). Correspondence: Dr Julie Reeve, Division of Rehabilitation and Occupation Studies, Faculty of Health The mode of inspiratory muscle training also differed and Environmental Studies, Private Bag 92006, AUT between studies and included threshold pressure training University, Auckland 1080, New Zealand. Email: julie. and adjustment of ventilator trigger sensitivity. It has [email protected] been suggested that with adjustment of the ventilator trigger sensitivity, maximal inspiratory pressure may not References be maintained as resistance is only offered initially when the valve opens (Cader et al 2010). These authors suggest Abelson H, Brewer K (1987) Inspiratory muscle training in the that threshold pressure training instead provides resistance mechanically ventilated patient. Physiotherapy Canada 39: for a longer duration and thus may be more effective for 305–307. inspiratory muscle training. Studies in our review also used differing training regimes with the starting pressures and Aldrich TK, Uhrlass RM (1987) Weaning from mechanical loads ranging from 20% of maximal inspiratory pressure ventilation: successful use of modified inspiratory resistive (Caruso et al 2005) to the highest pressure tolerated (Martin training in muscular dystrophy. 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Appraisal Critically Appraised Papers Manual lymph drainage when added to advice and exercise may not be effective in preventing lymphoedema after surgery for breast cancer Synopsis sessions of manual lymph drainage over 20 weeks with each session lasting 30 minutes and performed by trained Summary of: Devoogdt N et al (2011) Effect of manual therapists. Outcome measures: The primary outcomes were lymph drainage in addition to guidelines and exercise the cumulative incidence of and the time to develop arm therapy on arm lymphoedema related to breast cancer: lymphoedema (defined as a 200 ml increase) as measured randomized controlled trial. BMJ 343: d5326. [Prepared by with the water displacement method with measures taken at Nicholas Taylor, CAP Editor.] baseline and 1, 3, 6, and 12 months after surgery. Secondary outcome measures were lymphoedema measured with the Question: Does manual lymph drainage prevent arm circumference method, health-related quality of life lymphoedema in patients who have had surgery for using the SF-36 scale, and a patient reported questionnaire breast cancer? Design: Randomised, controlled trial with to score the presence of subjective arm lymphoedema. concealed allocation and blinded outcome assessment. Results: 154 participants (96%) completed the study at 12 Setting: A multidisciplinary breast centre of a tertiary months. At 12 months the incidence of lymphoedema in the hospital in Belgium. Participants: Patients were eligible intervention group (n = 18, 24%) was similar to the incidence to be included if they received unilateral surgery with of lymphoedema in the control group (n = 15, 19%, OR 1.3, axillary node dissection for breast cancer, and agreed to 95% CI 0.6 to 2.4); also there was no difference in incidence participate. Randomisation of 160 participants allocated at 3 or 6 months. There was no difference between the 79 to the intervention group and 81 to a control group. groups in the time taken to develop lymphoedema, and no Interventions: Both groups received guidelines about the difference between the groups in any secondary outcome prevention of lymphoedema in the form of a brochure, measure. Conclusion: The application of manual lymph and exercise therapy involving supervised individualised drainage after axillary node dissection for breast cancer in 30 minute sessions – initially twice a week, reducing to addition to providing guidelines and exercise therapy did once fortnightly as patients progressed. Participants in not prevent lymphoedema in the first year after surgery. both groups were also asked to perform exercises at home twice/day. In addition, the intervention group received 40 programs (Box 2002). In both of these studies similar exercise programs were used, but Devoogdt’s incidence of Commentary lymphoedema was high in both the intervention and control group. The interventions were delayed in Devoogdt’s The development of arm lymphoedema after axillary study (4–5 weeks after surgery) while the Torres Lacomba node dissection for breast cancer management has been intervention started 3–5 days after discharge from hospital, estimated to occur in 20–40% of women (Coen 2003, which might also have had some impact on outcome. How Hayes 2008). The effect on quality of life for the individual many manual lymphatic drainage sessions are required to and the cost to public health is well recognised. Therefore reduce the incidence of lymphoedema if at all? Devoogdt any research exploring the possibility of reducing the used 40 sessions compared to 9 in the Torres Lacomba development of lymphoedema is welcome. Devoogdt used study. Further research is required to answer the questions manual lymphatic drainage, one of the cornerstones of and to determine the benefit of adding manual lymphatic treatment for established lymphoedema, in this study (Földi drainage to early postoperative physiotherapy interventions. 2003). Combined with exercise and education the aim was to prevent lymphoedema. Intuitively every lymphoedema Hildegard Reul-Hirche therapist would agree that this would be worthy of pursuit. Physiotherapy Department, Royal Brisbane and However, this study does not show any benefit from the addition of manual lymphatic drainage. The incidence of Women’s Hospital, Brisbane, Australia lymphoedema within the first year is nearly equal in both groups. This is in stark contrast to Torres Lacomba’s study References (2010), also a randomised, single blinded clinical trial, including 120 women. Their intervention was manual Coen JJ et al (2003) Int J Radiat Oncol Biol Phys 55: 1209. lymphatic drainage, exercise, and education, compared to education alone. The results showed that after one year the Hayes SC et al (2008) J Clin Oncol 26: 3536. incidence of lymphoedema in the intervention group was 7% compared to 25% in the control group. Földi M et al (2003) Textbook of lymphology for physicians and lymphedema therapists. New York: Elsevier. Comparing the two studies the question arises whether exercise had a major impact and accounted for the better Torres Lacomba M et al (2010) BMJ 340: b5396. results in Torres Lacomba’s study. Exercise has been shown to be beneficial in early post-operative physiotherapy Box RC et al (2002) Breast Cancer Research and Treatment 75: 51. 258 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Editorial 1 Pain education for physiotherapists: is it time for curriculum reform? Lester E Jones1 and Julia M Hush2 1Department of Physiotherapy, La Trobe University, 2Discipline of Physiotherapy, The University of Sydney Australia Pain is the most common reason that people seek Pain education in pre-registration courses physiotherapy care. Despite major advances in our understanding of pain in the past 40 years, the burden of Research using the Pain Education Survey suggests that pain worldwide remains enormous, whether gauged in physiotherapy programs have a greater amount of pain humanitarian, health care, or financial terms (National Pain education than other health professions. In the UK, the Strategy 2010). Physiotherapists have an ethical imperative median amount of pain education for all health disciplines as health professionals to have an accurate understanding is 12 hours (range 2–158) but physiotherapists have 38 hours of the human pain experience so as to best help those (range 5–158), three times that of medical students (Briggs seeking their care. This means physiotherapists need to et al 2011). Similarly, in Canada, physiotherapists receive be educated appropriately in modern pain neuroscience, an average of 41 hours (range 18–69) of pain education, so they can assess relevant factors that might modulate the compared with 16 hours (range 0–38) in medicine (Watt- pain experience and provide effective pain management. Watson et al 2009). While this seems to be good news for physiotherapy, these data should be interpreted with For more than 10 years physiotherapy researchers such as caution. It can be difficult to attribute hours to categories David Butler, Louis Gifford, Lorimer Moseley, and Michael of pain education accurately, such as when pain content is Thacker, perhaps influenced by the intellectual courage embedded within other subjects or if content is integrated of pain neuroscientist Patrick Wall, have encouraged across several subjects. Also, the variable length of physiotherapists to adopt a new paradigm for understanding undergraduate and graduate-entry physiotherapy programs pain. The tissue-injury model becomes redundant when impacts on interpretation of these data. Finally and perhaps we consider situations where pain is experienced in the most important, it is unknown whether greater quantity absence of tissue damage, or when an individual does not of education actually results in better understanding and perceive pain despite frank tissue damage. A paradigm that skills. There is a need for further international research into emphasises neural structure and function is overwhelmingly physiotherapy pain education, including accurate estimates supported by 21st century pain neuroscience and the myriad not only of quantity but also effectiveness of education. of clinical presentations of patients suffering pain. This model does not ignore tissue-based pathology but accepts Perhaps we can be guided by the bigger picture. In 2010, that nociception associated with tissue damage is modifiable the International Pain Summit in Montreal and Australia’s at the periphery, at the spinal cord and in the brain. National Pain Summit were held to identify how to improve quality of life for people with pain. One of the Major advances have been made in our understanding of central messages was that there are major deficits in the pain in the past 40 years. The historic gate control theory knowledge of all health care professionals regarding the was a key development in the understanding of pain as a mechanisms and management of pain. Consequently, one multidimensional experience. It revealed that not only are recommendation was that Comprehensive education and afferent nerve impulses modulated in the spinal cord, but training in pain management will give medical, nursing also that it is possible for regions of the brain that regulate and allied health professionals in the public and private attention, emotion, and memory to exert control over sectors the knowledge and resources to deliver best-practice sensory input (Melzack and Wall 1965). Transcutaneous evidence-based care (National Pain Strategy 2010, p. 5). electrical nerve stimulation (TENS) has subsequently been used by physiotherapists to modify the pain experience. Reforming pain education Physiotherapists may give a variety of responses if asked how TENS modifies the pain experience. A common Useful resources have been available to physiotherapy response might be that by stimulating the large A-beta educators seeking to develop curricula for some time. mechanosensory fibres, nociceptor transmission is inhibited The International Association for the Study of Pain at the dorsal horn of the spinal cord. A more thorough (IASP) developed pain education curricula to support explanation might include that the prolonged stimulation pre-registration training and professional development for by TENS causes the release of endorphins, resulting in a health professionals. These are updated regularly and new systemic analgesic effect (Watson 2008). An additional on-line resources are currently in development. This would explanation is that if the person is given control of the TENS be a fundamental resource for physiotherapy educators unit, this will increase their perceived control of their pain, when designing curricula to ensure core competencies for reduce the threat value of pain, and modulate their pain the assessment and management of pain. For example, the experience. Indeed, from our current understanding of pain educators could map where elements of the curricula can be neuroscience, this may be the most important mechanism of integrated with existing content (Jones 2009). Interestingly, pain modification that TENS offers. Although we hope all of the nine physiotherapy programs investigated in the UK, physiotherapists would respond with all this information, the IASP pain curricula had been fully implemented in only we recognise that this may not be the case. one course (Briggs et al 2011). Two examples of well described published pain curricula Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 207
Editorial 1 may provide useful models. The first is a Canadian process for pain education may improve the effectiveness of interfaculty pain curriculum that has shown good outcomes understanding pain concepts. (Hunter et al 2008). The interdisciplinary program is mandatory and informed by the IASP core and discipline- An important issue to consider is that conflicting views specific curricula. It consists of a 20-hour package that about pain across the students’ learning experience can includes epidemiology, discipline-specific topics, and case- impact adversely on effective pain education (Foster and based sessions on acute and persistent pain, interprofessional Delitto 2011). For example, an influential clinical educator pain management planning, and a choice of electives in may have a view of pain that is quite different to that taught subjects such as lifespan issues, genetics, gender, and cancer in the classroom (Jones 2009, Foster and Delitto 2011). This pain. Importantly, this interprofessional learning reflects emphasises the point that the starting paradigm for students the real world where health professionals work together to needs to be robust so that they can counteract challenges manage patients suffering from chronic diseases, including – no matter how persuasive the challenges and challengers persistent pain (Hunter et al 2008, Foster and Delitto 2011). are! However, implementation of such a curriculum requires co- operation from all disciplines to overcome practical barriers Finally, an increasing number of online resources can such as aligning timetables and other teaching resources. facilitate learning about pain. As part of Australia’s National Pain Strategy, a multiprofessional group is The second example is a US medical program that addresses currently involved in preparing a register of such resources, affective and cognitive dimensions of pain (Murinson et al both for health professionals and consumers. These will be 2011). This novel curriculum incorporates different learning complemented by the new IASP pain curriculum resources. and teaching strategies, including workshops and role- play activities, and aligns with assessment tasks including Conclusion development of a portfolio. The portfolio is a unique approach, requiring students to document their affective and Pain is a common human experience and one that cognitive associations with, and responses to, pain and pain- frequently requires physiotherapy intervention. Therefore, related experiences. This includes students undertaking physiotherapists need to develop a comprehensive a cold pressor test, providing a personal narrative of pain understanding of the factors that influence pain and be experiences, and responding to representations of pain in able to apply or prescribe appropriate treatment. Ideally literature and fine art. The reflective and experiential nature this includes adopting a person-centred approach to care, of these tasks provides a strong message to students about and recognising that pain is influenced by life experiences, the importance of the personal and emotional context of is contextual and associated with threat to tissues and pain. perceived vulnerability. The amount of time currently spent on pain education appears to differ widely from A further consideration for curriculum review or design course to course but, on average, physiotherapy appears is appropriate emphasis on interpersonal communication, to provide more hours of pain education than other human behaviour change, and problem-solving skills (Foster and health disciplines in Canada and the UK. Data from other Delitto 2011). These skills align with person-centred care countries are lacking. There is a need for comprehensive and and the guidelines for chronic disease management. The up-to-date pain education in pre-registration physiotherapy adoption of person-centred models of care is particularly programs. Physiotherapy curricula need to be designed to helpful as it encourages the consideration of the person’s support students to develop clinical competencies based on individual life experiences and social context and how current pain neuroscience. these can impact on neurophysiological function (Hunter and Simmonds 2010). Butler and Moseley’s (2003) ‘brain as References an orchestra’ metaphor provides an accessible introduction to this concept, as does work by Norman Doidge (2007). Briggs EV et al (2011) Eur J Pain 15: 789. Another helpful recommendation is to integrate the contributors to the human pain experience into existing Butler D, Moseley GL (2003) Explain Pain. Adelaide: Noigroup curriculum content on the International Classification of Publications. Functioning Disability and Health (WHO ICF) framework for the biopsychosocial approach to pain (Foster and Delitto Cousin G (2006) Planet 17: 4. 2011). Doidge N (2007) The Brain That Changes Itself. Melbourne: Physiotherapy education frequently promotes learning of Scribe Publications. concepts and principles, which in turn can be applied to new and unfamiliar situations. This would seem a particularly Foster NE, Delitto A (2011) Phys Ther 91: 790. important consideration in pain education where some concepts, like pain is of the brain and not of the tissues, Hunter J et al (2008) Pain 140: 74. can prove troublesome. Once the concept that pain is of the brain is held, it is hard to return to the original thinking Hunter JP, Simmonds MJ (2010) Physiother Can 62: 1. that pain is produced in the tissues. Such a concept could be considered a threshold concept (Cousin 2006). There are Jones L (2009) Rev Pain 3: 11. recommended processes for identifying threshold concepts in discipline areas (Cousin 2006) and undertaking such a Melzack R, Wall PD (1965) Science 150: 971. Murinson BB et al (2011) Pain Med 12: 186. DWj_edWbFW_dIjhWj[]o (&'& ^jjf0%%mmm$fW_dWkijhWb_W$eh]$Wk% [Retrieved 03 October 2011]. Watson T (2008) Electrotherapy. In, Porter S (ed) Tidy’s Physiotherapy. London: Churchill Livingstone. Watt-Watson J et al (2009) Pain Res Manage 14: 439. 208 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Prosser et al: Diagnostic accuracy of provocative wrist tests Provocative wrist tests and MRI are of limited diagnostic value for suspected wrist ligament injuries: a cross-sectional study Rosemary Prosser1, Lisa Harvey2, Paul LaStayo3, Ian Hargreaves4, Peter Scougall4 and Robert D Herbert5 1Sydney Hand Therapy and Rehabilitation Centre, Australia, 2Rehabilitation Studies Unit, The University of Sydney, Australia, 3Department of Physical Therapy, University of Utah, USA, 4St Luke’s Hospital Hand Unit, Potts Point, Australia, 5The George Institute for Global Health, Sydney, Australia Question: What is the diagnostic value of provocative wrist tests and magnetic resonance imaging (MRI) for suspected wrist ligament injuries? Design: Cross-sectional study. Participants: 105 people presenting to hand clinics with wrist pain and suspected wrist ligament injuries were evaluated prospectively. Outcome measures: The integrity of wrist ligaments was tested with seven provocative tests. The results were compared to the reference standard of arthroscopy. In a subgroup of 55 participants, MRI findings were also compared to arthroscopy. The provocative tests were the scaphoid shift test (SS test), lunotriquetral test (LT test), midcarpal test (MC test), distal radioulnar joint test (DRUJ test), triangular fibrocartilage complex (TFCC) stress test (TFCC test), TFCC stress test with compression (TFCC comp test), and the gripping rotatory impaction test (GRIT). Results: Most provocative tests and MRI findings were of little or no value for diagnosing wrist ligament injuries. Exceptions were the SS test (+ve LR 2.88 and –ve LR 0.28), MC test (+ve LR 2.67) and DRUJ test (–ve LR 0.30), all of which were of mild diagnostic usefulness. MRI was moderately useful for diagnosing TFCC injuries (+ve LR 5.56, –ve LR 0.15), and was mildly useful for diagnosing scapholunate (SL) ligament injuries (+ve LR 4.17, –ve LR 0.32) and lunate cartilage damage (+ve LR 3.67, –ve LR 0.33). Adding MRI to provocative tests improved the accuracy of diagnosis of TFCC injuries slightly (by 13%) and lunate cartilage damage (by 8%). Conclusion: Provocative wrist tests of SL ligament injuries and midcarpal ligament injuries are mildly useful for diagnosing wrist injuries. MRI diagnostic findings of SL ligament injuries, lunate cartilage damage, and TFCC are mildly to moderately useful. MRI slightly improves the diagnosis of TFCC injury and lunate cartilage damage compared to provocative tests alone. <1SPTTFS3 )BSWFZ- -B4UBZP1 )BSHSFBWFT* 4DPVHBMM1 )FSCFSU3% 1SPWPDBUJWFXSJTUUFTUTBOE.3*BSFPGMJNJUFEEJBHOPTUJDWBMVFGPSTVTQFDUFEXSJTUMJHBNFOUJOKVSJFTBDSPTT TFDUJPOBMTUVEZJournal of Physiotherapyo> Keywords: Wrist, Diagnosis, Ligaments Introduction TFCC) test with arthroscopic results in 50 painful wrists. The sensitivity and specificity data enabled calculation of Wrist sprains are common. They are typically due to positive and negative likelihood ratios (LRs), which in turn trauma resulting in tears or ruptures of one or more of the can be used to estimate the probability of a diagnosis of carpal ligaments (Alexander and Lichtman 1988, Bishop ligament injury (Fischer et al 2003, Portney and Watkins and Reagan 1998, Blatt 1998, Bowers 1991, Cooney 1998, 2009, Schmitz et al 2000). The positive LRs for the SS test, Mayfield 1988, Taleisnik 1985, Taleisnik and Linscheid the LT test and the TFCC test were 2.0, 1.2, and 1.8, and the 1998). It is important that clinicians identify correctly negative LRs were 0.47, 0.80, and 0.53, respectively. These which ligaments are injured as this directs appropriate results suggest that the three provocative tests are of limited treatment (Anderson 2010, Garcia-Elias 2010, LaStayo use for diagnosing wrist ligament injuries. To our knowledge 2002, Prosser 1995, Prosser 2003, Skirven 2010, Wright no other study has examined the accuracy of these or other and Michlovitz 2002). The definitive diagnosis of wrist provocative tests of wrist ligament injuries. Therefore, the injuries is made with arthroscopy – the reference standard. first aim of this study was to determine the accuracy of Evaluation procedures that typically precede arthroscopy seven provocative tests commonly used to diagnose wrist include radiography and a clinical examination. Clinical ligament injuries. The seven tests were the SS test for the examination includes specific tests that are designed to help scapholunate (SL) ligament, the LT test for the lunotriquetral identify which wrist ligaments might be injured (Alexander (LT) ligament, the midcarpal test (MC test) for the arcuate and Lichtman 1988, Bishop and Reagan 1998, Cooney ligament, the distal radioulnar joint test (DRUJ test) for the 1998, Gaenslen and Lichtman 1996, LaStayo 2002, Prosser et al 2007, Taleisnik 1985, Taleisnik and Linscheid 1998, What is already known on this topic: Provocative Watson et al 1988, Wright and Michlovitz 2002) (see Box wrist tests and magnetic resonance imaging are used 1 for abbreviations of tests and ligaments). These tests are to diagnose wrist ligament injuries, but there is little collectively termed ‘provocative tests’ because they provoke evidence of their diagnostic accuracy. or reproduce an individual’s pain by stressing the ligaments. What this study adds: Provocative wrist tests are While provocative wrist tests are routinely used by clinicians generally of limited value for diagnosing wrist ligament to diagnose wrist ligament injuries, there is little evidence injuries, although they are mildly useful in the diagnosis of their accuracy. LaStayo and Howell (1995) compared the of scapholunate and arcuate ligament injuries. If findings of the scaphoid shift (SS) test, the lunotriquetral combined with provocative tests, MRI slightly improves ballottement (LT) test and the ulnomeniscotriquetral the diagnosis of triangular fibrocartilage complex injury (also known as the Triangular Fibrocartilage Complex, and lunate cartilage damage. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 247
Research #PY Summary of abbreviations for wrist structures and associated tests Wrist structure Abbreviation Test Abbreviation Scapholunate SL ligament scaphoid shift test SS test ligament Lunotriquetral LT ligament lunotriquetral LT test ligament ballottement test Arcuate ligament Arcuate ligament midcarpal test MC test (also known as the deltoid or v ligament) Distal radioulnar joint DRUJ ligaments distal radioulnar joint DRUJ test ligaments test Triangular TFCC 1. TFCC stress test 1. TFCC test 2. TFCC stress test 2. TFCC comp test fibrocartilage complex with compression Lunate cartilage Lunate cartilage gripping rotary GRIT damage damage impaction test distal radioulnar joint (DRUJ) ligaments, and the gripping Participants rotary impaction test (GRIT) for lunate cartilage damage (also known as Ulnar Impaction Syndrome). Two TFCC From April 2005 to May 2009, consecutive patients with tests were also investigated for the triangular fibrocartilage undiagnosed wrist pain of at least four weeks duration complex (TFCC), namely the TFCC stress test (TFCC test) who presented to any of three private hand clinics were and the TFCC stress test with compression (TFCC comp screened for inclusion in the study. Patients were from a test). Box 1 presents a summary of the abbreviations. The broad geographical catchment area including surrounding results of all provocative tests were compared to the results metropolitan and rural areas. Potential participants of arthroscopy, which is the reference standard. were excluded if they had wrist fractures (confirmed radiologically), previous carpal surgery, rheumatoid While arthroscopy is the reference standard for the diagnosis arthritis, or complex regional pain syndrome. Complex of wrist ligament injuries, it is an invasive and expensive regional pain syndrome was diagnosed according to the test. Partly for these reasons, clinicians have increasingly 2005 definition of the International Association of the used magnetic resonance imaging (MRI) rather than Study of Pain on the basis of pain, oedema, joint stiffness, arthroscopy for establishing definitive diagnoses. However, muscle tightness, reduced motion, changes in hair and nail it is not clear whether MRI is as accurate as arthroscopy. A growth, and vasospasm causing colour and temperature comprehensive review by Faber and colleagues (2010) found changes (Charlton 2005). that studies looking at the accuracy of MRI were difficult to interpret because of small sample sizes, failure to provide Outcome measures clear definitions of diagnoses, lack of blinding, and lack of consideration of underlying prevalence. In addition, no All participants underwent clinical examination prior to studies of the accuracy of MRI have reported LRs (Faber et arthroscopy. A subgroup of participants also underwent al 2010). Faber and colleagues concluded that the accuracy MRI investigation prior to arthroscopy. The decision to of MRI for diagnosing wrist ligament injuries was unclear. undertake an MRI investigation was made at the surgeons’ Accordingly, the second aim of this study was to determine discretion. The order of the provocative tests and MRI the accuracy of MRI for diagnosing wrist ligament injuries. was dictated by convenience, but both the provocative For this purpose findings from MRI were compared to tests and MRI were completed before the arthroscopy. All arthroscopy. provocative tests were performed as close as possible to arthroscopy. The longest delay was 21 days. Provocative The two research questions therefore were: tests were conducted blind to the results of MRI, and MRIs 1. How accurate are seven provocative tests commonly were interpreted blind to the results of the provocative tests. used to diagnose wrist ligament injuries? The surgeons performing the arthroscopies were blinded to 2. How accurate is MRI for diagnosing wrist ligament the results of the provocative tests but not to the results of injuries? the MRIs. Method Clinical examination Design Clinical examinations were performed primarily (87%) by one hand therapist (RP) with 27 years of experience. This was a cross-sectional study in which the diagnostic The other clinical examinations were performed by two accuracy of seven ligament tests was evaluated prospectively therapists with 20 and 10 years of experience. Initially, among people with wrist pain. The diagnostic accuracy of a subjective assessment was undertaken and included MRI was also assessed in a subgroup of participants. Wrist questions to determine the time of injury, location of pain, arthroscopy was used as the reference standard. and the functional demand on the wrist. The functional demand placed on the wrist by work and activities of 248 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Prosser et al: Diagnostic accuracy of provocative wrist tests 5BCMF Cross-tabulation of provocative tests and arthroscopy findings (n = 105). Arthroscopy Arthroscopy Likelihood ratio positive negative SS test for SL ligament 27 (26%) 13 (12%) 2.88 (1.68 to 4.92) Positive 9 (9%) 9 (9%) 1.39 (0.60 to 3.21) Uncertain 8 (8%) 39 (37%) 0.28 (0.15 to 0.55) Negative 1 (1%) 16 (15%) 1.03 (0.16 to 6.52) LT test for LT ligament 2 (2%) 21 (20%) 1.57 (0.48 to 5.18) Positive 3 (3%) 62 (59%) 0.80 (0.35 to 1.80) Uncertain Negative 35 (33%) 14 (13%) 1.88 (1.15 to 3.04) 8 (8%) 7 (7%) 0.86 (0.34 to 2.19) TFCC test (combined TFCC test 17 (16%) 24 (23%) 0.53 (0.33 to 0.86) and TFCC comp test) for TFCC 2 (2%) 15 (14%) 2.67 (0.83 to 8.60) Positive 3 (3%) 26 (25%) 2.31 (1.05 to 5.08) Uncertain 0 (0%) 59 (56%) Negative * MC test for arcuate ligament 9 (9%) 26 (25%) Positive 5 (5%) 11 (10%) 1.79 (1.03 to 3.11) Uncertain 3 (3%) 51 (49%) 2.35 (0.94 to 5.91) Negative 0.30 (0.11 to 0.86) DRUJ test for DRUJ 17 (17%) 45 (44%) Positive 9 (9%) 32 (31%) 1.12 (0.80 to 1.57) Uncertain 0.83 (0.46 to 1.50) Negative GRIT for lunate cartilage damagea Positive Negative *Not able to be calculated due to low prevalence, aGRIT data were missing on 2 participants daily living was classified by participants on a 3-point the location of pain, with the most painful area examined scale designed for this study. On this scale ‘light’ reflected last. sedentary or office work, ‘moderate’ reflected intermittent use with heavier activities such as gardening, and ‘heavy’ The SS test as described by Watson and colleagues reflected manual work or participation in manual sports (1988) and the LT test as described by Reagan and others such as martial arts and racquet sports on a regular basis. (Bishop and Reagan 1998, Garcia-Elias 2010, Reagan et al Participants were also asked to self-rate perceived wrist 1984) were used to assess the integrity of the SL and LT stability on a 4-point scale designed for this study. The levels ligaments, respectively. The SS test requires pressure to of the scale were ‘does not give way’, ‘gives way with heavy be applied through the examiner’s thumb to the scaphoid activity’, ‘gives way with moderate activity’, and ‘gives way tubercle. This produces a dorsally directed subluxation with light activity’. Pain and function were assessed with pressure that stresses the SL ligament and opposes the the Patient-Rated Wrist and Hand Evaluation questionnaire normal rotation of the scaphoid as it moves from ulnar to (MacDermid and Tottenham 2004). radial deviation. The LT test is a simple dorsal volar glide shear test of the triquetrum on the lunate. The MC test The physical examination consisted of an assessment of was used to evaluate the integrity of the arcuate ligament the integrity of various wrist ligaments, the TFCC, and (also known as the deltoid or v ligament) (Alexander and the lunate cartilage. The tests used were the SS test, LT Lichtman 1988, Gaenslen and Lichtman 1996). The MC test test, MC test, TFCC test, TFCC comp test, DRUJ test, and was only considered positive if there was a ‘catch-up clunk’ the GRIT (LaStayo and Weiss 2001). Both asymptomatic in the midcarpal joint in addition to the participant’s pain. and symptomatic wrists were tested to establish if there was hypermobility in the symptomatic wrist with respect The TFCC test was used to test the integrity of the TFCC. to the asymptomatic wrist and to determine if there was The test was performed as described by Hertling and pain. The outcomes of tests were reported as positive, Kessler (1990) with the wrist in ulnar deviation while negative or uncertain except for the GRIT which was only applying a shear force across the ulnar complex of the wrist. reported as positive or negative. A test was only reported The TFCC comp test was performed in the same position as as positive if it reproduced the participant’s pain (with or the TFCC test but with axial compression. A positive result without hypermobility compared to the contralateral side). on either of the two TFCC tests was considered positive for A test was reported as uncertain if there was hypermobility the TFCC. The DRUJ test was used to assess the dorsal and (compared to the contralateral side) or if the pain produced volar DRUJ ligaments. It involved gliding the ulna to its was not the primary pain that the participant presented maximum dorsal and volar positions in neutral, supination, with. The order of the wrist tests was varied depending on and pronation. The GRIT was used to assess lunate cartilage Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 249
Research 5BCMF Cross-tabulation of MRI and arthroscopy findings (n = 55). Arthroscopy Arthroscopy Likelihood ratio positive negative SL ligament 12 (22%) 4 (7%) 4.17 (1.54 to 11.30) Positive 5 (9%) 2 (4%) 3.48 (0.74 to 16.40) Uncertain 6 (11%) 26 (47%) 0.32 (0.16 to 0.65) Negative 0 (0%) 2 (4%) * LT ligament 0 (0%) 1 (2%) * Positive 3 (5%) 49 (89%) 1.06 (0.99 to 1.14) Uncertain Negative 27 (49%) 3 (5%) 5.56 (1.92 to 16.10) 3 (5%) 1 (2%) 1.85 (0.21 to 16.70) TFCC 4 (7%) 17 (31%) 0.15 (0.06 to 0.37) Positive Uncertain 0 (0%) 1 (2%) * Negative 0 (0%) 1 (2%) * 1 (2%) 52 (95%) 1.04 (0.99 to 1.09) Arcuate ligament Positive 1 (2%) 3 (5%) 0.89 (0.10 to 7.89) Uncertain 4 (7%) 6 (11%) 1.78 (0.59 to 5.43) Negative 10 (18%) 31 (56%) 0.86 (0.58 to 1.28) DRUJ 11 (20%) 8 (15%) 3.67 (1.84 to 7.32) Positive 4 (7%) 32 (58%) 0.33 (0.14 to 0.78) Uncertain Negative Lunate cartilage damage Positive Negative * Not able to be calculated due to low prevalence, DRUJ percentages do not add up to 100% because of rounding damage. Lunate cartilage damage (also known as ulnar was diagnosed by direct visualisation of the tear with or impaction syndrome) occurs when loss of axial stability of without 2 mm of shear or diastasis (Chow 2005, Geissler the DRUJ causes repeated impaction of the ulnar head on 2005). This may have included a within-substance tear. In the lunate. The GRIT consisted of three grip measurements addition, laxity was noted. The location of a TFCC tear was performed in neutral, supination, and pronation. A GRIT also recorded as either peripheral (indicative of a DRUJ value was calculated by dividing the supinated grip strength ligament injury) or central (indicative of an articular disc by the pronated grip strength. A GRIT of greater than 1.0 injury). Associated intra-articular pathologies, including was considered positive and indicative of lunate cartilage synovitis, chondromalacia, and ganglia were documented. damage provided it was accompanied by pain (LaStayo and Weiss 2001). The neutral grip strength was not used in any Data analysis of the analyses. Likelihood ratios were calculated for diagnostic prediction Magnetic resonance imaging: MRI of the wrist was of provocative tests and MRI, using arthroscopy as the performed with the following sequences: coronal T1, PD reference standard for both. Logistic regression was used with fat saturation, gradient echo T2, sagittal T1, axial PD to evaluate if MRI improved diagnostic accuracy compared and PD with fat saturation. T1 is considered low resolution to the provocative tests alone. For MRI, the number needed MRI. The MRI sequences were interpreted by a registered to scan (NNS) in order to make one additional correct radiologist. All findings for ligament injuries were recorded diagnosis was also calculated. as either positive (full or partial thickness tear), negative (normal), or uncertain (no tear detected but abnormal Results ‘signal’). Flow of participants through the study Arthroscopy: Arthroscopic technique involved examination of the radiocarpal, midcarpal, and TFCC regions and Of 143 patients screened for inclusion in the study, 105 were was performed under general or regional anaesthesia by eligible to participate. Three declined and 35 did not have one of two wrist surgeons, each with more than 15 years an arthroscopy. These patients believed that arthroscopy of experience. Intra-articular structures, including the was not warranted because they were improving. The articular cartilage, SL ligament, LT ligament, TFCC, and remaining 105 patients all consented to participate and arcuate ligament were examined. Motion between carpal went on to have arthroscopy. All participants underwent bones (shear and diastasis) was noted and documented. clinical examination prior to arthroscopy. Fifty-five of The results for each ligament were recorded as negative the 105 participants also underwent MRI investigation (intact) or positive (not intact). A positive ligament injury prior to arthroscopy. GRIT measures were missing on two participants but the dataset was otherwise complete. 250 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Prosser et al: Diagnostic accuracy of provocative wrist tests 5BCMF A summary of the utility of positive and negative provocative test results and MRI findings for diagnosing wrist ligament injuries. The classifications of utility are based on the LR (see legend). This classification does not take into account the imprecision associated with the LR. Provocative test Provocative test MRI MRI positive negative positive negative SL ligament Mildly useful Mildly useful Mildly useful Mildly useful TFCC Not useful Not useful Moderately useful Moderately useful LT ligament Not useful Not useful Arcuate ligament Unclear Unclear Not useful DRUJ Mildly useful Unclear Not useful Lunate cartilage damage Not useful Mildly useful Not useful Not useful Not useful Not useful Mildly useful Mildly useful 1PTJUJWF-3SFTVMUT /FHBUJWF-3SFTVMUT Not useful: less than 2.00 Not useful: more than 0.50 Mildly useful: between 2050 and 5.00 Mildly useful: between 0.20 and 0.50 Moderately useful: between 5.00 and 10.00 Moderately useful: between 0.10 and 0.20 Very useful: greater than 10.00 Very useful: less than 0.10 5BCMF Number of participants (percentage) correctly diagnosed with or without wrist ligament injuries using provocative tests only, and using provocative tests and MRI. The correct diagnosis was confirmed by arthroscopy. Ligament Correctly classified Correctly classified Difference Number using provocative using provocative (p value) needed to scan tests only tests and MRI SL ligament (n = 55) 43 (78%) 44 (80%) 2% (0.002) 55 LT ligament (n = 55) 52 (95%) 49 (94%) –0.3% * o TFCC (n = 55) 40 (73%) 47 (86%) 12.7% (< 0.001) 8 DRUJ (n = 55) 40 (73%) 39 (71%) –1.8% (0.60) o Arcuate ligament * * ** Lunate cartilage damage (n = 53) 38 (72%) 42 (79%) 7.5% (< 0.001) 13 * Not able to be to calculated Ninety-two (87%) of the 105 participants were right-handed, provocative tests and arthroscopies for TFCC injuries, 17 seven were left-handed, and five were ambidextrous. The (17%) had positive provocative tests and arthroscopies for mean age of participants was 37 years (SD 12). The median lunate cartilage damage, 9 (9%) had positive provocative (IQR) time from injury to assessment was 9.6 months (3.9 tests and arthroscopies for DRUJ injuries, 1 (1%) had to 14.8). Sixty-two (59%) of the participants’ work and positive provocative tests and arthroscopies for LT ligament activities of daily living necessitated a ‘heavy’ demand on injuries, and 2 (2%) had positive provocative tests and the wrist, 39 (37%) a ‘moderate’ demand, and four (4%) a arthroscopies for arcuate injuries. Most tests appeared to ‘light’ demand (as defined by the 3-point scale of functional have little or no diagnostic value. Possible exceptions were demand on the wrist). positive findings from the SS test (+ve LR 2.88, 95% CI 1.68 to 4.92) and the MC test (+ve LR 2.67, 95% CI 0.83 Fifty-eight participants (55%) reported symptoms in the to 8.60) and negative findings from the SS test (–ve LR right wrist. Wrist pain was located in the radial region in 15 0.28, CI 0.15 to 0.55) and the DRUJ test (–ve LR 0.3, CI (14%), in the ulnar region in 56 (53%), in the central region 0.11 to 0.86), all of which were mildly useful. There were in 30 (29%), and in all regions in four (4%). Forty-seven a number of incidental arthroscopic findings. Arthroscopic participants (44%) reported a sensation of giving way in the findings in addition to ligament injuries and lunate cartilage wrist on the 4-point participant-perceived stability scale. The damage included synovitis (66, 63%), ganglions (17, 16%), giving way was reported in approximately equal proportions and cartilage damage excluding the lunate (24, 23%). across heavy, moderate, and light activity. On the Patient- Rated Wrist and Hand Evaluation questionnaire, the mean Table 2 cross-tabulates findings of MRI and arthroscopy. pain score was 28 out of 50 (SD 10), the mean function score Positive MRI findings for SL ligament injuries (LR 4.17, was 21 out of 50 (SD 10), and the mean total score of pain and 95% CI 1.54 to 11.30), TFCC injuries (LR 5.56, 95% CI function combined was 49 out of 100 (SD 19). 1.92 to 16.10), and lunate cartilage damage (LR 3.67, 95% CI 1.84 to 7.32) were of mild to moderate diagnostic Table 1 cross-tabulates the provocative test and arthroscopic usefulness. Negative MRI findings for SL ligament injuries findings. Few participants had positive results for both the (0.32, 95% CI 0.16 to 0.65), TFCC injuries (0.15, 95% CI provocative tests and arthroscopies. For example, of the 105 0.06 to 0.37), and lunate cartilage damage (0.33, 95% CI participants, only 27 (26%) had positive provocative tests and 0.14 to 0.78) were likewise of mild to moderate diagnostic arthroscopies for SL ligament injuries, 35 (33%) had positive Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 251
Research usefulness. The usefulness of both provocative tests and and Howell (1995) who also reported similar poor positive MRI for diagnosing ligament injuries is summarised in LRs for the LT and TFCC tests (1.2 and 1.8 respectively, Table 3 according to a recommended interpretation of calculated from data provided in the paper). positive and negative LRs (Portney and Watkins 2009). The second question addressed in this study was the The incremental diagnostic value of adding MRI to usefulness of MRI for diagnosing wrist ligament injuries provocative tests was statistically significant for TFCC (Table 2). The data show that positive and negative MRI injuries and lunate cartilage damage, as shown in Table 4 (p findings of TFCC injuries are moderately useful for ruling < 0.001). An additional 13% of participants were correctly in (+ve LR 5.56, 95% CI 1.92 to 16.10) and ruling out (–ve diagnosed as having or not having TFCC injuries with MRI LR 0.15, 95% CI 0.06 to 0.37) these injuries. MRI was also over and above those correctly diagnosed with provocative mildly useful for ruling in and out SL ligament injuries (+ve tests alone. That is, for every eight scans there was one LR 4.17, 95% CI 1.54 to 11.30; –ve LR 0.32, 95% CI 0.16 more correct diagnosis of the presence or absence of TFCC to 0.65), and lunate cartilage damage (+ve LR 3.67, 95% injury (ie, the NNS was eight). The NNS for lunate cartilage CI 1.84 to 7.32; –ve LR 0.33, 95% CI 0.14 to 0.78). MRI lesions was 13. MRI did not significantly improve diagnostic findings for SL ligament injuries classified as ‘uncertain’ accuracy of any other ligament injury. MRI provided little on the provocative tests (indicated by hypermobility or pain incremental diagnostic accuracy because 72% to 95% of that was not the pain the participant presented with) were participants were diagnosed correctly by the provocative mildly useful for ruling in SL ligament injuries (positive tests alone. This was partly because a large proportion of LR 3.48, 95% CI 0.74 to 16.40). MRI was not useful in participants who went on to MRI did not have ligament diagnosing other wrist ligament injuries. The MRI findings injuries (Table 2). need to be interpreted with caution because surgeons who performed the arthroscopies were not blinded to the MRI Discussion results. Information about the accuracy of provocative tests While it is possible that our MRI results may have been better for diagnosing wrist ligament injuries is important for if we had used high resolution rather than low resolution clinicians. This study shows that provocative wrist tests are MRI, this would seem unlikely. Faber and colleagues (2010) not useful for diagnosing injuries to the TFCC, LT ligament, reported no difference in the positive predictive values of DRUJ, or lunate cartilage. Positive SS and MC tests, and high and low resolution MRI for diagnosing TFCC injuries, negative SS tests, are mildly useful for diagnosing SL and although higher resolution MRI was slightly better for arcuate ligament injuries. ruling out TFCC injuries. Anderson and colleagues (2008) argued that high resolution MRI was more useful than The conclusions of this study are dependent on the low resolution MRI for diagnosing wrist ligament injuries, interpretation of positive and negative LR. A positive LR however when we used the authors’ data to derive LRs we indicates how well a positive test finding ‘rules in’ a ligament found that their results were very similar to our own. injury and a negative LR indicates how well a negative test finding ‘rules out’ a ligament injury. A positive LR greater MRI combined with provocative tests improved the than ~2 or a negative LR less than ~0.5 may be indicative proportion of correct diagnoses of TFCC injuries by 13% of a useful test (Guyatt et al 2008, Portney and Watkins and lunate cartilage damage by 8%. That is, eight additional 2009). However, the implications of diagnostic accuracy scans would need to be performed to make one more can only be interpreted after taking into account the pre-test correct diagnosis of the presence or absence of TFCC injury probability of a ligament injury. For example, if the clinical compared to diagnosis by provocative tests alone, and 13 history of a participant suggests a pre-test probability of additional scans would need to be performed to make one SL ligament injury of 50% and the provocative test has a more correct diagnosis of the presence or absence of lunate positive LR of 2.88, these findings together indicate a 73% cartilage damage. There was no benefit in performing MRI probability that the participant has a SL ligament injury. in addition to provocative wrist tests for diagnosis of SL, LT, arcuate ligament, and DRUJ injuries. The additional The first question of this study concerned the usefulness diagnostic benefit of MRI scans needs to be weighed against of the seven provocative tests commonly used to diagnose the cost of 8–13 scans for one more correct diagnosis. wrist ligament injuries. The two most promising provocative tests were the SS test and MC test although neither is very The results of the arthroscopies indicated that 63% of wrists informative (Table 1). The SS test positive LR was 2.88 and had synovitis. Synovitis is often due to an inflammatory its negative LR was 0.28; both were estimated with moderate reaction following trauma in the absence of arthritis. precision as reflected by the narrow 95% CI. The MC test Perhaps those who had synovitis had an injury to the joint performed had a positive LR of 2.67, and the LR associated capsule. This might partly explain the limited value of the with an uncertain test result was 2.31. These estimates provocative tests for diagnosing wrist ligament injuries. were very imprecise (95% CI 0.83 to 8.60 and 1.05 to 5.08 This possibility was explored with post hoc exploratory respectively). While the negative LR for the DRUJ test analyses in which any finding of wrist synovitis was cross showed some promise (0.30), this was again associated with tabulated with the SS test and then with the TFCC test. considerable imprecision (95% CI 0.11 to 0.86). Imprecision The TFCC test did not perform any better. The positive LR of estimates was also a problem for the LT, DRUJ, and MC associated with an ‘uncertain’ test result (ie, hypermobile or tests. This may have been partly due to the low proportion pain different to the primary pain the participant presented of participants with LT, DRUJ, and arcuate ligament with) for the SS test appeared to be moderately useful, but injuries confirmed by arthroscopy. Only 6% of participants the estimate of diagnostic utility was very imprecise (LR had a confirmed LT ligament injury (Table 1). None of the 4.77, 95% CI 0.67 to 34). Further studies could explore the other provocative tests clearly demonstrated diagnostic value of provocative tests for diagnosing wrist synovitis or value. These findings are consistent with those of La Stayo other conditions. 252 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Prosser et al: Diagnostic accuracy of provocative wrist tests Strengths of this study include the recruitment of a its relationship with the evolution of treatments used for consecutive sample of participants suspected of wrist wrist instability. A historical approach. The International ligament injuries, and that all participants were tested Federation of Societies for Hand Therapists 8th Triannual with the reference standard. A limitation of this study was Congress. Orlando. that MRI was conducted at the surgeon’s discretion and performed on only a subgroup of participants. Arthroscopies Geissler W (2005) Management of scapholunate instability. In were not conducted blinded to the results of the MRIs but Geissler W (Ed) Wrist Arthroscopy. New York: Springer, pp. were performed blinded to the results of the provocative 86–93. tests. These limitations would tend to inflate estimates of the accuracy of MRI. Guyatt G, Rennie D, Meade M, Cook D (2008) User’s guides to the medical literature: essentials of evidence-based clinical In summary, the results of this study indicate that practice. New York: McGraw-Hill Professional. provocative wrist tests are of limited value for diagnosing wrist ligament injuries. The SS test and MC test are mildly Hertling D, Kessler R (1990) Management of common useful in the diagnosis of SL and arcuate ligament injuries. musculoskeletal disorders: physical therapy principles and MRI slightly improves the diagnosis of TFCC injury and methods. Philadelphia: Lippincott. lunate cartilage damage compared to provocative tests alone. Q LaStayo P (2002) Ulnar wrist pain and impairment: Therapist’s alogorithmic approach to the triangular fibrocartilage Ethics: The University of Sydney Ethics Committee complex. In Mackin E, Callahan A, Skirven T, Schneider approved this study. All participants gave written informed L, Osterman A (Eds) Rehabilitation of the hand and upper consent before data collection began. extremity. St Louis: Mosby, pp. 1156–1170. Correspondence: Ms Rosemary Prosser, Sydney Hand LaStayo P, Howell J (1995) Clinical provocative tests used in Therapy and Rehabilitation Centre, Australia. Email: evaluating wrist pain: a descriptive study. Journal of Hand [email protected] Therapy 8: 10–17. References LaStayo P, Weiss S (2001) The GRIT: a quantative measure of ulnar impaction syndrome. Journal of Hand Therapy 14: Alexander C, Lichtman D (1988) Triquetrolunate and midcarpal 173–179. instability. In Lichtman D (Ed) The wrist and its disorders. Philadelphia: Saunders, pp. 274–285. MacDermid JC, Tottenham V (2004) Responsiveness of the Disability of the Arm, Shoulder, and Hand (DASH) and Anderson H (2010) Rehabilitation of SL injuries – training and FWj_[dj#HWj[ZMh_ij%>WdZ;lWbkWj_ed FHM>; _d[lWbkWj_d] splinting in practice. The International Federation of Societies change after hand therapy. Journal of Hand Therapy 17: for Hand Therapists 8th Triannual Congress. Orlando. 18–23. Anderson ML, Skinner JA, Felmlee JP, Berger RA, Amrami Mayfield J (1988) Pathogensis of wrist ligament instability. In KK (2008) Diagnostic comparison of 1.5 Tesla and 3.0 Tesla Lichtman D (Ed) The wrist and its disorders. Philadelphia: preoperative MRI of the wrist in patients with ulnar-sided Saunders, pp. 53–73. wrist pain. Journal of Hand Surgery 33: 1153–1159. Portney L, Watkins M (2009) Foundations of critical research– Bishop A, Reagan D (1998) Lunotriquetral sprains. In Cooney applications to practice. (3rd ed.) New Jersey: Pearson W, Linscheid R, Dobyns J (Eds) The wrist: diagnosis and Education. operative treatment. St Louis: Mosby, pp. 527–549. Prosser R (1995) Conservative management of ulnar carpal Blatt G (1998) Scapholunate instability. In Lichtman D (Ed) The instability. Australian Journal of Physiotherapy 41: 41–46. wrist and its disorders. Philadelphia: Saunders, pp. 251–273. Prosser R (2003) Management of carpal instabilities. In Prosser Bowers W (1991) Instability of the distal radioulnar articulation. R, Conolly W (Eds) Rehabilitation of the hand and upper Hand Clinics 7: 311–327. limb. Edinburgh: Butterworth Heinemann, pp. 148–159. Charlton JE (Ed) (2005) Core curriculum for professional Prosser R, Herbert R, LaStayo PC (2007) Current practice education in pain. Seattle: The International Association for in the diagnosis and treatment of carpal instability–results the Study of Pain. of a survey of Australian hand therapists. Journal of Hand Therapy 20: 239–332. Chow J (2005) Repair and treatment of TFCC injury. In Geissler W (Ed) Wrist Arthroscopy. New York: Springer, pp. 36–41. Reagan DS, Linscheid RL, Dobyns JH (1984) Lunotriquetral sprains. Journal of Hand Surgery 9: 502–514. Cooney W (1998) Tears of the triangular fibrocartilage of the wrist. In Cooney W, Linscheid R, Dobyns J (Eds) The wrist: Schmitz N, Kruse J, Tress W (2000) Application of stratum- diagnosis and operative treatment. St Louis: Mosby, pp. specific likelihood ratios in mental health screening. Social 710–742. Psychiatry and Psychiatric Epidemiology 35: 375–379. Faber KJ, Iordache S, Grewal R (2010) Magnetic resonance Skirven T (2010) Strategies in the conservative management imaging for ulnar wrist pain. Journal of Hand Surgery 35: of midcarpal instabilities. The International Federation of 303–307. Societies for Hand Therapists 8th Triannual Congress. Orlando. Fischer JE, Bachmann LM, Jaeschke R (2003) A readers’ guide to the interpretation of diagnostic test properties: Clinical Taleisnik J (1985) Scapholunate dissociation: medial carpal example of sepsis. Intensive Care Medicine 29: 1043–1051. instability. In Taleisnik J (Ed) The wrist. New York: Churchill Livingstone, pp. 239–305. Gaenslen E, Lichtman D (1996) Midcarpal instability: description, classification, and treatment. In Buchler U (Ed) Taleisnik J, Linscheid R (1998) Scapholunate instability. In Wrist Instability. London: Martin Dunitz, pp. 163–174. Cooney W, Linscheid R, Dobyns J (Eds) The wrist: diagnosis and operative treatment. St Louis: Mosby, pp. 501–526. Garcia-Elias M (2010) Understanding carpal mechanics and Watson HK, Ashmead D, Makhlouf V (1988) Examination of the scaphoid. Journal of Hand Surgery 13: 657–660. Wright T, Michlovitz S (2002) Management of carpal instability. In Mackin E, Callahan A, Skirven T, Schneider L, Osterman A (Eds) Rehabilitation of the Hand and Upper Extremity (5th ed). St Louis: Mosby, pp. 1185–1194. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 253
Appraisal Critically Appraised Papers Questioning the role of targeted respiratory physiotherapy over and above a standard clinical pathway in the postoperative management of patients following open thoracotomy Synopsis Summary of: Reeve JC et al (2010) Does physiotherapy and nursing care via a standardised clinical pathway, which reduce the incidence of postoperative pulmonary included early and frequent position changes, sitting out complications following pulmonary resection via open of bed on the first postoperative day, early ambulation and thoracotomy? A preliminary randomised single-blind frequent pain assessment. In addition, the intervention clinical trial. Eur J Cardiothorac Surg 37: 1158–1166. group received daily targeted respiratory physiotherapy, [Prepared by Kylie Hill, CAP Editor.] which comprised deep breathing and coughing exercises, assistance with ambulation, and progressive shoulder and Question: Does routine prophylactic targeted respiratory thoracic cage exercises. Outcome measures: The primary physiotherapy after elective pulmonary resection via outcome was incidence of postoperative pulmonary open thoracotomy decrease the incidence of postoperative complications, defined using a standardised diagnostic pulmonary complications and reduce length of hospital tool. The secondary outcome was the length of hospital stay? Design: Randomised, controlled trial with concealed stay. Results: The primary and secondary outcomes were allocation in which those who collected outcome measures available for all enrolled patients. Neither the incidence of were blinded to group allocation. Setting: Hospital ward postoperative pulmonary complications [mean difference of a tertiary referral centre in Auckland, New Zealand. intervention-control 1.8% (95% CI –10.6 to 13.1%)] nor Participants: Adults scheduled for pulmonary resection the hospital length of stay [intervention group median 6.0 via open thoracotomy. Exclusion criteria: (i) unable to days, control group median 6.0 days; p = 0.87) differed understand written and spoken English, (ii) tumour invasion significantly between groups. The overall incidence of the chest wall or brachial plexus, (iii) physiotherapy of postoperative pulmonary complications (3.9%) was for a respiratory or shoulder problem within 2 weeks lower than expected. Conclusion: In adults following prior to admission, (iv) development of a postoperative open thoracotomy, the addition of targeted respiratory pulmonary complication prior to randomisation on Day 1 physiotherapy to a standardised clinical pathway that postoperatively, or (v) intubation and mechanical ventilation included early mobilisation did not reduce the incidence of ≥ 24 hours following surgery. Randomisation of 76 patients postoperative pulmonary complications or change length of allocated 42 to the intervention group and 34 to the control hospital stay. group. Interventions: Both groups received usual medical Commentary for thoracic surgical populations. Is our putative role solely to prevent complication? Or is it to accelerate the return to This study is a high-quality randomised controlled trial, pre-morbid function? Interestingly, secondary findings of and novel in comparing the efficacy of a postoperative the study (Reeve et al 2010) showed that the physiotherapy physiotherapy program with a no-physiotherapy control program did improve shoulder pain/function at discharge. group in patients undergoing open lung resection. Findings accord with the conclusion of a systematic review of Notwithstanding economic pressures to rationalise physiotherapy after cardiac surgery (Pasquina et al 2003) healthcare, wholesale withdrawal of respiratory that there is no evidence of benefit of routine, prophylactic physiotherapy services from thoracic surgical units would respiratory physiotherapy over standard medical/nursing likely meet opposition, from both surgical teams (being care. In response, one would anticipate that physiotherapists cognisant of the severity of PPC when it does occur) working in this field, particularly those in Australia and and physiotherapists themselves. Redefining the role of New Zealand (Reeve et al. 2007), would re-examine their physiotherapy in terms of: i) identification of high (PPC) current practices. risk patients, ii) treatment of those (few) patients developing PPC, and/or iii) restoration of pre-morbid physical function, Notably, primary and secondary outcomes exhibited ‘floor’ would appear a prudent method of ‘translating’ this effects, testament to the quality of care in such a first world, evidence into practice. tertiary referral hospital setting. Postoperative pulmonary complication (PPC) incidence for the study cohort was Andrew Hirschhorn remarkably low (3.9%), as was length of stay (median 6 Westmead Private Physiotherapy Services, days, against the median 4–5 days to chest drain removal), Clinical Research Institute, Sydney, Australia suggesting limited scope for physiotherapy-mediated reductions. References The described ‘respiratory-targeted’ physiotherapy Pasquina P et al (2003) BMJ 327: 1379. program was arguably equally focussed on restoration of physical function through mobilisation and limb exercises. Reeve J et al (2007) Physiother Res Int 12: 59. This raises the larger question of the role of physiotherapy Reeve J et al (2010) J Physiother 56: 245. 256 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Appraisal Critically Appraised Papers Surgery with disc prosthesis may produce better outcomes than multidisciplinary rehabilitation for patients with chronic low back pain Synopsis 3 and 6 months, and 1 year after the intervention. Surgical intervention consisted of replacement of the degenerative Hellum C et al (2011) Surgery with disc prosthesis intervertebral lumbar disc with an artificial lumbar disc. versus rehabilitation in patients with low back pain and Surgeons were required to have inserted at least six disc degenerative disc: two year follow-up of randomised study. prostheses before performing surgery in the study. Patients BMJ 342: d2786 doi:10.1136/bmj.d2786. [Prepared by were not referred for postoperative physiotherapy, but at 6 Margreth Grotle and Kåre Birger Hagen, CAP Editors.] weeks follow-up they could be referred for physiotherapy if required, emphasising general mobilisation and non- Question: What are the effects of surgery with disc specific exercises. Outcome measures: The primary prosthesis compared to multidisciplinary rehabilitation outcome was the Oswestry Disability Index (ODI, 0–100 for patients with chronic low back pain? Design: A single scale) at 2 years. Secondary outcomes included low back blind randomised controlled multicentre trial. Setting: pain (0–100 VAS), SF-36, and EQ-5D scores. Results: Five university hospitals in Norway. Participants: Men The drop-out rate at 2 years was 15% in the surgical arm and women 25–55 years with low back pain as the main and 24% in the rehabilitation arm. At 2 years follow up, symptom for at least one year, physiotherapy or chiropractic the between group differences (95% CI) in favour of the treatment for at least six months without sufficient effect, a surgical treatment were –8.4 (–13.2 to –3.6) for ODI, score of at least 30 on the Oswestry disability index, and –12.2 (–21.3 to –3.1) for pain, and 5.8 (2.5 to 9.1) for SF- degenerative intervertebral disc changes at L4/L5 or L5/S1, 36 physical health summary. No differences were found or both. Patients with nerve root involvement were excluded. in SF-36 mental health summary or EQ-5D. Conclusion: Randomisation of 179 participants allocated 86 patients to Surgery with disc prosthesis produced significantly greater surgical treatment and 87 to rehabilitation. Interventions: improvement in variables measuring physical disability Rehabilitation consisted of a cognitive approach and and pain, but the difference in ODI between groups did not supervised physical exercise directed by physiotherapists exceed the pre-specified minimally important difference and specialists in physical medicine and rehabilitation. of 10 points, so it is unclear whether the observed changes Intervention was standardised and organised as outpatient were clinically meaningful. treatment in groups; it lasted for about 60 hours over 3–5 weeks. Follow-up consultations were conducted at 6 weeks, weeks of personal contact during rehabilitation should not be underestimated, and these effects may be counterbalanced. Commentary Indications were found that patients with Modic I and II disc changes may have a superior result in the surgery arm while Disc replacement in chronic low back pain has shown patients with a high Oswestry score may be more suitable for promising results during the past decades, showing at rehabilitation, and this result underlines that it is important least equivalent effects to that of fusion surgery (Berg to select treatment individually for each patient. Surgery et al 2009). The present study represents an important carries a risk of serious complications and these occurred contribution comparing surgery with disc prosthesis with in one patient in the study. This risk of complication and multidisciplinary rehabilitation. This well-designed and the considerable improvement also demonstrated in the executed multicentre study demonstrates that surgery is rehabilitation group, in addition to the mixed causes of superior to multidisciplinary treatment when measured by chronic low back pain, support the view that it is reasonable disability and pain, but the difference in the main outcome to consider multidisciplinary rehabilitation before surgery Oswestry of 8.4 points was smaller than the difference of in chronic low back pain. 10 points that the study was designed to detect. As there is no consensus regarding how large the difference between Liv Heide Magnussen groups must be in order to demonstrate clinical importance, Department of Physiotherapy, Faculty of Health and it is not possible to conclude that the difference in effect in this study is of clinical importance. However, clinical Social Sciences, Bergen University College, and important improvement for one individual was defined as Department of Public Health and Primary Health Care, 15 points on Oswestry, and 70% in the surgical group versus 47% in the rehabilitation group achieved this improvement, Physiotherapy Research Group, University of Bergen, supporting the positive effect of disc replacement. It Norway should also be mentioned that both groups experienced considerable improvement. A limitation of the study is Reference the lack of a control group. The placebo effect might have been higher in the surgery group due to patient expectation Berg S et al (2009) Eur Spine J 18: 1512. of surgery, although possible placebo effects after several Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 257
Iles et al: Telephone coaching for low back pain Telephone coaching can increase activity levels for people with non-chronic low back pain: a randomised trial Ross Iles, Nicholas F Taylor, Megan Davidson and Paul O’Halloran La Trobe University, Australia Question: Does the addition of telephone coaching to usual physiotherapy care improve activity for people with non-chronic low back pain and low to moderate recovery expectations? Design: Randomised trial with concealed allocation and intention- to-treat analysis. Participants: People attending the physiotherapy department of a public hospital for treatment within eight weeks of onset of non-specific low back pain. Eligible participants had low to moderate recovery expectations, defined as a response of 7 or less to the question ‘How certain are you that you will return to all of your usual activities one month from today?’ on a scale from 0 (not certain at all) to 10 (completely certain). Intervention: Five sessions of telephone coaching by a physiotherapist trained in health coaching techniques in addition to usual physiotherapy compared to usual physiotherapy alone. Outcome measures: The Patient Specific Functional Scale, Oswestry Disability Index, Pain Self Efficacy Questionnaire, and recovery expectation were measured at baseline, 4, and 12 weeks. Results: 30 participants were recruited, with 26 completing all measures at 12 weeks. There were no significant differences between groups at 4 weeks. After 12 weeks the coaching group improved significantly more than the control group on two 10-point scales: the Patient Specific Functional Scale (mean difference 3.0 points, 95% CI 0.7 to 5.4) and recovery expectation (mean difference 3.4 points, 95% CI 1.1 to 5.7). Estimates of effect sizes were moderate to large in favour of the intervention. Conclusion: The addition of telephone health coaching to usual physiotherapy care for people with non-chronic non-specific low back pain led to clinically important improvements in activity and recovery expectation. Trial registration: ACTRN12607000458437 <*MFT3 5BZMPS/' %BWJETPO. 0)BMMPSBO1 5FMFQIPOFDPBDIJOHDBOJODSFBTFBDUJWJUZMFWFMTGPSQFPQMFXJUIOPODISPOJDMPXCBDLQBJOBSBOEPNJTFEUSJBM Journal of Physiotherapyo> Key words: Low back pain, Physiotherapy, Randomised controlled trial, Telephone, counselling, Physiotherapy Introduction Return to usual activity levels is acknowledged as an important step in recovery from non-specific low back Non-specific low back pain is common, with up to 90% of pain (van Tulder et al 2006). Coaching via the telephone adults experiencing low back pain at some stage in their lives improves activity levels in people with diabetes (Mortimer (Waddell 2004, Walker et al 2004). Psychosocial factors and Kelly 2006) and asthma (McLean et al 2010), as well as are thought to play a large role in developing continuing in healthy adults (Castro and King 2002). Health coaching problems (Loisel et al 2001, Waddell 2004) and the most is therefore a promising intervention that may be useful consistent psychosocial predictor of poor outcome in non- for people with non-specific low back pain who are at risk specific low back pain is a person’s own recovery expectation of ongoing activity limitation. However a search of the (Iles et al 2008, Iles et al 2009). Early identification of PubMed database before the trial commenced and repeated individuals with lower recovery expectations may provide in September, 2011, did not locate any evidence regarding an opportunity for intervention. the efficacy of health coaching for people with non-specific low back pain. Health coaching is one method of increasing the level of physical activity and improving outcomes in people with Therefore the research question was: some chronic diseases (Castro and King 2002, McLean et Does the addition of telephone coaching to usual al 2010, Vale et al 2002). Health coaching has been defined physiotherapy care improve activity levels in people as an interactive role undertaken by a peer or a professional with non-chronic non-specific low back pain and low to support a person to be an active participant in the to moderate recovery expectations? management of their illness or injury (Lindner et al 2003). Based on the transtheoretical model of change (Prochaska What is already known on this topic: Low expectation et al 1992), health coaching represents an intervention that of recovery is a predictor of poor outcome in people addresses psychosocial aspects of greatest importance to with non-specific low back pain. Health coaching the individual. Utilising techniques including motivational increases activity and improves outcomes in several interviewing, cognitive behavioural strategies, and effective chronic diseases. goal setting, health coaching has the added benefit of being able to be applied via the telephone. As a result, coaching What this study adds: In people with non-chronic non- does not require the patient to travel to a specific location specific low back pain and low to moderate expectation and can be scheduled at a time that is convenient for the of recovery, health coaching improves both recovery patient, reducing potential barriers to accessing treatment. expectation and activity-related functional status. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 231
Research Method exercise therapy at the discretion of the therapist. To ensure appropriate care was provided to participants with potential Design psychological problems, every participant was screened for high levels of non-specific psychological distress using the The study was a randomised trial of telephone coaching plus Kessler 10 Questionnaire (Kessler et al 2002). In the event usual physiotherapy care versus usual physiotherapy care of a participant scoring above 30, which is associated with a alone for people with non-chronic (within 8 weeks of onset) high probability of serious psychological distress (Victorian non-specific low back pain and low to moderate recovery Public Health Survey 2006), the treating physiotherapist expectations. Outcomes were measured at baseline, 4, and 12 was notified and requested to refer the participant to an weeks via posted questionnaire. The coaching intervention appropriately trained professional within the health service. was applied once per week for the first four weeks, with one further session three weeks later. Usual physiotherapy care Participants in the experimental group also received was at the discretion of the treating therapists. health coaching via telephone. The telephone coaching involved the application of health coaching principles by Recruitment was performed by RI, who was also the health a physiotherapist with three years of clinical experience coach. After baseline testing participants were allocated and three years of tertiary level teaching experience who to the treatment or the control group according to a had received three days of training in health coaching. A randomly generated sequence of numbers from a random coaching protocol was developed to guide each coaching number generator in permuted blocks of eight sealed in session. The first coaching session aimed to develop rapport opaque envelopes previously prepared by an independent and identify which of the three activities the participant had researcher. This process was performed away from the identified on the Patient Specific Functional Scale was most recruitment site, with participants informed of their group important for them to focus on. The first step in the coaching allocation the following day. The health coach was blinded process was to identify whether the participant was not to the baseline measures; however, the health coach was contemplating return, considering return, attempting to aware of unscored activities listed on the Patient Specific return, or maintaining return to the nominated activity Functional Scale since these activities were used during the (Prochaska et al 1992). Consistent with this stage-based coaching sessions. Treating physiotherapists were blinded approach to behaviour change, information was used by the to group allocation and the self-reported outcome measures coach to help determine which coaching techniques were were entered into a database by a researcher blind to group likely to be more useful during coaching. allocation. The second step was to ask the participant to rate the Participants, therapists, centres importance of returning to the activity in one month’s time on a scale from 0 to 10, where 0 was not important at all and People attending a public hospital physiotherapy outpatient 10 was as important as it could be. Where the participant department for treatment of low back pain were screened reported a score below 7, the coach applied techniques for eligibility by the treating physiotherapist. Eligible such as motivational interviewing to increase the perceived participants were those aged between 18 and 64 years, importance of the activity. Once the score was 7 or higher, who had non-specific low back pain as diagnosed by the the coach moved on to establish the participant’s confidence physiotherapist, an onset of pain within the previous 8 about returning to the activity. This third step required weeks (in the case of recurrent pain, an onset was defined participants to rate their confidence to return to the activity as an increase in symptoms after an 8-week period of in one month’s time from 0 to 10, where 0 was not confident stability), and a low to moderate expectation of recovery. at all and 10 was as confident as they could be. Where the Recovery expectation was measured as the response to the score was below 7, the coach applied cognitive behavioural question ‘How certain are you that you will return to all strategies to increase confidence. When the score was 7 of your usual activities one month from today?’ on a scale or higher, the coach then went through goal setting and from 0 (not certain at all) to 10 (completely certain), with planning for any potential setbacks in order to improve the a score of 7 or less classified as low to moderate recovery likelihood of successful return to the activity. expectation. During our pilot testing this score represented the 33rd percentile of the first 20 people screened (ie, the Not all steps in the process were part of each coaching lowest third of recovery expectation responses). Exclusion session. The anticipated length of each coaching session criteria were suspected neural compromise, a history of was approximately 30 minutes, with the actual duration back surgery, or pain due to a specific cause (such as tumour, of each coaching session dependent on the rate of progress fracture, or recent pregnancy). The therapists who delivered through the protocol. The coach did not offer any treatment outpatient physiotherapy were those allocated to the study advice or comment on the treatment provided by the treating participants as part of usual clinical care. Patients with non- physiotherapist or any other treating health practitioner. specific low back pain accounted for approximately 15% of If the participant had specific questions regarding their the workload of the outpatient department. treatment, the coach encouraged the participant to discuss the concerns with the relevant practitioner. Intervention Coaching was applied via telephone once per week for 4 All participants received usual physiotherapy care. The weeks after baseline, and once more 3 weeks later. In order physiotherapy management provided was at the discretion of to provide support throughout return to usual activity, the treating therapist, including treatment type, frequency, coaching continued for a total of 5 sessions even if the referral, and discharge according to usual practice. In an participant reported returning to full activities. Coaching attempt to ensure physiotherapy treatment reflected usual also continued for 5 sessions if the participant reported physiotherapy care, no directives were provided regarding being discharged from physiotherapy or decided to pursue the nature of physiotherapy treatment during the study. alternative forms of treatment. Treatments applied included manual techniques and 232 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Iles et al: Telephone coaching for low back pain Patients with low back pain screened for eligibility (n = 185) Excluded (n = 155) Not meeting inclusion criteria (n = 139) Declined participation (n = 9) Unable to be contacted (n = 7) Week 0 Measured Patient Specific Functional Scale, primary non-leisure activity, Oswestry Disability Index, recovery expectation, and Pain Self Efficacy Questionnaire Randomised (n = 30) (n = 15) (n = 15) Lost to follow-up Experimental group Control group Lost to follow-up (n = 2) (n = 1) Usual physiotherapy Usual physiotherapy Unable to be care care Unable to be contacted contacted Five telephone coaching sessions: 1 per week for 4 weeks and once three weeks later Week 4 Measured Patient Specific Functional Scale, primary non-leisure activity, Oswestry Disability Index, recovery expectation, and Pain Self Efficacy Questionnaire (n = 13) (n = 14) Lost to follow-up Lost to follow-up (n = 0) (n = 1) Unable to be contacted Week 12 Measured Patient Specific Functional Scale, primary non-leisure activity, Oswestry Disability Index, recovery expectation, and Pain Self Efficacy Questionnaire (n = 13) (n = 13) 'JHVSF Design and flow of participants through the trial. Coaching was applied independently to physiotherapy and averaged to yield a total score between 0 and 10 where a there was no correspondence between the treating therapist higher score indicates better functioning. The score for the and the coach. The treating physiotherapists were blind single-item primary non-leisure activity was also analysed to group allocation in order to ensure knowledge of the separately. The Patient Specific Functional Scale has high coaching intervention did not influence their management test-retest reliability (ICC = 0.97) (Stratford et al 1995), of the patient. concurrent validity with other measures of back-specific activity limitation (r = 0.55 to 0.74) (Donnelly and Carswell Outcome measures 2002), and responsiveness to change in low back pain populations (Pengel et al 2004). The minimum clinically Primary outcome: The primary outcome was activity important difference established in previous studies was limitation measured by the Patient Specific Functional 2 points on the average Patient Specific Functional Scale Scale (Stratford et al 1995). For this scale, participants score (Maughan and Lewis 2010), and 3 points on the identified their primary non-leisure activity and two other primary non-leisure activity (Stratford et al 1995). activities they were unable to perform to the same level as they could before the problem. The item ratings were Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 233
Research 5BCMFCharacteristics of all participants, the experimental effect sizes (standardised mean differences) were calculated group and the control group at baseline. by dividing the difference in post intervention means by the pooled standard deviation (Hedges g) (Hedges and Olkin Characteristic Groups 1985). An effect size of 0.2 was considered small, 0.5 a medium sized effect, and 0.8 or greater a large effect size All Exp Con (Cohen 1992). (n = 30) (n = 15) (n = 15) The primary non-leisure activity score from the Patient Age (years) 39.5 39.5 39.5 Specific Functional Scale was also analysed by calculating (12.0) (11.7) (12.7) the absolute risk reduction and number needed to treat statistic by comparing the proportion in each group Gender, n male (%) 18 (60) 8 (53) 10 (67) achieving a successful return to the specified activity (determined a priori as a score of 7 or higher out of 10 on Recovery 4.6 4.8 4.4 the Patient Specific Functional Scale) at 12 weeks. expectation at (2.2) (2.2) (2.3) screening (0–10) Results 25.1 Time from injury to 25.3 25.5 (15.5) Flow of participants and therapists through the baseline (days) (16.5) (17.9) study Exp = experimental group, Con = control group Thirty participants were recruited from 185 people screened between January 2008 and March 2010. Four Secondary outcomes: The modified Oswestry Disability participants (2 from each group) could not be contacted to Index (Fritz and Irrgang 2001) was also used as a region- complete final outcome measures at 12 weeks. The final specific measure of activity limitation. The Oswestry analysis consisted of 26 participants, 13 from each group. Index is scored as a percentage, with a higher percentage The flow of participants through the trial and reasons for indicating a higher level of back-related disability. It has loss to follow-up are illustrated in Figure 1. Five different demonstrated evidence of reliability and validity (Davidson physiotherapists treated patients from the intervention and Keating 2002, Jolles et al 2005, Ostelo and de Vet group and seven different therapists treated patients from 2005, Roland and Fairbank 2000). The minimum clinically the usual care group. The therapists had a mean of 4.6 (SD important difference for the Oswestry has previously been 4.0) years of clinical experience. established as 10 points (Ostelo and de Vet 2005). The baseline characteristics of the participants are presented Further secondary outcomes were recovery expectation in Table 1 and the first two columns of Table 2. The two and pain self efficacy. Recovery expectation was measured groups appeared well matched for demographic factors using the same question used to determine eligibility, and baseline measures. The primary non-leisure activity scored from 0 to 10 with a higher score indicating more for 25 of the 30 participants was work and the majority (18 positive expectations (Iles et al 2009). The minimum of 30) worked full time. Other activities forming part of clinically important difference for this measure has not the Patient Specific Functional Scale included gardening been established. Pain self efficacy was measured using the (7 participants), playing with children (5 participants), and Pain Self Efficacy Questionnaire, a measure of a person’s walking for longer than half an hour (5 participants). confidence to complete specific activities despite their current level of pain (Nicholas 2007). The Pain Self Efficacy Compliance with trial method Questionnaire is scored out of a total of 60 points, with a higher score indicating a higher level of pain self efficacy. The mean duration of each coaching session was 19 min The Pain Self Efficacy Questionnaire has good test-retest (SD 5, range 9 to 30), with a mean total coaching time of reliability over a 3-month period (r = 0.73) (Nicholas 2007) 84 min (SD 26, range 52 to 120). There was no difference and sensitivity to change in patients with chronic low back in the number of physiotherapy treatments received by pain (Maughan and Lewis 2010). The minimum clinically the coaching group (mean 6.3, SD 5.1) and the usual care important difference for this measure is 11 points (Maughan group (mean 5.4, SD 3.7) (p > 0.05). The effectiveness of and Lewis 2010). therapist blinding was assessed at the end of the trial, with therapists identifying the correct group allocation in 57% Data analysis of cases, marginally higher than the 50% expected due to chance alone. The Kessler 10 screening questionnaire To achieve a power of 80% with 95% confidence to detect identified 5 participants (4 usual care, 1 coaching group) a clinically important difference of 2.0 points on the with high levels of non-specific psychological stress. In all Patient Specific Functional Scale (Maughan and Lewis cases the treating therapist was notified and advised of the 2010), assuming a standard deviation of 1.6 points similar score, leaving referral to a psychologist up to the therapist’s to that found in other studies of non-specific low back judgement as per usual practice. pain (Stratford et al 1995), 24 participants were required (Buchner et al 2007). A target sample size of 30 was set to Effect of intervention allow for some loss to follow up. Group data for all outcomes are presented in Table 2. Outcomes were analysed on an intention-to-treat basis Individual data are presented in Table 3 (see eAddenda for all available data. To compare the two groups on the for Table 3). After four weeks there were no statistically primary and secondary outcomes, analysis of covariance significant differences between the groups on any of the (ANCOVA) was applied comparing the means at 4 and 12 outcomes. weeks using the baseline scores as covariates (Vickers and Altman 2001). To evaluate the impact of the intervention, 234 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
JournalofPhysiotherapy2011 Vol.57 – ©AustralianPhysiotherapyAssociation2011 5BCMF Mean (SD) for all outcomes for each group, mean (SD) difference within groups, and Outcome Groups Week 4 Baseline Week 12 Exp Con Exp Con Exp Con (n = 15) (n = 15) (n = 13) (n = 14) (n = 13) (n = 13) Patient Specific 3.7 3.1 6.5 5.1 8.3 5.2 Functional Scale (2.3) (2.3) (2.7) (1.8) (2.1) (3.4) (0 –10) Primary non-leisure 4.7 3.3 7.5 5.3 8.5 5.2 activity (0 –10) (2.5) (2.7) (2.3) (2.8) (2.2) (4.0) Oswestry Disability 40 41 22 30 14 30 Index (0 –100)b (20) (13) (17) (9) (17) (26) Recovery expectation 5.8 5.5 6.9 5.8 8.5 5.2 (0 –10) (3.0) (2.5) (3.1) (2.3) (1.9) (3.5) Pain Self Efficacy 33 32 48 41 52 42 Questionnaire (0 – 60) (15) (10) (11) (9) (13) (18) Exp = experimental group, Con = control group; Shaded row = primary outcome; amean difference calc activity limitation) 235
d mean (95% CI) difference between groups. Difference within groups Difference between groupsa Week 4 minus Week 12 minus Week 4 Week 12 baseline baseline Exp Con Exp Con Exp minus Con Exp minus Con 2.7 2.4 4.5 2.2 1.0 3.0 (2.7) (2.5) (2.5) (3.9) (– 0.8 to 2.9) (0.7 to 5.4) 2.6 2.5 3.6 2.2 1.5 2.2 (2.7) (2.9) (2.6) (3.5) (– 0.9 to 3.8) (– 0.6 to 5.0) –17 –12 –23 –12 –7 –14 (19) (12) (21) (26) (–17 to 3) (–32 to 4) 0.9 0.2 3.0 – 0.5 1.0 3.4 (2.5) (3.3) (2.9) (4.2) (–1.1 to 3.0) (1.1 to 5.7) 12 10 17 10 6 10 (19) (11) (20) (17) (–2 to 14) (–3 to 23) ulated using baseline scores as a covariate, bsmaller number indicates better outcome (reduced Iles et al: Telephone coaching for low back pain
Research After 12 weeks the coaching group had significantly better indication that the intervention may be able to change scores on the Patient Specific Functional Scale compared expectations regarding return to usual activities may be with the usual care group (mean difference of 3.0 points, important, since low recovery expectations have been found 95% CI 0.7 to 5.4). This mean difference was larger than to be a strong predictor of poor outcome in non-specific low the minimum clinically important difference of 2.0 points back pain (Iles et al 2008). and the corresponding standardised effect size (g = 1.1) was large. The mechanism behind the impact of coaching on return to activity is likely to be a result of the increased emphasis At 12 weeks there was no significant difference between on self management and empowerment of the participant. the groups on the primary non-leisure activity item from Increased self management is seen as a goal for those with the Patient Specific Functional Scale, despite the large chronic conditions, but this is traditionally not a focus standardised effect size of g = 1.0. Two of the 13 participants of health care during the earlier stages of a condition (15%) in the coaching group did not return to their primary (Lawn and Schoo 2010). Coaching has been identified as non-leisure activity compared to 7 out of 13 (54%) in the a means to help patients take greater responsibility for the usual care group. The absolute risk reduction (ARR) was achievement and maintenance of treatment goals (Vale 38% (95% CI 2 to 64). The corresponding number needed et al 2002) and this seems to be the case for return to to treat was 3 (95% CI 2 to 51). That is, for every three activity. The use of the transtheoretical model of change people who received the coaching intervention, one more to tailor coaching techniques to the appropriate level for successful return to primary non-leisure activity was the individual may also lead to an increased adherence to achieved than would have been with usual care alone. rehabilitation strategies (Lindner et al 2003, Prochaska et al 1992). A greater understanding of these mechanisms and in The between-group difference on the Oswestry Disability particular of how they relate to recovery from non-specific Index did not reach significance, but the point estimate of low back pain may lead to the development of even more the mean difference at 12 weeks (14.1 points) in favour of effective coaching models, not only for low back pain but the coaching group was larger than the minimum clinically also for other musculoskeletal conditions. important difference of 10 points. The standardised effect size of the intervention on this outcome (g = 0.7) was Since the coaching model utilised the activities within moderate to large. the Patient Specific Functional Scale, improvements on this measure could be expected. Despite not achieving At 12 weeks the coaching group had significantly higher statistical significance, the size of the treatment effect on recovery expectation (mean difference of 3.4 points, 95% CI the Oswestry Index supports the notion that the intervention 1.1 to 5.7) than the usual care group, and the standardised had a clinically important effect on region-specific effect size for this outcome was large (g = 1.2). activity limitation as well as patient-specific limitation. Interestingly, the effects observed on the measures of There was no significant difference between groups on activity and recovery expectation were not matched on the the Pain Self Efficacy Questionnaire with a medium measure of self efficacy. This result was unexpected given standardised effect size (g = 0.6) in favour of the coaching that an increase in self efficacy could be expected due to the group. nature of the intervention. A possible explanation was the difference in focus of the self-efficacy measure (pain) and Discussion the focus of the coaching intervention (activity). Telephone coaching added to usual physiotherapy care Previous psychosocial interventions in the non-chronic resulted in clinically significantly increased levels of self- phase of non-specific low back pain have shown little reported activity and improved recovery expectation at success in the prevention of chronic disability (George et 12 weeks in people with non-chronic non-specific low al 2003, Heymans et al 2004, Jellema et al 2005). However, back pain and low to moderate recovery expectation. The previous interventions have focused on patient education intervention had a large effect on both patient-specific and with no psychotherapeutic content (George et al 2003, region-specific measures of activity limitation. The mean Heymans et al 2004) or consisted of a single discussion difference on the Patient Specific Functional Scale was with a doctor regarding potential psychosocial barriers larger than the minimum clinically important difference to recovery (Jellema et al 2005). The treatment effects (Maughan and Lewis 2010) and the mean difference on the obtained in this study suggest the coaching intervention Oswestry, although not statistically significant, was 14.1 – could be an effective addition to usual physiotherapy care. larger than the minimum clinically important difference of 10 points (Ostelo and de Vet 2005). Participants in This trial was performed with individuals at risk of poor this study were at risk of developing chronic activity outcome due to low recovery expectations and the coaching limitation and effective interventions in this population are intervention could represent large savings in terms of particularly important, as the majority of resources devoted financial and human costs if the results are replicated in to non-specific low back pain are consumed by the small a larger trial. The trial was designed in order to satisfy the proportion of people experiencing ongoing disability (Shaw CONSORT requirements for reporting of clinical trials et al 2001, Truchon and Fillion 2000). For the addition of (Schulz et al 2010). an average of less than 90 minutes of therapy time, health coaching via the telephone may represent a cost-effective As a result of the small sample 95% CIs were large; addition to usual physiotherapy care. For every 3 people however, the trial was sufficiently powered to detect a who received the coaching intervention, 1 more successful clinically important difference in the primary outcome. return to primary non-leisure activity was achieved than A larger sample, assuming effects are maintained, would would have been with usual care alone. Furthermore, the increase the precision of the results and would be likely to 236 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Iles et al: Telephone coaching for low back pain provide sufficient power to detect significant differences physiotherapists at the Angliss Hospital for their assistance in secondary outcomes, namely the Oswestry and primary in the screening and recruitment of participants. non-leisure activity. A larger, fully powered trial would require recruitment from multiple sites given that only a Correspondence: Ross Iles, Department of Physiotherapy, small proportion of people screened were eligible for this La Trobe University, Australia. Email: [email protected]. study. In the current study participants were recruited from au a single metropolitan hospital, so a larger study including a wider range of referral sources would also enhance the References generalisability of results to the wider non-chronic non- specific back pain population. Buchner A, Erdfelder E, Faul F (2007) G*Power 3: A flexible statistical power analysis for the social, behavioral, and It should be considered whether the results would be biomedical sciences. Behavior Research Methods 39: 175– strengthened by the addition of a placebo coaching group. 191. It may be possible that the extra attention resulting from regular telephone contact rather than the coaching content Castro CM, King AC (2002) Telephone-assisted counseling for of the phone call contributed to the favourable outcome. physical activity. Exercise and Sports Science Reviews 30: It is also possible that the results of the study are strongly 64–68. influenced by the individual providing the coaching, and other coaches may achieve different results. These Cohen J (1992) A power primer. Psychological Bulletin 112: issues could be addressed in future trials through the use 155–159. of multiple coaches, complete with measures to ensure a consistent approach to coaching is employed by all coaches, Davidson M, Keating JL (2002) A comparison of five low back and the inclusion of a sham coaching group receiving disability questionnaires: reliability and responsiveness. equivalent non-therapeutic telephone contact. However, the Physical Therapy 82: 8–24. last coaching contact in our trial occurred one month before the final measures, and this was likely to reduce the effect of Donnelly C, Carswell A (2002) Individualized outcome any expectation bias in the self-reported outcomes. Another measures: a review of the literature. Canadian Journal of aspect that should be considered in future trials is the effect Occupational Therapy. 69: 84–94. of any co-interventions, such as analgesia use, during the trial. Measurement of such co-interventions could increase Fritz JM, Irrgang JJ (2001) A comparison of a modified the confidence that any difference found between groups Oswestry Low Back Pain Disability Questionnaire and the was a true reflection of the coaching intervention and not Quebec Back Pain Disability Scale. Physical Therapy 81: due to differences in other treatments. 776–788. The 12-week follow up utilised in this trial was not long George SZ, Fritz JM, Bialosky JE, Donald DA (2003) The effect enough to determine maintenance of these behaviour changes of a fear-avoidance-based physical therapy intervention for or gather information about recurrence of symptoms, nor patients with acute low back pain: results of a randomized was it long enough to determine whether coaching would clinical trial. Spine 28: 2551–2560. reduce the risk of progressing to persistent chronic non- specific low back pain. Measures of participation restriction Hedges LV, Olkin I (1985) Statistical methods for meta-analysis. such as return to work would also provide a useful indication Orlando: Academic Press. of longer-term outcomes. A future trial should include these factors with at least a 12-month follow up, and include Heymans MW, van Tulder MW, Esmail R, Bombardier C, Koes measures of cost benefit, such as more detailed information BW (2004) Back schools for non-specific low-back pain. on health care utilisation. Future trials could also investigate Cochrane Database Systematic Review: CD000261. the effectiveness of coaching alone, as well as the impact of coaching on conditions other than low back pain. Iles RA, Davidson M, Taylor NF (2008) A systematic review of psychosocial predictors of failure to return to work in In conclusion, this trial provides preliminary evidence that non-chronic non-specific low back pain. Occupational and the addition of telephone coaching to usual physiotherapy Environmental Medicine 65: 507–517. care for people with non-chronic non-specific low back pain and low to moderate recovery expectations leads to increased Iles RA, Davidson M, Taylor NF, O’Halloran P (2009) activity levels when compared to usual physiotherapy care Systematic review of the ability of recovery expectations to alone. Health coaching via the telephone has the potential predict outcomes in non-chronic non-specific low back pain. to prevent the progression of non-specific low back pain to Journal of Occupational Rehabilitation 19: 25–40. chronic activity limitation. Q Jellema P, van der Windt DA, van der Horst HE, Blankenstein eAddenda: Table 3 available at jop.physiotherapy.asn.au AH, Bouter LM, Stalman WA (2005) Why is a treatment aimed at psychosocial factors not effective in patients with Ethics: The La Trobe University Faculty Human Ethics (sub)acute low back pain? Pain 118: 350–359. and the Eastern Health Research and Ethics Committees approved this study. All participants gave written informed Jolles BM, Buchbinder R, Beaton DE (2005) A study compared consent before data collection began. nine patient-specific indices for musculoskeletal disorders. Journal of Clinical Epidemiology 58: 791–801. Acknowledgements: We are grateful for the help of Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL et al (2002) Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine 32: 959–976. Lawn S, Schoo A (2010) Supporting self-management of chronic health conditions: common approaches. Patient Education and Counseling 80: 205–211. Lindner H, Menzies D, Kelly J, Taylor S, Shearer M (2003) Coaching for behaviour change in chronic disease: a review of the literature and the implications for coaching as a self- management intervention. 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Appraisal Clinical Practice Guidelines Tension-type headache Tension-type headache Description: These guidelines present evidence for the acute and prophylactic treatment of tension-type Latest update: 2010. Next update: Within 5 years. Patient headache using drug and non-drug interventions. It begins group: Adults with a tension-type headache as defined by by outlining the known epidemiology of tension-type the International Headache Society. Intended audience: headache, common clinical characteristics, and diagnostic Clinicians managing patients with tension-type headaches. criteria. Evidence for drug treatment of acute tension-type Additional versions: Nil. Expert working group: A task headache is then presented, covering simple analgesics, force of 6 representatives from the European Federation non-steroidal anti-inflammatory drugs, combination of Neurological Societies (EFNS), associated with analgesics, triptans, muscle relaxants and opioids. Next, Neurology Departments in Denmark, Germany, Sweden, evidence for prophylactic pharmacotherapy is presented, Norway, Greece, Italy and Belgium.Funded by: European discussing interventions including amitriptyline, other Federation of Neurological Societies. Consultation with: antidepressants and other agents such as muscle relaxants or Representatives of over 20 British and American medical botulinum toxin. The final section details evidence for non- societies, including the APTA and the Chartered Society pharmacological interventions including EMG biofeedback, of Physiotherapists. Approved by: EFNS. Location: The cognitive-behavioural therapy, relaxation training, physical guidelines were published as: Bendtsen L et al (2010) therapy, acupuncture, and nerve blocks. Physical therapy in EFNS guideline on the treatment of tension-type headache this guideline encompassed a variety of treatment options, – report of an EFNS task force. European Journal of such as exercise, manipulation, massage, and electrotherapy Neurology 17: 1318–1325. They are also available at: and was investigated in 13 articles. Overall, the guidelines h t t p: // w w w.ef n s.o r g / f i le a d m i n / u s e r_ u plo a d /g u id l i n e _ are supported by 129 references. p a p e r s / E F NS _ g u id el i n e _ 2 010 _ t r e a t m e nt _ of _ t e n sio n - type_headache.pdf Sandra Brauer The University of Queensland, Australia Arthroscopic shoulder surgery Arthroscopic Anterior Capsulolabral Repair of the Shoulder Latest update: 2010. Next update: Not indicated. Patient Description: These guidelines relate specifically to patients group: Adults who have undergone an arthroscopic who have undergone arthroscopic anterior capsulolabral anterior capsulolabral repair of the shoulder to restore repair in which the detached labrum has been anchored stability. Intended audience: Therapists involved with the back to the glenoid rim and/or capsular tension has been rehabilitation of patients who have undergone this surgical restored through suture tightening of the plicated capsule. procedure. Additional versions: Nil. Expert working They are based on the best available evidence, along with group: Six representatives from the American Society of ASSET member expertise and clinical opinion. The article Shoulder and Elbow Therapists (ASSET) including physical begins by providing detailed information about this surgical therapists, an orthopaedic surgeon, and an athletic trainer. procedure, the likely anatomical structures affected, tissue Funded by: Not indicated. Consultation with: Guidelines healing, and factors including mechanical stress that could were sent to all members of ASSET for comment. This influence the progression of healing such as exercise and included American and international physical therapists, immobilisation. The second half of the document outlines athletic trainers, and occupational therapists, in addition rehabilitation guidelines across three phases: weeks 0 to 6, to orthopaedic surgeons. Approved by: ASSET and the 6 to 12, and 12 to 24. The guidelines are presented in detail American Shoulder and Elbow Surgeons Society. Location: at the end of the document and include goals, interventions The guidelines were published as: Gaunt BW et al (2010) to avoid, specific interventions such as techniques to gain The American Society of Shoulder and Elbow Therapists’ range, neuromuscular re-education, strength, endurance, consensus rehabilitation guideline for arthroscopic anterior and pain management. capsulolabral repair of the shoulder. Journal of Orthopaedic and Sports Physical Therapy 40: 155–168 and are available Sandra Brauer at: http://www.asset-usa.org/Rehab_Guidelines.html The University of Queensland, Australia Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 261
Dalton et al: Assessment of professional competence of students The Assessment of Physiotherapy Practice (APP) is a valid measure of professional competence of physiotherapy students: a cross-sectional study with Rasch analysis Megan Dalton1,3, Megan Davidson2 and Jenny Keating3 1Griffith University, 2School of Allied Health, La Trobe University, 3School of Primary Health Care, Monash University Australia Question: Is the Assessment of Physiotherapy Practice (APP) a valid instrument for the assessment of entry-level competence in physiotherapy students? Design: Cross-sectional study with Rasch analysis of initial (n = 326) and validation samples (n = 318). Students were assessed on completion of 4, 5, or 6-week clinical placements across one university semester. Participants: 298 clinical educators and 456 physiotherapy students at nine universities in Australia and New Zealand provided 644 completed APP instruments. Results: APP data in both samples showed overall fit to a Rasch model of expected item functioning for interval scale measurement. Item 6 (Written communication) exhibited misfit in both samples, but was retained as an important element of competence. The hierarchy of item difficulty was the same in both samples with items related to professional behaviour and communication the easiest to achieve and items related to clinical reasoning the most difficult. Item difficulty was well targeted to person ability. No Differential Item Functioning was identified, indicating that the scale performed in a comparable way regardless of the student’s age, gender or amount of prior clinical experience, and the educator’s age, gender, or experience as an educator, or the type of facility, university, or clinical area. The instrument demonstrated unidimensionality confirming the appropriateness of summing the scale scores on each item to provide an overall score of clinical competence and was able to discriminate four levels of professional competence (Person Separation Index = 0.96). Person ability and raw APP scores had a linear relationship (r2 = 0.99). Conclusion: Rasch analysis supports the interpretation that a student’s APP score is an indication of their underlying level of professional competence in workplace practice. <%BMUPO. %BWJETPO. ,FBUJOH+ 5IF\"TTFTTNFOUPG1IZTJPUIFSBQZ1SBDUJDF \"11 JTBWBMJENFBTVSF PG QSPGFTTJPOBM DPNQFUFODF PG QIZTJPUIFSBQZ TUVEFOUT B DSPTTTFDUJPOBM TUVEZ XJUI 3BTDI BOBMZTJT Journal of Physiotherapyo> Key words: Educational measurement, Professional competence, Clinical competence, Physical therapy (specialty) Introduction of supervised workplace practice. If valid interpretations of such scores are to be made, the assessment instrument Workplace-based learning and assessment is an essential must be both psychometrically sound and educationally component of physiotherapy and other health professional informative (Prescott-Clements et al 2008, Streiner and education programs. Professional competence includes Norman 2003). These requirements were fundamental understanding and dealing with highly variable considerations in the development and evaluation of the circumstances and assessment is therefore difficult to Assessment of Physiotherapy Practice (APP) instrument standardise across students (Rethans et al 2002). Controlled (Dalton et al 2009), which has been adopted in all but one assessments such as Objective Structured Clinical Australian and all New Zealand entry-level programs. Examinations and the use of standardised patients have been developed in response to concerns regarding standardised The development of the APP was guided by the framework and reliable measurement of student competencies. While of Wilson (2005). An initial item pool was constructed assessment reliability may be enhanced by standardised from all available assessment instruments and reduced by testing, the validity of controlled examination procedures removing redundancy and applying criteria related to good has been challenged because competence under controlled conditions may not be an adequate surrogate for performance What is already known on this topic: Assessment under the complex and uncertain conditions encountered in of clinical competence under controlled conditions usual practice (Southgate et al 2001). of practical examinations may not be an adequate surrogate for performance in clinical practice. A A solution to this complexity is to monitor students over a standard assessment tool is needed for physiotherapy sufficient period of time to enable observation of practice students on clinical placements. in a range of circumstances and across a spectrum of patient types and needs. This has been argued as superior What this study adds: The Assessment of to one-off ‘exit style’ examinations (van der Vleuten 2000). Physiotherapy Practice (APP) is a valid measure of Longitudinal assessment of professional competence of professional competence of physiotherapy students. physiotherapy students in the workplace is the assessment It is appropriate to sum the scale scores on each item approach used within all Australian and New Zealand to provide an overall score of clinical competence. The physiotherapy programs. Clinical educators (registered APP performs in a comparable way regardless of the physiotherapists) generally rate a student’s performance characteristics of the student, the clinical educator, or on a set of items on completion of a 4, 5, or 6-week block the clinical placement. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 239
Research item design. The test content development included input options 0 = infrequently/rarely demonstrates performance and collaboration from physiotherapy educators across indicators, 1 = demonstrates few performance indicators to Australia and New Zealand. The iterative cycles included an adequate standard, 2 = demonstrates most performance a pilot trial and two field test stages. A detailed description indicators to an adequate standard, 3 = demonstrates of these stages is presented in Figure 1 (see eAddenda for most performance indicators to a good standard, 4 = Figure 1). Continuous refinement of the instrument based on demonstrates most performance indicators to an excellent qualitative and quantitative evaluation occurred throughout standard, and not assessed. A rating of 0 or 1 indicates that each stage (Coghlan and Brannick 2001). There were three a minimum acceptable standard has not been achieved for phases of workplace-based testing – a pilot trial and two that item. A global rating scale of overall performance (not field tests (Dalton et al 2009). This paper reports the results adequate, adequate, good, excellent) is also completed by of the second field test. the educator, but this item does not contribute to the APP score. Examples of performance indicators for each item Rasch analysis of data was used at each stage of testing are provided on the reverse of the APP. A total raw score the APP. This statistical model calibrates the difficulty of for the APP ranges from 0 to 80, and can be transformed items and the ability of persons on a common scale with to a 0 to 100 scale by dividing the raw score by the total interval-level units called logits (log-odds units) (Bond and number of items scored (ie, excluding any items that were Fox 2007, Rasch 1960). Rasch analysis provides validity not assessed) and multiplying the result by 100. evidence based on instrument internal structure. It enables analysis of unidimensionality (considered an essential Participants quality of an additive scale) and the targeting of item difficulty to the persons’ abilities (Bond and Fox 2007). Students enrolled in entry-level physiotherapy programs Rasch analysis also enables assessment of the functioning from 9 universities in Australia and New Zealand were of the rating scale when applied to students with different assessed by educators using the APP on completion of a 4, characteristics (eg, age and gender) or applied by assessors 5, or 6-week full-time clinical placement block scheduled with different characteristics (eg, years of experience as across one university semester. The placements occurred a clinical educator). If data fit a Rasch model, a number during the last 18 months of the students’ physiotherapy of qualities should be evident in the data. Items should program and represented diverse areas of physiotherapy present a stable hierarchy of difficulty. It should be easy practice including musculoskeletal, cardiorespiratory, to achieve high scores on easy items and difficult on hard neurological, paediatric, and gerontological physiotherapy. items, with items in between ranking in a predictable way. An instrument with these properties would make the user Recruitment procedures optimised representation of confident that a student who achieved a higher total score physiotherapy clinical educators by location (metropolitan, was able to cope with the more difficult, as well as the easier, regional/rural, and remote), clinical area of practice, years challenges. Educators could identify challenging items and of experience as a clinical educator, and organisation appropriate educational support could be developed to help (private, public, hospital based, community based, and non- students achieve these more challenging aspects of practice. government). Further detail on the methods of Rasch analysis and the applicability of its results in the clinical environment is Field test procedure provided in an excellent paper by Tennant and Conaghan (2007). Prior to commencement of clinical placements, educators and students were sent an information sheet and consent The aim of this study was to ascertain whether the APP form and invited to participate. Data were excluded from instrument is a valid measure of professional competence analysis if either the student or their clinical educator did not of physiotherapy students when tested using the Rasch consent to participate in the research. All clinical educators measurement model. Therefore the specific research received training in the use of the APP through attendance questions were: at a 4-hour workshop, access to the APP resource manual, or both. Compulsory workshop attendance for all clinical 1. Is the APP a unidimensional measure of the educators participating in the field test was not feasible in professional competence of physiotherapy students? the authentic clinical education environment where face-to- face training opportunities are constrained by geographical, 2. What is the hierarchy of difficulty of items from workload, and financial considerations. During the trial easiest to hardest? a member of the research group was available to answer questions by phone or email. Students were educated in the 3. Is there any evidence of differential item functioning, assessment process and use of the APP instrument using a which indicates the scale exhibits item bias? standardised presentation prior to placements commencing and information about the APP was included in each 4. Are the APP items appropriately targeted for the university’s student clinical education manual. student population? Data management and analysis Method On completion of each placement the completed APP This was a cross-sectional study using Rasch analysis of forms were returned by mail, de-identified, and entered two samples (n = 326 and n = 318). Students were assessed into a spreadsheet. Data were analysed with RUMM2020 at completion of clinical placements across one university software using a partial credit model (Andrich et al 2003). semester in 2008. Approval was obtained from the human The analysis tested the overall fit of data to the model, the ethics committee of each participating university. overall and individual item and person fit, item threshold order, targeting, item difficulty, person separation, The APP (Version 4) used in this final field trial comprised differential item functioning, and dimensionality. 20 items, presented in Appendix 1 (see the eAddenda for Appendix 1). Each of the 20 items has the response 240 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Dalton et al: Assessment of professional competence of students The Rasch measurement model the abilities of people in the sample. A well-targeted scale would have a mean person location around zero (Tennant Conversion of ordinal data to interval level measurement and Conaghan 2007). data: The current approach in workplace-based assessment is to score a physiotherapy student’s performance on a Functioning of the rating scale: Rasch analysis generates rating scale across items that sample behaviours considered a person separation index that provides an indication essential for professional competence. Rating scale options of the internal consistency of the scale and the power of are allocated sequentially ordered integers, and item scores the instrument to discriminate amongst respondents with are summed to give a total score. While this approach is different levels of professional competence. A minimum common, there is little evidence to support the proposition person separation index of 0.70 and 0.85 is required that ordinal-level total scores approximate interval-level for group and individual use respectively (Tennant and measurements (Cliff and Keats 2003, Streiner and Norman Conaghan 2007). 2003). Rasch modeling enables the abstraction of equal units of measurement from raw (ordinal data) scores on items of Rasch analysis also enables investigation of difficulty that an assessment tool. These can be calibrated and then used clinical educators may have in discriminating between with confidence to measure and quantify attributes such different levels on the 0–4 rating scale. For a good fit to as competence in physiotherapy practice (Bond and Fox the model it is expected that for any item, student with high 2007). This conversion facilitates appropriate interpretation levels of the attribute (professional competence indicated of differences between individuals and tallying of converted by total scores) would typically achieve a higher item score scores provides interpretable total scores. than individuals with low levels of the attribute. In Rasch analysis this is demonstrated by an ordered set of response Functioning of items: In this study the construct of interest thresholds for each item. Ordered thresholds indicate that was competence to practice physiotherapy. If scores for the respondents (ie, clinical educators) use the response items fit a Rasch model, a number of qualities should be categories (ie, scoring scale) in a manner consistent with evident in the data. Items should present a stable hierarchy the level of the trait (ie, competence) being measured. of difficulty. It should be easy to achieve high scores on This occurs when the educators consistently discriminate some items and difficult on others, with items in-between between response options in a predictable way. ranking in a reliable way. An instrument with these properties would make the user confident that a student who Results achieved a higher total score was able to cope with the more difficult, as well as the easier, challenges. Educators could A total of 644 APP assessments from 456 students were identify challenging items and appropriate educational returned by 298 clinical educators. Tables 1 and 2 present support could be developed to help students achieve these the characteristics of the participating students and more challenging targets. educators. Table 3 presents the characteristics of the APP forms received. The mean APP total score was 61 (SD 12, Item bias: A scale that fits a Rasch model should function range 16–80). If converted to the 0–100 scale, this equates consistently irrespective of subgroups within the sample to a mean total score of 76 (SD 15, range 20–100). All 5 being assessed. For example, male and female students with points on the rating scale were used for the majority of equal levels of the underlying construct being measured items. Missing data was rare (0.4% of all data points) and should not be scored significantly differently (Lai et al 0.2% of all items were rated as not assessed. 2005). Rasch analysis enables assessment of item bias through investigation of Differential Item Functioning. In the Data were randomly divided into two samples. Sample 1 development of the APP, the research team was particularly was used for model development (n = 326) and sample 2 for interested to determine whether the scale performed in a model validation (n = 318). The data were stratified before comparable way regardless of the student’s age, gender, randomisation to optimise representation of completed APP or the total number of weeks of clinical experience, the instruments according to clinical area of the placement, educator’s age, gender, or experience as an educator, the level of student experience, facility type (hospital, non- type of facility where the clinical placement occurred, the government agency, community health centre, private university that delivered the student’s education, or the practice), and university program type (undergraduate, clinical area. graduate entry). Dimensionality: One of the primary tenets underpinning Overall model fit: The item-trait interaction chi-square Rasch analysis is the concept of unidimensionality. If statistic for Sample 1 was 65.1 (df = 80, p = 0.88) and 100 the scale scores on each item of the APP are to be added (df = 80, p = 0.57) for Sample 2. The chi-square probability together to provide a total score representing an overall values for Sample 1 (p = 0.88) and Sample 2 (p = 0.57) level of professional competence, Rasch analysis should indicated adequate fit between the data and the model. indicate a scale that is unidimensional, a scale that measures one construct. Unidimensionality was explored using the Overall item and person fit: The residual mean value for independent t-test procedure (Tennant and Pallant 2006). items for Sample 1 was –0.33 (SD 1.71), and for Sample 2 was –0.32 (SD 1.73), indicating some misfit of items. The Targeting of instrument: It is important, particularly in residual mean value for persons for Sample 1 was –0.26 (SD clinical practice, that the assessment items are appropriately 1.19) and for Sample 2 was –0.19 (SD 1.13), indicating no targeted for the population being assessed. Poorly targeted misfit of persons in either sample. measures result in floor or ceiling effects, and this would mean that either very weak or very strong students may Individual item and person fit: In both samples, Item 6 not be graded appropriately. Rasch modeling provides an (Demonstrates clear and accurate written documentation) indication of the match between the item difficulty and exhibited a positive item fit residual above +2.5, suggesting Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 241
Research 5BCMF. Characteristics of participating students. 5BCMF. Sources and characteristics of the APP forms received. Characteristic n = 456 Characteristic n = 644 Age (yr), mean (SD) 23 (3) Responder burden 29 (19) Age (yr), range 20–48 duration to complete (min), mean (SD) 8–120 Gender, n female (%) 301 (66) duration to complete (min), range 32 5BCMF. Characteristics of participating clinical educators. Clinical area, (%) 25 musculoskeletal 23 Characteristic n = 298 neurological 6 34 (8) cardiorespiratory 5 Age (yr), mean (SD) 22–60 paediatric 8 215 (72) specialtya Age (yr), range 6 (5) unknown 4 3 Gender, n female (%) 0–34 Patient age group, (%) 51 children (0 to 12 yr) 36 Experience as a clinical educator (yr), 13 (4) adolescents (13 to 20 yr) 5 mean (SD) 58 (19) adults (21 to 65 yr) 88 (30) older persons (> 65 yr) 54 Experience as a clinical educator (yr), range 86 (29) unknown 9 53 (18) 7 Self-rated level of experience as a clinical Type of facilityb, (%) 6 educator, n (%) public hospital 3 community based services 21 no experience private hospital some experience non-government organisation 28 average experience private practice 20 above average experience unknown 19 very experienced 7 University program poor discrimination. None of the items exhibited a Monash University (Victoria, Australia) 7 significant chi-square value (Table 4). To investigate if the Griffith University (Queensland, Australia) misfit of Item 6 was contributing to the overall item misfit La Trobe University (Victoria, Australia) 6 to the model, Item 6 was removed from each sample and James Cook University (Queensland, Rasch analysis repeated. The residual mean value for overall Australia) 3 item fit changed from –0.33 (SD 1.71) to –0.33 (SD 1.53) Curtin University (Western Australia, in Sample 1 and from –0.33 (SD 1.73) to –0.32 (SD 1.51) Australia) 1 in Sample 2. The reduction in score variability indicated a The University of Sydney (New South 1 small improvement in the overall fit of items to the model. Wales, Australia) Charles Sturt University (New South 7 Threshold order: There were no disordered thresholds for Wales, Australia) any of the 20 items in either Sample 1 or 2. The threshold Otago University (New Zealand) map for Sample 1 is illustrated in Figure 2. Auckland University of Technology (New Zealand) Targeting: The average person location in both samples unknown was close to zero (–0.06) indicating that overall the item difficulty was well targeted to the students’ abilities. aspinal injuries, burns, women’s health, oncology, mental health, The person-item threshold graph (Figure 3) presents the hand therapy, plastic surgery, bn = 423 distribution of the students (top half of the graph) and item thresholds (bottom half of the graph) on a logit scale for representing professional behaviour and communication Sample 1. This graph shows that a majority of item thresholds were amongst the least difficult items whereas the most correspond to the main cluster of persons (students). Logits difficult items related to analysis and planning, progressing of increasing negative value indicate less difficult items intervention, and applying evidence-based practice. and less able students. Logits of increasing positive value indicate more difficult items and more able students. There Person separation index: The person separation index appears to be an even spread of item thresholds across the was 0.95 for Sample 1 and 0.96 for Sample 2, indicating full range of student abilities, suggesting effective targeting that the APP is able to discriminate at least four levels of of APP items. Similar results were seen for the first field performance. test. At the far right end of the X-axis, there are a few person abilities that have no equivalent item threshold difficulties Differential item functioning: The presence of item bias that could differentiate their performance. These represent was explored by analysis of differential item functioning high performing students. The number of students who are with a Bonferroni-adjusted p value of 0.0025. No significant performing at a level too low to be captured by the scale is negligible. Hierarchy of item difficulty: The sequence or hierarchy of average difficulty of the 20 items on the APP for both samples is presented in Table 4. In both samples, items 242 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
JournalofPhysiotherapy2011 Vol.57 – ©AustralianPhysiotherapyAssociation2011 5BCMF Individual item fit of 20 APP items to the Rasch model: sample 1 (n = 326) and samp Sample 1 Location Standard Fit DF Chi- p Sa (n = 326) error residual squarea (n APP item AP 1 –2.088 0.136 0.796 306.73 1.94 0.746 1 3 –1.296 0.121 2.267 306.73 3.723 0.444 3 2 – 0.997 0.137 1.418 306.73 6.152 0.188 2 6 – 0.647 0.121 4.479 306.73 13.939 0.007 5 7 – 0.455 0.116 –1.078 306.73 1.161 0.884 6 4 – 0.174 0.121 – 0.358 306.73 3.856 0.425 7 5 – 0.154 0.114 0.46 306.73 1.759 0.779 4 20 – 0.073 0.119 –1.85 306.73 3.346 0.501 20 14 – 0.025 0.122 – 0.539 305.79 1.537 0.820 14 15 0.286 0.114 – 0.235 306.73 3.295 0.509 15 16 0.297 0.115 –1.105 306.73 1.052 0.901 9 18 0.401 0.122 –1.308 306.73 4.864 0.301 16 8 0.440 0.112 –2.54 306.73 6.308 0.177 18 9 0.496 0.114 –2.166 306.73 3.993 0.406 8 11 0.508 0.114 – 4.023 305.79 6.733 0.150 13 13 0.509 0.113 2.14 304.85 3.857 0.425 19 19 0.514 0.113 – 0.178 304.85 2.162 0.706 11 12 0.716 0.116 0.165 306.73 1.365 0.850 17 17 0.845 0.115 –1.455 305.79 2.27 0.686 10 10 0.896 0.115 –2.096 306.73 7.796 0.099 12 Item 1 = understands client rights, 2 = committed to learning, 3 = ethical practice, 4 = teamwork, 5 = com assessment skills, 10 = interprets assessment, 11 = prioritises problems, 12 = sets goals, 13 = intervent 17 = progresses intervention, 18 = discharge planning, 19 = applies evidence-based practice, 20 = asse 243
ple 2 (n = 318), with items ordered from least to most difficult. ample 2 Location Standard Fit DF Chi– p n = 318) error residual squarea PP item –1.824 0.128 1.104 280.98 5.765 0.217 –1.516 0.119 1.726 280.98 4.587 0.332 – 0.532 0.124 – 0.887 280.05 1.597 0.809 – 0.486 0.129 1.219 280.98 1.105 0.893 – 0.466 0.112 3.671 280.05 0.665 0.955 – 0.451 0.117 0.478 280.98 2.165 0.705 – 0.133 0.11 –2.121 280.98 1.462 0.833 0 – 0.106 0.111 –1.863 280.98 5.841 0.211 4 – 0.094 0.123 – 0.724 280.98 8.107 0.087 5 – 0.011 0.119 1.108 280.98 2.286 0.683 0.01 0.111 – 0.14 280.05 3.503 0.477 6 0.062 0.112 1.266 278.17 5.059 0.281 8 0.11 0.119 –2.612 280.98 1.094 0.895 Dalton et al: Assessment of professional competence of students 0.158 0.111 0.741 273.49 8.757 0.067 3 0.32 0.11 –1.285 278.17 3.389 0.494 9 0.321 0.112 –2.317 280.98 11.03 0.026 1 0.719 0.111 – 3. 286 279.11 6.669 0.154 7 0.784 0.112 –1.008 280.98 8.001 0.091 0 0.847 0.111 – 0.61 280.05 7.732 0.101 2 1.016 0.115 – 0.827 280.05 3.024 0.553 mmunication skills, 6 = documentation, 7 = interview skill, 8 = measures outcomes, 9 = tion choice, 14 = intervention delivery, 15 = effective educator, 16 = monitors intervention effects, esses risk. DF = degrees of freedom, aChi-square degrees of freedom was 4 for all items
Research understands client rights 0 1 23 4 committed to learning 0 34 ethical practice 0 1 2 teamwork 0 1 4 communication skills 0 1 12 3 34 documentation 0 interview skill 0 1 12 34 measures outcomes 0 34 assessment skills 0 12 interprets assessment 0 34 prioritises problems 0 12 34 sets goals 0 34 intervention choice 0 12 34 intervention delivery 0 34 effective educator 0 2 34 0 34 monitors intervention effects 12 progresses intervention 0 34 Items discharge planning 0 12 34 0 applies evidence-based practice 0 12 34 assesses risk 34 12 34 12 34 34 2 12 12 12 2 12 12 –9 –8 –7 –6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6 7 Person location (logits) 'JHVSF. Threshold map in Sample 1 (n = 326). person item 25 7.7% 20 6.1% Frequency 15 4.6% 10 3.1% 5 1.5% Frequency 0 0.0% –7 –6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6 7 Location (logits) –7 –6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6 7 0 0.0% 5 8.3% 10 16.7% 'JHVSF. Person-item threshold distribution for Sample 1 (n = 326). Grouping set to interval length of 0.20 making 70 groups. 244 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Dalton et al: Assessment of professional competence of students 90 y = 5.08x + 40.5 R2 = 0.99 80 70 60 Raw APP score 50 40 30 20 10 0 –6 –4 –2 0 2 4 6 8 10 Location 'JHVSF. Plot of person logit location and raw APP score (Sample 1 n = 326). differential item functioning was demonstrated in either of that is used as anticipated and that is able to discriminate at the two samples for the following variables: the student’s least four distinct levels of student performance. age, gender, or amount of prior clinical experience, the educator’s age, gender, or experience as an educator, or the The sequence or hierarchy of average difficulty of the 20 type of facility, university, or clinical area. This indicates competencies on the APP provides an indication of which the APP item ratings were not systematically affected by clinical competencies may be easier to acquire, such as any of these nine variables. communication and professional behaviours, and those that are more difficult and therefore may be expected to take Local independence and dimensionality: Local longer to master. The hierarchies of both samples in the independence is the assumption that responses to items are current study revealed that items related to analysis and independent. Some local dependence was evident, with four planning (critical thinking), goal setting, and selection and items showing positive residual correlations greater than progression of interventions were the most difficult items 0.3 in both samples. The items showing positive residual for students to perform. correlations were Item 1 (Demonstrates an understanding of patient rights and consent), Item 2 (Demonstrates a Rheault and Coulson (1991) demonstrated a similar ranking commitment to learning), Item 3 (Demonstrates ethical, of a 6-item physiotherapy practice assessment instrument. legal and culturally sensitive practice), and Item 5 (Verbal From easiest to most difficult the items were: exhibits communication). professionalism, exhibits communication skills, performs effective treatment skills, performs safe treatment skills, A unidimensional set of items measures a single underlying can problem solve, and works from an adequate knowledge construct. APP dimensionality was tested by an independent base. t-test procedure of person ability locations derived from two subsets of items – one loading positively and the other While the data collected in the field test demonstrated negatively > 0.30 on the first residual factor of the principal overall fit to the Rasch model for both participant samples, components analysis in RUM2020 (Tennant and Pallant Item 6 (Written communication) showed misfit to the 2006). The proportion of persons with significantly different Rasch model. Pallant and Tennant (2007) state that one of person estimates based on the two item subsets was 7.3% the most common sources of item misfit is respondents’ and 6.9% for the two samples. The confidence intervals for (educators) inconsistent use of the scoring options a binomial test of proportions both included 5%, providing resulting in disordered thresholds. However, investigation evidence of the unidimensionality of the scale. of threshold ordering of the 20 polytomous items on the APP showed there were no disordered thresholds in either Figure 4 shows the relationship between raw ordinal APP sample. Despite a small improvement in overall item fit to scores and person logit location for Sample 1. Sample 2 the model when Item 6 was deleted, removal of this item is exhibited the same relationship. not justified given that written communication is part of the current Australian Standards for Physiotherapy (Australian Discussion Physiotherapy Council 2006) and represents an essential aspect of professional competence. Exploration of this This second and final field trial of the 20-item APP confirmed issue with clinical educators suggests that there is a lack of that it is a unidimensional instrument with a response scale consensus with respect to the timing of recording patient- Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 245
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