Australian Physiotherapy Journal

de Morton et al: Measuring mobility of patients in the Transition Care Program 5BCMF
 Responsiveness to change of the de Morton Mobility Index and the Modified Barthel Index. Responsiveness index Tool n Estimate (95% CI) Guyatt Responsiveness to Change DEMMI 265 1.58 (1.39 to 1.77) MBI 269 0.72 (0.61 to 0.82) Effect Size Index DEMMI 501 0.34 (0.25 to 0.42) MBI 586 0.14 (0.06 to 0.22) DEMMI = de Morton Mobility Index, MBI = Modified Barthel Index 5BCMF
 Estimates of the minimum clinically important difference of the de Morton Mobility Index and the Modified Barthel Index. Method Tool n Estimate (95% CI) Criterion based DEMMI 265 12 (10 to 13) MBI 269 13 (11 to 15) Distribution based DEMMI 678 10 MBI 670 15 DEMMI = de Morton Mobility Index, MBI = Modified Barthel Index Minimum clinically important difference: The minimum were Rasch analysed at admission to and discharge from clinically important difference was calculated using the Transition Care Program. criterion- and distribution-based methods. The criterion- based method was calculated where clinically important Results change was considered to have occurred for patients who rated their mobility as ‘much better’ at discharge Of the 14 health services invited to participate, 11 health assessment. The distribution-based method estimated the services participated in this study. Three health services minimum clinically important difference by calculating declined due to understaffing. Of the included health half the baseline standard deviation of raw scores (Norman services, the mean number of Transition Care Program et al 2003). beds was 40 (SD 24), ranging from 10 (in a rural setting) to 94 (in a metropolitan setting). A total of 696 participants Rasch analysis: Rasch analysis was conducted to investigate were included in this study. Table 1 shows the baseline the unidimensionality of the DEMMI in a population demographics of included participants. of patients on the Transition Care Program. The Rasch model is a probabilistic model that confers confidence that Modified Barthel Index and DEMMI assessments were scores obtained using the instrument are a valid measure conducted at admission and discharge to the Transition of a subject’s ability. The DEMMI was developed based Care Program; the scores are presented in Figures 1 and 2. on the Rasch model in an older acute medical population Allied Health Assistants conducted assessments on 1% and (de Morton et al 2008b) and if the data fit the Rasch 17% of occasions at admission and discharge, respectively. model in this study, this also provides confidence that the At admission, 678 participants (97%) were assessed with DEMMI is indeed measuring one construct (ie, that it is the DEMMI and 669 participants (96%) were assessed with a unidimensional measure of mobility) in a population of the Modified Barthel Index. At discharge, 502 participants patients on the Transition Care Program and can be applied (72%) were assessed with the DEMMI and 594 participants to obtain interval level measurement. (85%) were assessed with the Modified Barthel Index. Neither instrument had a floor or ceiling effect. Fit to the model is indicated by an overall item-trait interaction chi-squared value of greater than 0.05, indicating Validity: Similar evidence of validity was obtained for the no significant deviation of the data from the Rasch model, DEMMI and Modified Barthel Index (Table 2). A significant and a finding of 5% or less using the t-test procedure is moderate correlation was identified between DEMMI and recommended (Tennant and Pallant 2006). Item misfit Modified Barthel Index scores and provides evidence of is considered to have occurred if fit residuals of greater convergent validity for both instruments (Table 2, Figure than ±2.5 or a significant Bonferroni adjusted p value are 3). Both instruments had low correlations with the Charlson identified. Differential item functioning occurs when an Comorbidity Index, providing evidence of discriminant item performs differently based on another variable (eg, validity. Significantly higher scores were obtained for low age or gender). In this study differential item functioning level care residents compared to high level care residents at for the DEMMI items was investigated for age (< 80 years, discharge using the DEMMI and Modified Barthel Index, 80–84 years and 85+ years), gender, Charlson comorbidity which provided evidence of known-groups validity for both score (0, 1, or ≥ 2), and whether a physiotherapist or allied tools (Table 3). health assistant administered the DEMMI. DEMMI data Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 113

Research Responsiveness to change: The DEMMI was significantly between instrument scores in this study. The Modified more responsive to change than the Modified Barthel Index Barthel Index is a measure of independence in activities when assessed using the criterion-based index, Guyatt’s of daily living and the DEMMI is a unidimensional responsiveness to change, and distribution-based index, measure of mobility. Consequently, for physiotherapists, effect size (Table 4). The effect size for the DEMMI was the Modified Barthel Index could be a relatively ‘blunt’ in the small to moderate range, while the effect size for the measure of effectiveness as changes in other domains such Modified Barthel Index was in the small range. as continence can confound changes in the targeted area of interest – mobility. This may be why the DEMMI was Minimum clinically important difference: Similar identified as more responsive to change than the Modified estimates of the minimum clinically important difference Barthel Index in this study. were obtained using criterion- and distribution-based methods for the DEMMI and Modified Barthel Index Neither the DEMMI nor the Modified Barthel Index (Table 5). had floor or ceiling effects. This is often a limitation of instruments that are applied in heterogeneous populations Rasch analysis: At admission, no item had high positive fit who range from bed-bound to high levels of independent residuals to indicate multidimensionality but the sit to stand mobility. Both the DEMMI and Modified Barthel Index item had a high negative fit residual, suggesting possible have the scale width required to measure and monitor redundancy. Six items (roll, sit to stand, stand, walking changes, both improvement and deterioration, for patients independence, picking up pen, and walking backwards) in the Transition Care Program. A greater proportion of showed mild deviation from the Rasch model based on patients scored the highest possible score of 100 at discharge significant Bonferroni adjusted p values across class on the Modified Barthel Index than with the DEMMI. This intervals and/or for individuals. There were no disordered finding may indicate that the DEMMI has a broader scale thresholds or differential item functioning by age, gender, width than the Modified Barthel Index and demonstrate Charlson score, or whether an allied health assistant or its potential to measure improvement after discharge from physiotherapist administered the DEMMI. Item difficulty the Transition Care Program and return to independence in and person ability were well matched. However, overall activities of daily living. fit to the Rasch model was not achieved, evidenced by a significant p value for χ2 testing for item trait interaction (p Rasch analysis identified that the DEMMI items performed < 0.01). However, 10 random samples of 100 fitted the model consistently regardless of whether a physiotherapist or an on each occasion and suggest that sample size influenced allied health assistant administered the assessment. This fit to the model in this population. The t-test procedure on finding has important workforce implications as allied health admission data indicated unidimensionality with a result of staff recruitment and retention is a challenge for Transition 2.17%. Care Programs. Three of the programs across Victoria were unable to participate in this research due to staff shortages. Rasch findings were similar for hospital discharge data. No In response to these findings, the physiotherapy profession items had high positive or negative fit residuals. Four items could review the boundaries of the scope of practice of showed some mild deviation from the Rasch model (bridge, allied health assistants and physiotherapists. Our findings roll, stand, stand feet together). There was no differential increase the potential for physiotherapists to work more as a item functioning for age, gender, or Charlson comorbidity consultant for all appropriate patients, with the allied health score but there was significant systematic differential item assistant able to administer the prescribed assessments and functioning depending on whether an allied health assistant therapy as directed by the physiotherapist. Such a shift in or physiotherapist administered the DEMMI for the bridge the allied health assistant/physiotherapist scope of practice item. However, there were no patients in the first class would potentially allow for aspects of workforce shortages interval among those assessed by an allied health assistant in physiotherapists to be explored. and this is likely to explain this finding. There were no disordered thresholds. Again, overall fit to the model was In this study patients were referred for allied health assistant not achieved with a significant item trait interaction χ2 value assessment when the physiotherapist deemed the patient of p < 0.01 but random samples of 100 fitted the model on appropriate and subsequently a larger proportion of the allied 9 out of 10 occasions. The t-test procedure on discharge health assistant assessments were conducted at discharge data indicated unidimensionality with a result of 3.04%. (17%) than at admission (1%). An inter-rater reliability study The hierarchy of item difficulty was almost identical in needs to be conducted between physiotherapists and allied admission and discharge samples. health assistants using the DEMMI to investigate further whether allied health assistants can complete assessments Discussion for physiotherapists in this cohort. This study supports the validity of the DEMMI for The participants in this study had a wide variety of measuring the mobility of patients making the transition admission diagnoses. This is typical of the heterogeneity from hospital to the community. Currently it is required that is commonly observed in other clinical settings with that the Modified Barthel Index is administered in this older populations such as a general community population patient cohort. However, the DEMMI has been identified in in primary care, rehabilitation centre, or acute medical this study as more responsive to change than the Modified hospital wards. The results of this study support the findings Barthel Index and is a unidimensional measure of mobility of DEMMI clinimetric validation studies in other clinical – a construct of particular interest to physiotherapists. settings (Davenport and de Morton 2010, de Morton et al 2008b, de Morton and Lane 2010, de Morton et al 2010). The Modified Barthel Index and the DEMMI serve different purposes and this is reflected in the moderate correlation The strength of this study is that it included a large sample 114 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011

de Morton et al: Measuring mobility of patients in the Transition Care Program from two Australian states that was inclusive of both References metropolitan and regional areas, which suggests that our study was based on a representative sample of patients Barrett B, Brown D, Mundt M, Brown R (2005a) Sufficiently referred for physiotherapy in Transition Care Programs. important difference: expanding the framework of clinical Limitations of this study are that the analysis comparing significance. Medical Decision Making 25: 250–261. assessments between allied health assessments and physiotherapists was preliminary and may have been biased Barrett B, Brown R, Mundt M, Dye L, Alt J, Safdar N, et al as the assistants completed a relatively larger proportion (2005b) Using benefit harm tradeoffs to estimate sufficiently of discharge compared to admission assessments. The important difference: the case of the common cold. Medical methods selected for estimating the minimum clinically Decision Making 25: 47–55. important difference in this study (both criterion- and distribution-based) have limitations. These methods do Belvedere S, de Morton N (2010) The application of Rasch not incorporate how the patient feels with regards to the analysis in healthcare is increasing and is applied for magnitude of the effect, taking into account factors such variable reasons in mobility instruments. Journal of Clinical as the cost, inconvenience, and harms (Barrett et al 2005a, Epidemiology 63: 1287–1297. Barrett et al 2005b, Ferreira and Herbert 2008). Patients were excluded from this study if they were not discharged Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new within the study period and this systematic bias is a method of classifying prognostic comorbidity in longitudinal limitation of this study. The most missing data in this study studies: development and validation. Journal of Chronic were for discharge DEMMI assessments (n = 194), but still Disease 40: 373–383. included 502 participants. The influence of missing data on study results is unknown and reflects the busy caseload Collin C, Wade DT, Davies S, Horne V (1988) The Barthel ADL of Transition Care Program physiotherapists and limited Index: a reliability study. International Disability Studies 10: staffing. 61–63. The DEMMI and Barthel are both valid measures of activity Davenport S, de Morton N (2010) The reliability and validity of limitation for Transition Care Program patients. This study the de Morton Mobility Index (DEMMI) in healthy community has validated the DEMMI as an instrument for accurately dwelling older adults. Archives of Physical Medicine and measuring and monitoring the mobility of Transition Care Rehabilitation 92: 51–58. Program patients. It has a broad scale width that captures the diverse range of mobility levels that are commonly Davenport S, Paynter S, de Morton N (2008) What instruments observed in Transition Care Program cohorts. The DEMMI have been used to assess the mobility of community dwelling is more responsive to change than the Modified Barthel older adults? Physical Therapy Reviews 13: 345–354. Index and offers physiotherapists an advanced method for accurately measuring and monitoring changes in mobility de Morton N, Berlowitz D, Keating J (2008a) A systematic for Transition Care Program patients. Q review of mobility instruments and their measurement properties for older acute medical patients. BMC Health and Ethics: The study was approved by the following Human Quality of Life Outcomes 6(44) Research Ethics Committees (HREC): Alfred Health HREC; Bendigo Health HREC; Eastern Health HREC; de Morton N, Davidson M, Keating J (2008b) The de Morton Echuca Regional Health HREC; Goulburn Valley HREC; Mobility Index (DEMMI): an essential index for an ageing La Trobe University Faculty HREC; Peninsula Health world. BMC Health and Quality of Life Outcomes 6(63) HREC; Tasmania Health and Medical Human Research Ethics Council; St Vincent’s Health HREC; Southern de Morton N, Keating J, Davidson M (2008c) Rasch analysis Health HREC; Melbourne Health HREC. This study was a of the Barthel Index in the assessment of hospitalised older de-identified analysis of data collected within usual clinical patients following admission for an acute medical condition. care. Archives of Physical Medicine & Rehabilitation 89: 641–647. Support: Funding sources for this research were the de Morton N, Lane K (2010) Validity and reliability of the de National Health and Medical Research Council of Australia Morton Mobility Index (DEMMI) in the subacute hospital (NHMRC Post Doctoral Fellowship for Dr Natalie de setting in a geriatric evaluation and management (GEM) Morton, Grant no. 519555) and Eastern Health Allied population. Journal of Rehabilitation Medicine 42: 956–961. Health Research Scholarship for Natasha Brusco. de Morton N, Meyer C, Moore K, Dow B, Jones CJ, Hill K (In Acknowledgements: The authors would like to acknowledge press) Validation of the de Morton Mobility Index (DEMMI) the 11 Transition Care Program managers and physiotherapy with older community care recipients. Australasian Journal site managers for the ongoing support of their staff to of Ageing. participate in the study. de Morton NA, Keating JL, Berlowitz DJ, Jackson B, Lim Competing interests: None declared. WK (2007) Additional exercise does not change hospital or patient outcomes in older medical patients: a controlled Correspondence: Dr Natalie de Morton, Musculoskeletal clinical trial. Australian Journal of Physiotherapy 53: 105–111. Research Centre and School of Physiotherapy, La Trobe University, Australia. Email: [email protected]. Department of Health and Ageing (2008) National Evaluation of the Transition Care Program: Final Evaluation Report. 7YY[ii[Z Wj ^jjf0%%mmm$^[Wbj^$]el$Wk ed '+j^ I[fj[cX[h 2010. Dewing J (1992) A critique of the Barthel Index. British Journal of Nursing 1: 325–329. <[hh[_hW C\" >[hX[hj H (&&. M^Wj Ze[i ¼Yb_d_YWbbo _cfehjWdj½ really mean? Australian Journal of Physiotherapy 54: 229– 230. Guyatt GH, Walter S, Norman G (1987) Measuring change over time: assessing the usefulness of evaluative instruments. Journal of Chronic Disease 40: 171–178. Hachisuka K, Ogata H (1997) Test-retest and inter- method reliability of the self-rating Barthel Index. Clinical Rehabilitation 11: 28–35. Hill K, Moore K, Dorevitch M, Day L (2008) Effectiveness of falls clinics: an evaluation of outcomes and client adherence Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 115

Research to recommended interventions. Journal of the American Norman GR, Sloan JA, Wyrwich KW (2003) Interpretation of Geriatrics Society 56: 600–608. changes on health related quality of life. The remarkable universality of half a standard deviation. Medical Care 41: Husted J, Cook R, Farewell V, Gladman D (2000) Methods 582–592. for assessing responsiveness: a critical review and recommendations. Journal of Clinical Epidemiology 53: Shah S, Vanclay F, Cooper B (1989) Improving the sensitivity of 459–468. the Barthel Index for stroke rehabilitation. Journal of Clinical Epidemiology 42: 703–709. Jensen G, Gwyer J, Hack L, Shepard K (1999) Expertise in physical therapy practice. Cochrane Database of Systematic Tennant A, Pallant J (2006) Unidimensionality matters! (A tale Reviews (4): CD003010, of two Smiths?). Rasch measurement transactions 20: 1048– 1051. Kazis LE, Anderson JJ, Meenan RF (1989) Effect sizes for interpreting changes in health status. Medical Care 27: World Health Organisation (2001) International Classification S178–189. of Functioning, Disability and Health. Geneva: World Health Organisation. Submitting systematic reviews to Journal of Physiotherapy To conform with PRISMA requirements, Journal of Physiotherapy now requires registration of systematic reviews. All systematic reviews submitted 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 (such as PROSPERO at www. crd.york.ac.uk/PROSPERO/). Authors must provide the name and website address of the register and the registration number on submission. 116 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011

Appraisal Clinimetrics The six-minute walk test in paediatric populations Description The only requirements are a 15–20 metre corridor or exercise room, four cones, measuring tape, a stop-watch, a heart rate The six-minute walk test (6MWT) is a self-paced, monitor, and written instructions for the encouragements. submaximal exercise test used to assess functional exercise capacity in patients with chronic diseases (Chang 2006, In children, varying associations have been reported Solway et al 2001). It has been used widely in adults, and between age, height, weight, and gender, and 6MWT is being utilised increasingly in paediatric populations; distance. Several studies have reported reference values it has been used as an estimate of physical fitness in, for from healthy children from different geographic regions, example, children with severe cardiopulmonary disease, Europe, Asia, Africa, and North America (Ben Saad et al cystic fibrosis, and juvenile idiopathic arthritis (Hassan et 2009, Geiger et al 2007, Klepper and Muir 2011, Lammers al 2010). et al 2007, Li et al 2007), making it possible to determine the predicted 6MWT distance for individual patients. Instructions to clients and scoring: Standardised guidelines for the performance of the 6MWT are published Reliability: Reproducibility testing has shown good by the American Thoracic Society (ATS) (ATS 2002). reliability (ICC 0.96 to 0.98) for children with or without Walking distance is accepted as the main outcome measure chronic disease. In the same literature, agreement varies of the 6MWT, although the product of walking distance among paediatric populations with smallest detectable times body weight is suggested as an alternative outcome differences ranging from 36 metres in children with spina (Hassan et al 2010). bifida (de Groot et al 2011) up to 139 metres in children with cystic fibrosis (Cunha et al 2006), so caution is advised The 6MWT is performed individually with standardised when evaluating individual changes in 6MWT distance encouragements during the test (ATS 2002). The subject is after interventions or follow-up. instructed to cover as much distance as possible in 6 minutes without running. We recommend using a distance of 15–20 Validity: Several publications have indicated that there metres between turning points, in contrast to the 30 metres are only low correlations between walking distance and recommended for adults. In addition, the test is performed VO2max in children. The following Pearson’s correlations indoors in a quiet corridor or exercise room with no ‘pacer’ between 6MWT distance and VO2max are reported: juvenile (therapist who walks behind the patient) except when there idiopathic arthritis, r = 0.25; hemophilia, r = 0.31; spina is a high risk of falling (as has been described for children bifida, r = 0.46; end-stage renal disease, r = –0.25. Recently it with Duchenne muscular dystrophy) (McDonald et al 2010). was reported that in children with pulmonary hypertension correlation between 6MWT distance and VO2max was It is recommended that heart rate should be monitored significant when the walk distance is lower than 300 m, consistently both at rest and during the walk when using the and there was no association when the 6MWT distance 6MWT (Verschuren et al 2011). This might help differentiate was > 300 m (Lammers et al 2011). Because of these low whether low scores are because the child was more or less correlations, the 6MWT cannot be used as a replacement prepared psychologically to complete a 6MWT, or because for a maximal exercise test (Takken 2010). the child was able to move with less ease and, thus, had higher physiological strain. References Commentary ATS (2002) Am J Respir Crit Care Med 166: 111–117. The 6MWT is an inexpensive instrument for measuring Ben Saad H et al (2009) Pediatr Pulmonol 44: 316–324. functional exercise capacity in paediatric populations. Care should be taken to ensure appropriate execution of Chang A (2006) Aus J Physiother 52: 228. the test. Our experience from a recent unpublished survey among Dutch (paediatric) physiotherapists is there is a large Cunha MT et al (2006) Pediatr Pulmonol 41: 618–622. variety in performance of the 6MWT among therapists, especially distance between turning points (variation 5–50 de Groot JF et al (2011) Phys Ther 91: 267–276. metres), lay-out of circuit (circle, squares, and even on treadmill), instructions for turning, as well as differences Geiger J et al (2007) J Pediatr 150: 395–399, 9 e1-2. in encouragements. For optimal reliability it is important that the test is performed in a standardised manner as Hassan J et al (2010) Br J Sports Med 44: 270–274. recommended by the ATS (ATS 2002). Furthermore, the various sets of reference values differ substantially. Klepper SE, Muir N (2011) Pediatr Phys Ther 23: 32–40. Therefore, it is advised to use the same set of norm values all the time. Lammers AE et al (2011) Arch Dis Child 96: 141–147. Janke F de Groot and Tim Takken Lammers AE et al (2007) Arch Dis Child 93: 464–468. Wilhelmina Children’s Hospital, University Medical Li AM et al (2007) Am J Respir Crit Care Med 176: 174–180. Center Utrecht, Utrecht, the Netherlands McDonald CM et al (2010) Muscle Nerve 41: 500–510. Solway S et al (2001) Chest 119: 256–270. Takken T (2010) Acta Paediatr 99: 958. Verschuren O et al (2011) Dev Med Child Neurol 53: 470–472. 128 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011

Harvey et al: Training unsupported sitting after spinal cord injury Training unsupported sitting does not improve ability to sit in people with recently acquired paraplegia: a randomised trial Lisa A Harvey1, Donna Ristev2, Mohammad S Hossain3, Mohammad A Hossain3, Jocelyn L Bowden1, Claire L Boswell-Ruys4, Mohammad M Hossain3 and Marsha Ben2 1Rehabilitation Studies Unit, University of Sydney, Australia, 2Moorong Spinal Unit, Royal Rehabilitation Centre Sydney, Australia, 3Centre for the Rehabilitation of the Paralyzed, Savar, Bangladesh, 4Neuroscience Research Australia, Australia Question: Do people with recently acquired paraplegia benefit from a six-week motor retraining program aimed at improving their ability to sit unsupported? %FTJHO A randomised controlled trial with concealed allocation, assessor blinding, and intention-to- treat analysis. Participants: 32 people with recently acquired paraplegia and limited ability to sit unsupported. *OUFSWFOUJPO All participants undertook standard inpatient rehabilitation over a six-week period. Experimental participants received three additional 30-minute sessions per week of motor retraining directed at improving their ability to sit unsupported. Outcome measures: The three primary outcomes were the Maximal Lean Test, Maximal Sideward Reach Test, and the Performance Item of the Canadian Occupational Performance Measure (COPM). The secondary outcomes were the Satisfaction Item of the COPM, Participants’ Impressions of Change, Clinicians’ Impressions of Change, the T-shirt Test, and the Spinal Cord Injury Falls Concern Scale. 3FTVMUT The mean between-group differences for the Maximal Lean Test, Maximal Sideward Reach Test and the Performance Item of the COPM were –20 mm (95% CI –64 to 24), 5% arm length (95% CI –3 to 13) and 0.5 points (95% CI –0.5 to 1.5), respectively. The secondary outcomes did not differ significantly between groups. Conclusion: People with recently acquired paraplegia do not benefit from a six-week motor retraining program directed specifically at improving their ability to sit unsupported. Their ability to sit unsupported does, however, improve over time, suggesting that the practice of activities of daily living has important carry-over effects on unsupported sitting, rendering additional training redundant. Trial registration: ACTRN12608000464369. [Harvey LA, Ristev D, Hossain MS, Hossain MA, Bowden JL, Boswell-Ruys CL, )PTTBJO
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XPSET: Spinal cord injuries, Physical therapy, Motor relearning Introduction because therapists need to ensure that they concentrate on the most important and most effective interventions The ability to sit unsupported is important for people with during rehabilitation. A recent study indicated that people paraplegia because they perform most activities of daily with spinal cord injury receive a mere 33 minutes of active living from a seated position (Anderson 2004). Paralysis therapy a day during their initial rehabilitation following of the trunk and lower limbs makes sitting unsupported injury (van Langeveld et al 2010). It is imperative that this difficult and, not surprisingly, physiotherapists devote time is spent on interventions with proven efficacy, but it is large amounts of therapeutic attention to improving sitting not clear whether training unsupported sitting is good use ability. Therapy typically involves exercises and practice of therapists’ and patients’ time. of functional activities in a seated position following the principles of motor relearning. For example, a person with In a recent clinical trial (Boswell-Ruys et al 2010b), we complete paraplegia may practise reaching for objects while demonstrated small changes in the ability of people with sitting unsupported over the edge of the bed. Alternatively, paraplegia to sit unsupported following an intensive motor a person with incomplete paraplegia may practise lifting, training program (mean between-group difference for the moving, or manipulating objects while trying to maintain an Maximal Lean Test was 64 mm, 95% CI 20 to 108). This upright seated position. A key aspect of this type of training trial was conducted in people with chronic spinal cord is repetitive practice combined with clear instructions, well- injury (ie, at least one year after injury) when responsiveness timed and accurate feedback, and appropriate progression to therapy is probably weakest. We were interested in (Carr and Shepherd 2000, Harvey et al 2008). investigating the effects of training unsupported sitting in people with recently acquired paraplegia. Therefore, the Despite the time and effort devoted to training unsupported question underpinning this study was: sitting, little is known about its effectiveness. In particular, it is not known whether people with paraplegia intuitively Do people with recently acquired paraplegia benefit learn strategies to sit unsupported or whether they require from an intensive motor training program directed at specific training in this area. The question is important improving the ability to sit unsupported? Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 83

Research Method 'JHVSF
 Examples of the types of exercises performed XofWhj_Y_fWdji_cW][iYekhj[ioe\\^jjf0%%mmm$ Design physiotherapyexercises.com). An assessor-blinded, randomised controlled trial was Each of the 84 exercises was written on a card and placed undertaken, in which participants with recent spinal cord in a pack. Participants arbitrarily chose cards from the pack injury were randomised to standard inpatient rehabilitation for each session. Details about each participant’s exercise or to standard inpatient rehabilitation with additional program were recorded. motor retraining directed at improving their ability to sit unsupported. A computer-generated random allocation Control participants did not practise any of the 252 schedule was compiled before commencement by a exercises. However, all participants continued to receive person not involved in the recruitment of participants. The standard physiotherapy and occupational therapy which randomisation schedules were blocked and stratified by included training for transfers, wheelchair skills, dressing site. Initially, the study was planned for just the Australian and showering. The protocol also dictated that control site. Therefore, a blocked randomisation schedule for 32 participants receive three 5-minute sessions per week of participants was developed. However, when the Bangladesh training in unsupported sitting. However, this was provided site entered the study a year later, a second blocked only to the control participants from the Bangladesh site. randomisation schedule was set up for 16 participants from The control participants from the Australian site did not the Bangladesh site. Participants’ allocations were placed in receive any training in unsupported sitting for the duration opaque, sequentially numbered, sealed envelopes that were of the study. held offsite by an independent person based in Australia. Once a participant passed the screening process and Outcome measures completed the initial assessment, an envelope was opened and allocation revealed. The participant was considered to All assessments were conducted at the beginning and end of have entered the trial at this point. the 6-week study period by one assessor from the Bangladesh site and one of two assessors from the Australian site; all Participants blinded to participants’ allocation. Participants were asked not to discuss their training or group allocation with the Participants were included if they were over 18 years of assessors. The success of blinding was verified at the end of age, had sustained a complete or incomplete spinal cord each participant’s assessment by asking assessors to reveal injury below T1, had sustained their spinal cord injury less whether they had been unblinded. than 6 months prior, and were receiving physiotherapy and occupational therapy as part of a comprehensive in-patient Three primary outcomes were measured: the Maximal rehabilitation program. Participants were eligible for Lean Test (also called the Maximal Balance Range), the inclusion only if they had limited ability to sit unsupported Maximal Sideward Reach Test, and the Performance Item of as verified by a score of 5/7 or less on the unsupported sitting the Canadian Occupational Performance Measure (COPM). item of the Clinical Outcomes Variable Scale (Campbell et Five secondary outcomes were used: the Satisfaction Item al 2003). Participants were excluded if they were unlikely of the COPM, the T-shirt Test, Participants’ Impressions to co-operate or had pressure areas necessitating bedrest. of Change, Clinicians’ Impressions of Change, and Spinal Participants were referred to the study by hospital-based Cord Injury Falls Concern Scale. These outcomes were therapists. Intervention Participants in the experimental group received 30 minutes of task-specific training by a physiotherapist skilled in the management of people with spinal cord injuries, three times a week for six weeks. This intervention was provided in addition to the participants’ standard in-patient therapy. This was the most intensive dose of motor training that could be realistically provided within the rehabilitation facilities. The 30 minutes did not include time spent in set up, rest, or conversation. Consequently, each session took between 45 and 60 minutes. A stopwatch was used to ensure that 30 minutes of active therapy was achieved. The training was tailored to each participant’s stage of rehabilitation with the emphasis on providing clearly defined goals for each therapy session as well as appropriate and well-timed instructions and feedback. Participants sat in an unsupported position on a physiotherapy bed with hips and knees flexed to 90o and feet supported on the ground. Participants were required to practise repeatedly specifically-designed exercises that involved moving the upper body over and outside the base of support (Figure 1). There were 84 different exercises each with three grades of difficulty (ie, a total of 252 exercises). The 84 exercises were developed as part of a previous trial and developed in consultation with senior spinal cord injury physiotherapists from Sydney (Boswell-Ruys et al 2010b). 84 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011

Harvey et al: Training unsupported sitting after spinal cord injury selected on the basis of a study comparing the validity and using the best available estimates of standard deviation and reliability of each test (Boswell-Ruys et al 2010a, Boswell- where necessary predicted initial scores (ie, an initial score Ruys et al 2009) and on the basis of the results of a similar of 250 mm and SD of 50 mm for the Maximal Lean Test, clinical trial (Boswell-Ruys et al 2010b). an initial score of 100 and SD of 15 mm for the Maximal Sideward Reach Test, and a SD of 2 points for the COPM). The Maximal Lean Test assessed participants’ ability to lean The power calculations assumed a drop-out rate of 5%, a as far forwards and backwards as possible without falling power of 80%, an alpha of 0.05, and a strong correlation and without using the hands for support. The Maximal (0.8) between initial and final values. Sideward Reach Test assessed participants’ ability to reach in a 45º direction to the right while seated unsupported on All statistical analyses were performed using the principle of a physiotherapy bed (Boswell-Ruys et al 2009). The T-shirt ‘intention to treat’ although a secondary exploratory analysis Test measured the time taken for participants to don and doff was also performed excluding data from participants who a T-shirt (Boswell-Ruys et al 2009, Chen et al 2003). The completed less than 17 of the 18 training sessions. All data best attempt of two trials was analysed for each outcome. A are reported as means (SD) unless otherwise stated. Data mean between-group difference equivalent to 20% of mean for the Maximal Lean Test, Maximal Sideward Reach Test, baseline data was deemed clinically important for the three T-shirt Test, and Spinal Cord Injury Falls Concern Scale outcomes prior to the commencement of the study. were analysed with a factorial analysis of covariance using a linear regression approach. The Performance Item of the The COPM determines participants’ perceptions about COPM, the Satisfaction Item of the COPM, Participants’ treatment effectiveness in relation to self-nominated goals Impressions of Change, and Clinicians’ Impressions of (Law et al 1990). The Performance and Satisfaction ratings Change data were analysed using the ‘cendif’ routine in of the COPM were averaged across the two activities Stata softwarea to derive the 95% CIs for median between- identified as most important to the participant. A mean group differences. This method does not make assumptions between-group difference of 2 points was deemed clinically about the distribution of the data. Significance for all tests important prior to the commencement of the study as was set at p < 0.05, but all data were interpreted with respect recommended by others (Law et al 2010). to pre-determined clinically meaningful change. Participants’ Impressions of Change were assessed at the Results end of the 6-week study period by asking both control and experimental participants to rate their global impressions 'MPX
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TUVEZ of change in their ability to sit unsupported over the preceding six weeks on a 15-point Likert-style scale, in Thirty-two people with recently acquired paraplegia were which –7 indicated ‘a very great deal worse’, 0 indicated recruited from the Moorong Spinal Cord Injury Unit in ‘no change’, and +7 indicated ‘a very great deal better’ Australia (n = 16) and the Centre for the Rehabilitation (Barrett et al 2005, Jaeschke et al 1989). Clinicians’ of the Paralyzed in Bangladesh (n = 16). The flow of Impressions of Change were assessed with the use of video participants through the trial is shown in Figure 2. clips (Harvey et al 2011). Short video clips of participants Outcomes were attained for all variables on all participants sitting unsupported were taken at the beginning and end of with the following two exceptions: data for one participant the 6-week study period. The video clips were then shown were missing for Clinicians’ Perceptions of Change (due to to two blinded physiotherapists who were asked to rate problems with the video clip) and data for one participant their global impressions of change in performance of each were incomplete for the Maximal Lean Test due to the participant after viewing the first video clip in relation to participant’s inability to tolerate the test. For this participant, the second video clip. The therapists used the same 15-point the backward lean aspect of the measure was recorded but rating scale used by participants. A mean between-group not the forward lean aspect of the measure. difference of one point was deemed clinically meaningful prior to the commencement of the study for both outcomes Participant characteristics as recommended by others (Schneider and Olin 1996). The median age and time since injury were 27 years (IQR 24 The Spinal Cord Injury Falls Concern Scale is a standardised to 31) and 11 weeks (IQR 8 to 16), respectively. According questionnaire that asks participants to rate their concern to the International Standards for Classification of Spinal about falling when performing 16 common tasks such Cord Injury, participants were categorised as American as dressing or pushing a wheelchair (Boswell-Ruys et al Spinal Injury Association Impairment Scale (AIS) A (n 2010a). Each task is rated on a 4-point Likert-style scale = 29), AIS B (n = 2), or AIS C (n = 1) with neurological anchored at one end with ‘not at all concerned’ and at the and motor levels ranging from T1 to L1 (see Table 1). The other end with ‘very concerned’. In addition, experimental groups were similar at baseline. participants were asked to rate the ‘inconvenience’ of the training on a 10-cm visual analogue scale anchored at one Compliance with trial method end with ‘extremely inconvenient’ and at the other end with ‘not at all inconvenient’. Adherence to the study protocol was reasonable. The protocol dictated that participants receive 18 training Data analysis sessions over six weeks. In reality, they received a median of 18 training sessions (IQR 12 to 18) over 6 weeks (IQR Power calculations were based on the results of two studies: 6 to 7). There were four participants from the Sydney site one a clinical trial (Boswell-Ruys et al 2010b), the other who received only six (1 participant), 11 (2 participants), or a study of the psychometric properties of the scales used 12 (1 participant) sessions due to poor compliance, and one in this study (Boswell-Ruys et al 2009). The current study participant from the Bangladesh site who received only five was, however, powered for only the three primary outcomes sessions due to back pain. All three assessors indicated that blinding had been maintained throughout the study. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 85

Research Patients screened for eligibility (n = 478) (Sydney n = 102, Bangladesh n = 376) Excluded (n = 446) š Tetraplegia (Sydney n = 40, Bangladesh n = 145) š Clinical Outcomes Variable Scale > 5 (Sydney n = 26, Bangladesh n = 111) š < 18 years old (Sydney n = 0, Bangladesh n = 25) š Pressure area preventing sitting (Sydney n = 0, Bangladesh n = 57) š Medical complications (Sydney n = 5, Bangladesh n = 22) š Declined (Sydney n = 3, Bangladesh n = 0) š Unlikely to comply (Sydney n = 7, Bangladesh n = 0) š > 6 mo since injury (Sydney n = 5, Bangladesh n = 0) Randomised (n = 32) (n = 16) (n = 16) Week 0 Measured Maximal Lean Test, Maximal Sideward Reach Test, Canadian Occupational Performance Measure, T-shirt Test and Spinal Cord Injury Falls Concern Scale (n = 16) (n = 16) Lost to follow-up Experimental Group Control Group Lost to follow-up (n = 0) (n = 0) š standard š standard rehabilitation rehabilitation š )i[ii_edi%m[[a of additional exercises intended to improve ability to sit unsupported Week 6 Measured Maximal Lean Test, Maximal Sideward Reach Test, Canadian Occupational Performance Measure, T-shirt Test, Participants’ and Clinicians’ Impressions of Change, and Spinal Cord Injury Falls Concern Scale (n = 16) (n = 16) 'JHVSF
. Design and flow of participants through the trial. 86 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011

Harvey et al: Training unsupported sitting after spinal cord injury 5BCMF
 Characteristics of participants at baseline. Characteristic Randomised (n = 32) Age (yr\"c[Z_Wd?GH Exp Con Time since injury (wk\"c[Z_Wd?GH (n = 16) (n = 16) Gender (male:female) 26 (24 to 31) 27 (24 to 31) Motor level, n 11 (9 to 17) 10 (8 to 14) T1 to T4 14:2 16:0 T5 to T8 T9 to L1 4 1 American Spinal Injury Association 3 4 Impairment Scale, n 9 11 A B 16 13 C 0 2 Clinical Outcome Variables Scale score 0 1 2 (1 to 2) 2 (1 to 3) 5BCMF

The intention-to-treat analysis. Mean (SD) pre and post values and mean between-group difference (95% CI) adjusted for baseline score for Maximal Lean Test, Maximal Sideward Reach Test, T-shirt Test and SCI Falls Concern Scale. Median (interquartile) pre and post values and median between-group difference (95% CI) for COPM Performance, COPM Satisfaction, Participants’ Impressions of Change and Clinicians’ Impressions of Change. The predetermined minimally worthwhile treatment effects are also indicated. NA indicates not applicable. Maximal Lean Test Control group Experimental group Between– Minimally (n = 16) (n = 16) group worthwhile (mm) treatment Pre Post Pre Post difference Maximal Sideward effect Reach Test 125 206 111 177 –20 24 (% arm length) (55) (58) (47) (73) (–64 to 24) 20 COPM Performance 94 98 102 112 5 2 fe_dji%'& (8) (7) (34) (36) (–3 to 13) 2 COPM Satisfaction 4.0 7.5 3.5 7.8 0.5 14 fe_dji%'& (2.3 to 4.8) (6.5 to 8.3) (2.3 to 4.5) (7.3 to 8.5) (–0.5 to 1.5) 1 T-shirt Test 3.5 7.5 5.0 7.5 –1.0 1 (sec) (3.0 to 4.8) (7.0 to 9.0) (3.3 to 7.0) (7.0 to 8.5) (–2.5 to 0.0) D%7 Participants’ 65 35 74 46 8 Impressions of (40) (15) (35) (27) (–5 to 20) 9^Wd][fe_dji%- D%7 5.0 D%7 5.5 1.0 Clinicians’ (4.0 to 6.0) (5.0 to 6.0) (0.0 to 2.0) Impressions of 9^Wd][fe_dji%- D%7 3.0 D%7 3.0 0.0 (2.0 to 3.8) (2.5 to 3.5) (–1.0 to 1.0) SCI Falls Concern IYWb[fe_dji%,* 38 28 38 26 –2 (12) (9) (12) (6) (–8 to 3) Treatment effect minimally worthwhile treatment effects. The corresponding values for the secondary outcomes are also presented The mean between-group difference for the Maximal Lean in Table 2. Individual data are presented in Table 3 (see Test was –20 mm (95% CI –64 to 24). The mean between- eAddenda for Table 3). The results of the exploratory per- group difference for the Maximal Sideward Reach was protocol analysis of all outcomes are presented in Table 4. 5% of arm length (95% CI –3 to 13). The mean between- The only notable deleterious effect was an increase in back group difference for the Performance item of the COPM pain in one participant. The median rating of inconvenience was 0.5 points (–0.5 to 1.5). Group data for these outcomes of the intervention provided by experimental participants are presented in Table 2. Individual data are presented in was 9 (IQR 8 to 9) where 1 was ‘extremely inconvenient’ Table 3 (see eAddenda for Table 3). None of these findings and 10 was ‘not at all inconvenient’. was statistically significant and the upper end of all 95% confidence intervals fell short of the pre-determined Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 87

Research 5BCMF

J^[f[h#fhejeYebWdWboi_i_dm^_Y^ZWjW\\hecj^[Ål[[nf[h_c[djWbfWhj_Y_fWdjim^eYecfb[j[Zb[iij^Wdj^['-%'. training sessions were removed. Mean (SD) pre and post values and mean between-group difference (95% CI) adjusted for baseline score for Maximal Lean Test, Maximal Sideward Reach Test, T-shirt Test and SCI Falls Concern Scale. Median (interquartile) pre and post values and median between-group difference (95% CI) for COPM Performance, COPM Satisfaction, Participants’ Impressions of Change, and Clinicians’ Impressions of Change. The predetermined minimally worthwhile treatment effects are also indicated. Control group Experimental group Between- Minimally (n = 16) (n = 11) group worthwhile treatment Pre Post Pre Post difference effect Maximal Lean Test 125 206 102 183 –14 23 (55) (58) (44) (82) (–70 to 42) 19 (mm) 94 98 (8) 98 (14) 106 5 2 Maximal Sideward (7) (15) (–3 to 13) 2 Reach Test (% arm 4.0 3.5 13 length) (2.3 to 4.8) 7.5 (2.0 to 4.0) 7.5 1.0 1 (6.5 to 8.3) (6.5 to 9.5) (0.0 to 2.0) COPM Performance 3.5 5.0 1 fe_dji%'& (3.0 to 4.8) 7.5 (3.0 to 6.0) 7.5 –1.0 (7.0 to 9.0) (7.0 to 9.0) (–2.5 to 0.5) D%7 COPM Satisfaction 65 64 fe_dji%'& (40) 35 (29) 46 13 NA (15) NA (30) (–4 to 30) T–shirt Test 5.0 6.0 (sec) D%7 (4.0 to 6.0) D%7 (5.0 to 7.0) 1 (0.0 to 2.0) Participants’ 38 3.0 41 3.3 Impressions of (12) (2.0 to 3.8) (12) (2.5 to 4.0) 0.5 9^Wd][fe_dji%- (–1.0 to 1.5) 28 25 Clinicians’ (9) (7) –4 Impressions of (–10 to 3) 9^Wd][fe_dji%- SCI Falls Concern IYWb[fe_dji%,* Discussion research investigating treatment effectiveness. Without control groups, one is tempted to merely look at pre to post The results of this study indicate no added benefit from a changes in experimental participants and conclude that the 6-week training program specifically targeting unsupported training is highly effective. This logic is clearly flawed. sitting. We can be confident that within the limitation of this The improvements seen in participants may be due to a study, the results are conclusive because the upper end of the number of factors. The most appealing interpretation for 95% CIs from the three primary outcomes falls short of the the improvements seen in the current study is that standard pre-determined minimally worthwhile treatment effects. care provided to all participants improved their ability to These findings are largely consistent when data from the sit unsupported rendering the additional therapy provided five non-compliant experimental participants are removed to experimental participants redundant. Standard care although there is less precision and certainty associated included training for activities of daily living. Participants with some outcomes. Needless to say, the interpretation may have learnt appropriate strategies for sitting as part of of the results relies on what is considered a worthwhile the new demands of dressing, showering, and adapting to treatment effect. Some may disagree with the values we set a largely seated life. Of course, some of the improvements a priori and believe that any treatment effect is worthwhile seen in participants may have been due to natural recovery or regardless of how small it is. This approach ignores the cost exposure to the testing protocol. The only way to determine of providing interventions as well as the pressing need to the relative importance of all these factors is through future ensure that the limited time patients spend in physiotherapy randomised controlled trials where each factor is examined. is directed at the most important and effective interventions (Harvey 2011). It is possible that the training provided to participants was insufficient and if more intensive training had been provided The results of this study indicate that both experimental then a more convincing treatment effect may have been and control participants improved over the 6-week demonstrated. This interpretation is supported by research intervention period. These findings are in contrast to in other areas of neurology demonstrating the importance those of a similar study we conducted in people with of intensive and repetitious practice (Dean et al 1997, established paraplegia (Boswell-Ruys et al 2010b). In this Kwakkel 2006, Kwakkel et al 2005, Kwakkel et al 1997). previous study, experimental participants improved but However it is difficult to envisage any rehabilitation facility control participants did not. The parallel improvements being able to offer more than what was provided in this in control and experimental participants in the current trial on a one-to-one basis, especially when one considers study is critical to the interpretation of the results and that 30 minutes of active practice equated to approximately highlights the importance of including control groups in 45 to 60 minutes of therapist and patient time and that 88 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011

Harvey et al: Training unsupported sitting after spinal cord injury this time was devoted solely to one motor task. It is also can concentrate on practice of functional activities. Patients difficult to envisage that participants would tolerate a more probably learn appropriate strategies to sit while mastering intensive training program. We had difficulties getting the these activities and adjusting to a largely seated life, thus full co-operation of some participants. (This was more of a rendering additional training for unsupported sitting problem at the Australian site than at the Bangladesh site.) redundant. Q Some participants complained that the training was boring and repetitious. We were acutely aware of this potential Footnote: aStata v11, Statacorp, TX, USA. problem before we started the trial and tried to a guard against this possibility by devising 84 different exercises eAddenda: Table 3 available at jop.physotherapy.asn.au each with three variations. Yet, regardless, we exhausted the patience of some participants. Perhaps linking training with Ethics: The study was approved by the ethics committees the playing of computer games might help overcome this of the Northern Sydney Area Health Service and Royal issue; however, fundamentally, effective motor retraining Rehabilitation Centre, Sydney Australia. We certify that requires repetitious practice, and repetitious practice is not all applicable institutional and governmental regulations well tolerated by everyone. concerning the ethical use of human volunteers were followed. All participants gave written informed consent Perhaps only certain types of people with paraplegia benefit before data collection began. from the type of training provided and if we could identify these patients then we could target therapy appropriately. Competing interests: None declared. This may be the case, although the inclusion criteria in this study were already narrow and restricted to people with Support: The Rehabilitation and Disability Foundation. paraplegia and difficulties sitting. Four hundred and twenty people with recent spinal cord injury had to be screened over Acknowledgements: We acknowledge the assistance of a two-year period to attain 32 suitable participants. If only Vivian Lau, Fatema Akhter, Corny Marina Momen, Paresh a subgroup of our sample benefit from training, then one Chakma, and all the patients and staff of the Moorong has to ask whether it is worth the time, money, and effort Spinal Unit, Australia, and Centre for Rehabilitation of the required to identify them. Interestingly, although people Paralyzed, Bangladesh. We also thank Joanne Glinsky and with incomplete paraplegia were eligible for inclusion, the Josh Simmons for rating the videos. majority of participants had motor complete lesions. A future study that focuses on people with incomplete lesions Correspondence: A/Professor Lisa Harvey, Rehabilitation may reap different findings although triallists will have Studies Unit, Royal Rehabilitation Centre Sydney, difficulties recruiting sufficient participants with incomplete P.O. Box 6, Ryde, NSW, 1680, Australia. Email: lesions and difficulties sitting. [email protected]. Some may question the validity of conducting this trial References across two spinal cord injury units in such different countries as Australia and Bangladesh. While there American Spinal Injury Association (2003) Reference manual are clearly very big differences between Australia and for the international standards for neurological classification Bangladesh, the two spinal cord injury units provide of spinal cord injury. Chicago: American Spinal Injury remarkably similar rehabilitation, albeit tailored to their Association. socioeconomic situations. The inclusion of the two sites therefore broadens the generalisability of the results. The Anderson KD (2004) Targeting recovery: priorities of the spinal Centre for the Paralyzed in Bangladesh is a 100-bed unit cord-injured population. Journal of Neurotrauma 21: 1371– servicing the 1.1 million population of Bangladesh and 1383. provides comprehensive rehabilitation. Its services have been developed over 30 years with international support. Barrett B, Brown D, Mundt M, Brown R (2005) Sufficiently Physiotherapy staff from the Australian and Bangladesh sites important difference: expanding the framework of clinical were highly experienced in the rehabilitation of people with significance. Medical Decision Making 25: 250–261. spinal cord injury. Importantly, both sites were subjected to rigorous quality checks and all staff involved in the trial Boswell-Ruys C, Harvey L, Delbaere K, Lord S (2010a) A Falls were trained. This included a 3-day training program for Concern Scale for people with spinal cord injury (SCI–FCS). the Bangladesh site by the principal investigator, and a Spinal Cord 48: 704–709. 4-week visit by the principal investigator of the Bangladesh site to the Australian site. In addition, we guarded against Boswell-Ruys CL, Harvey LA, Barker JJ, Ben M, Middleton JW, biasing by stratifying by site and entering site as a covariate Lord SR (2010b) Training unsupported sitting in people with in the analysis. Interestingly, site had no significant effect on chronic spinal cord injuries: a randomized controlled trial. outcome. This was further explored with post-hoc analyses Spinal Cord 48: 138–143. indicating very similar improvements in all participants’ ability to sit unsupported over the 6-week study period Boswell-Ruys CL, Sturnieks DL, Harvey LA, Sherrington irrespective of site. That is, the improvements in the C, Middleton JW, Lord SR (2009) Validity and reliability of Australian and Bangladesh participants were comparable. assessment tools for measuring unsupported sitting in people with spinal cord injury. Archives of Physical Medicine In some respects the results of this trial are disappointing and Rehabilitation. 90: 1571–1577. because they do not support a widely administered approach to training unsupported sitting. However, by not spending Campbell J, Kendall M (2003) Investigating the suitability of time on training unsupported sitting, therapists and patients the clinical outcome variables scale (COVS) as a mobility outcome measure in spinal cord injury rehabilitation. Physiotherapy Canada 55: 135–144. Carr JH, Shepherd RB (2000) A motor relearning model for rehabilitation. In Carr JH, Shepherd RB (Eds): Movement science: Foundations for physical therapy in rehabilitation (2nd ed.). Aspen, Rockville pp. 33–110. Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 89

Research Chen C, Yeung K, Bih L, Wang C, Chen M, Chien J (2003) Kwakkel G, van Peppen R, Wagenaar R, Dauphinee S, The relationship between sitting stability and functional Richards C, Ashburn A, et al (2005) Effects of augmented performance in patients with paraplegia. Archives of Physical exercise therapy time after stroke: a meta-analysis. Stroke Medicine and Rehabilitation 84: 1276–1281. 35: 2529–2536. Dean C, Shepherd R (1997) Task-related circuit training Kwakkel G, Wagenaar R, Koelman T, Lankhorst G, Koetsier improves performance of seated reaching tasks after stroke. J (1997) Effects of intensity of rehabilitation after stroke: a A randomized controlled trial. Stroke 28: 722–728. research synthesis. Stroke 28: 1550–1556. Harvey L (2008) Management of spinal cord injuries: a guide Law M, Baptiste S, Carswell A, McColl M, Polatajko H, Pollock for physiotherapists. London: Elsevier. N (2010) COPM–the Canadian Occupational Performance C[Wikh[$ ^jjf0%%mmm$YWej$YW%Yefc%gk[ij_edi$^jcb$ BWij Harvey L (2011) Invited commentary on: Lynch EA, Watson accessed on 24th December 2010. SC (2011) Is circuit class physiotherapy possible during inpatient spinal cord injury rehabilitation? A feasibility trial. Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, The International Journal of Therapy and Rehabilitation 18: Pollock N (1990) The Canadian Occupational Performance 595–606. Measure: an outcome measure for occupational therapy. Canadian Journal of Occupational Therapy 57: 82–87. >Whl[o B\" <ebff <\" :[d_i I\" 8WhhWjj :\" Gk_ha H\" 7bb_ied =\" [j al (2011) Clinicians’ and patients’ impressions of change Schneider LS, Olin JT (1996) Clinical global impressions of in motor performance as potential outcome measures for change. Clinical global impressions in Alzheimer’s clinical clinical trials. Spinal Cord 49: 30–35. trials. International Psychogeriatrics 8: 277–288. Jaeschke R, Singer J, Guyatt GH (1989) Measurement of van Langeveld S, Post MW, van Asbeck FW, Gregory M, health status. Ascertaining the minimal clinically important Halvorsen A, Rijken H, et al (2010) Comparing content difference. Controlled Clinical Trials 10: 407–415. and quality of therapy for patients with SCI in postacute rehabilitation in Australia, Norway and Netherlands. In 49th Kwakkel G (2006) Impact of intensity of practice after stroke: ISCoS, 10th SCS and 9th ASCoN Annual Scientific Meeting, issues for consideration. Disability and Rehabilitation 28: Delhi, India, pp. 156. 823–830. Submitting randomised trials to Journal of Physiotherapy Authors are reminded that Journal of Physiotherapy accepts only registered trials. From 2012 the journal requires prospective registration of trials unless data collection began before 2006, in which case retrospective registration is acceptable. Trials must be registered in a publicly-accessible trials register. We will accept any register that satisfies the International Committee of Medical Journal Editors requirements (such as The Australian Clinical Trial Registry at www.actr.org.au or the US trial register at ClinicalTrials.gov). Authors must provide the name and website address of the register and the trial registration number on submission. 90 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011

Appraisal Correspondence Was the effect of sitting time interpreted appropriately? The recent study ‘Duration of physical activity is normal time spent in moderate to vigorous physical activity. The but frequency is reduced after stroke: an observational paper by Alzahrani et al (2011) reports that stroke survivors study’ (Alzahrani et al 2011) found that while community- underwent few transitions (changes in body position) per dwelling stroke survivors took far fewer steps each day day compared to controls. It would be of interest to know compared to age-matched controls, they spent a similar whether this means that stroke survivors sat for longer duration of time each day walking. This finding was both periods at a time and accumulated their active time in fewer novel and interesting. However, I have some concerns bouts per day. If so, this may lead to an increased risk of about the conclusions drawn by the authors in regard to cardiovascular disease, including further stroke. daily energy expenditure, sedentary behaviour, and the implications for risk of stroke. Second, both the stroke survivors and control participants in this study accumulated more than seven hours of sedentary Several large scale international epidemiological studies time during the day, which was more than half of the time have found a substantial link between sitting for prolonged they were observed. While we do not yet know how much periods each day and negative changes in metabolic health, sitting time is too much, sitting for seven hours a day, increased risk of all-cause mortality, and cardiovascular particularly if this time is accumulated in long bouts, may disease (Stamatakis et al 2011, Dunstan et al 2010). well be placing both stroke survivors and healthy people at Importantly, these effects remain even when adjusted for an increased risk of cardiovascular disease. More research other cardiovascular disease risk factors (Dunstan et al is needed to investigate how we can encourage stroke 2010). While research into the cause and effect of sitting survivors to increase incidental daily activity levels in a time on cardiovascular disease risk is in its infancy, the sustainable way, and to determine if changes in sitting time epidemiological findings are convincing enough for the behaviour will result in reduced cardiovascular disease risk National Heart Foundation of Australia to have recently for individuals. launched an information sheet recommending that people should aim to reduce the amount of time they sit each day Coralie English (National Heart Foundation of Australia 2011). Alzahrani Stroke Division, Florey Neuroscience Institutes, Melbourne, and colleagues suggest that, because the total duration of and School of Health Sciences, University of South Australia sitting time was similar between stroke survivors and age- matched controls, stroke survivors are no more at risk of Australia recurrent stroke. This interpretation may be incorrect. References First, it is not the total time spent in sedentary behaviour (sitting or lying) each day that is of primary importance, Alzahrani A et al (2011) J Physiother 57: 47–51. but the way in which this time is accumulated. Healy and colleagues (2008) found that breaking up sitting time with Stamatakis E et al (2011) J Am Coll Cardiol 57: 292–299. frequent, short bursts of light activity (such as standing and walking for a few minutes) was significantly associated Dunstan D et al (2010) Circulation 121: 384–391. with reduced cardiovascular disease risk. Importantly, this finding was independent of either total daily sitting time, or National Heart Foundation of Australia (2011) ^jjf0%%mmm$ ^[Whj\\ekdZWj_ed$eh]$Wk%I_j[9ebb[Yj_ed:eYkc[dji%>MUF7U I_jj_d]B[iiU7ZkbjiU?D<9U<?D7B$fZ\\ accessed 21st March 2011. Healy G et al (2008) Diabetes Care 31: 661–666. 132 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011