Journal of Physiotherapy 61 (2015) 94 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Adding a structured education intervention to a program of exercise training may not benefit people with chronic obstructive pulmonary disease Synopsis Summary of: Blackstock FC, Webster KE, McDonald CF, Hill CJ. related quality of life, measured using the Chronic Respiratory Disease Comparable improvements achieved in chronic obstructive pulmo- Questionnaire, and functional exercise capacity, measured with the nary disease through pulmonary rehabilitation with and without a 6-minute walk distance. Other outcomes included functional structured educational intervention: a randomized controlled trial. limitation due to dyspnoea, functional activity via the grocery Respirology 2014;19:193-202. shelving task, self-efficacy and healthcare usage. Outcomes were evaluated at program completion as well as 6 and 12 months later. Question: In people with chronic obstructive pulmonary disease, Results: A total of 149 participants completed the study. what effect does adding disease-specific group education to super- Considering all assessment time points, there were no between- vised exercise training have on health outcomes? Design: Random- group differences in any domain of the Chronic Respiratory Disease ised, controlled trial with concealed allocation and blinding of the Questionnaire (overall mean difference for dyspnoea domain was – outcome assessor. Setting: An outpatient department of a tertiary 0.9 points per item, 95% CI –2.0 to 0.7) or the 6-minute walk distance hospital in Melbourne, Australia. Participants: Adults with stable (–16 m, 95% CI –9 to 42). Likewise, with the exception of a small chronic obstructive pulmonary disease were included if they reported difference in health-related quality of life, measured via the dyspnoea with daily activities and were referred for pulmonary Assessment of Quality of Life Questionnaire (in favour of the rehabilitation. Exclusion criteria were any condition that compro- control group), there were no between-group differences for any mised the capacity to learn, presence of comorbid conditions that other outcome measure collected at any time. Conclusion: In people limited ability to exercise, or participation in pulmonary rehabilitation with stable chronic obstructive pulmonary disease who have been in the previous 2 years. Randomisation allocated 141 and 126 to the referred to pulmonary rehabilitation, the addition of a structured intervention and control groups, respectively. Interventions: Partici- education program produced no benefit over and above a program pants in both groups attended twice-weekly supervised exercise of supervised exercise training. training for 8 weeks. Each exercise session comprised endurance training (walking and cycling) as well as upper and lower body Kylie Hill resistance exercises. Those in the intervention group also completed School of Physiotherapy and Exercise Science, Curtin University, 16 face-to-face group education sessions, each of 45 minutes in duration. These sessions were facilitated by members of a multidisci- Australia plinary team and included the development of behaviour-specific action plans. Outcome measures: The primary outcomes were health- http://dx.doi.org/10.1016/j.jphys.2015.02.003 Commentary The current definition of pulmonary rehabilitation from the program, which may be the key to the improvements in both groups American Thoracic Society/European Respiratory Society Statement – an improvement that could not be further increased by the highlights the importance of education and b$F1D[_]IT ehaviour change in the addition of an education component. management of people with chronic obstructive pulmonary disease (COPD).1 The study by Blackstock [TFID_$a2] nd [_FDTc]$I3 olleagues was a large well- Achieving _[Tb]FDI$1 ehaviour change in chronic disease is complex and designed trial with a low risk of bias (PEDro score 7/10). While the currently there is only limited evidence that ITDF_1]b[$ ehaviour change dropout rate of 26% reduced the trial quality, it is unlikely that any interventions can improve health outcomes in COPD.2 There is still a long-term trial in this chronic disease population will achieve low need to find the ‘holy grail’ in terms of an effective T_D[b$F]I1 ehaviour change dropout rates. Importantly, the outcomes of D$[I_FhT4] ospitalisation and intervention to enable long-term adherence to exercise and positive healthcare FT[D]$5I_utilisation were unaffected by dropout, due to the ability health b]_7FITD$[ ehavioural in people with COPD, and for appropriate to source data on all participants. measures to detect these outcomes. The findings that both groups improved exercise capacity and Jennifer Alison quality of life, and reduced hospital admissions and healthcare Discipline of Physiotherapy, The University of Sydney, Australia ID$[F]u5_T tilisation, with no between-group differences, casts doubt on the need to include a formal education program during pulmonary References rehabilitation, even when elements of D_IF]bT$[1 ehaviour change are included. The clinical implications are that people involved in 1. Spruit M, et al. Am J Resp Crit Care Med. 2013;188:e13–e64. pulmonary rehabilitation programs that are unable to offer a distinct 2. Zwerink M, et al. Cochrane Database Syst Rev. 2014;19:CD002990. education and T[$D6_IF]behavioural change component will not be disadvantaged in terms of major outcomes. However, it is http://dx.doi.org/10.1016/j.jphys.2015.02.002 important to note that both groups in the study had access to experienced health professionals through the exercise training 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 94 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Adding a structured education intervention to a program of exercise training may not benefit people with chronic obstructive pulmonary disease Synopsis Summary of: Blackstock FC, Webster KE, McDonald CF, Hill CJ. related quality of life, measured using the Chronic Respiratory Disease Comparable improvements achieved in chronic obstructive pulmo- Questionnaire, and functional exercise capacity, measured with the nary disease through pulmonary rehabilitation with and without a 6-minute walk distance. Other outcomes included functional structured educational intervention: a randomized controlled trial. limitation due to dyspnoea, functional activity via the grocery Respirology 2014;19:193-202. shelving task, self-efficacy and healthcare usage. Outcomes were evaluated at program completion as well as 6 and 12 months later. Question: In people with chronic obstructive pulmonary disease, Results: A total of 149 participants completed the study. what effect does adding disease-specific group education to super- Considering all assessment time points, there were no between- vised exercise training have on health outcomes? Design: Random- group differences in any domain of the Chronic Respiratory Disease ised, controlled trial with concealed allocation and blinding of the Questionnaire (overall mean difference for dyspnoea domain was – outcome assessor. Setting: An outpatient department of a tertiary 0.9 points per item, 95% CI –2.0 to 0.7) or the 6-minute walk distance hospital in Melbourne, Australia. Participants: Adults with stable (–16 m, 95% CI –9 to 42). Likewise, with the exception of a small chronic obstructive pulmonary disease were included if they reported difference in health-related quality of life, measured via the dyspnoea with daily activities and were referred for pulmonary Assessment of Quality of Life Questionnaire (in favour of the rehabilitation. Exclusion criteria were any condition that compro- control group), there were no between-group differences for any mised the capacity to learn, presence of comorbid conditions that other outcome measure collected at any time. Conclusion: In people limited ability to exercise, or participation in pulmonary rehabilitation with stable chronic obstructive pulmonary disease who have been in the previous 2 years. Randomisation allocated 141 and 126 to the referred to pulmonary rehabilitation, the addition of a structured intervention and control groups, respectively. Interventions: Partici- education program produced no benefit over and above a program pants in both groups attended twice-weekly supervised exercise of supervised exercise training. training for 8 weeks. Each exercise session comprised endurance training (walking and cycling) as well as upper and lower body Kylie Hill resistance exercises. Those in the intervention group also completed School of Physiotherapy and Exercise Science, Curtin University, 16 face-to-face group education sessions, each of 45 minutes in duration. These sessions were facilitated by members of a multidisci- Australia plinary team and included the development of behaviour-specific action plans. Outcome measures: The primary outcomes were health- http://dx.doi.org/10.1016/j.jphys.2015.02.003 Commentary The current definition of pulmonary rehabilitation from the program, which may be the key to the improvements in both groups American Thoracic Society/European Respiratory Society Statement – an improvement that could not be further increased by the highlights the importance of education and b$F1D[_]IT ehaviour change in the addition of an education component. management of people with chronic obstructive pulmonary disease (COPD).1 The study by Blackstock [TFID_$a2] nd [_FDTc]$I3 olleagues was a large well- Achieving _[Tb]FDI$1 ehaviour change in chronic disease is complex and designed trial with a low risk of bias (PEDro score 7/10). While the currently there is only limited evidence that ITDF_1]b[$ ehaviour change dropout rate of 26% reduced the trial quality, it is unlikely that any interventions can improve health outcomes in COPD.2 There is still a long-term trial in this chronic disease population will achieve low need to find the ‘holy grail’ in terms of an effective T_D[b$F]I1 ehaviour change dropout rates. Importantly, the outcomes of D$[I_FhT4] ospitalisation and intervention to enable long-term adherence to exercise and positive healthcare FT[D]$5I_utilisation were unaffected by dropout, due to the ability health b]_7FITD$[ ehavioural in people with COPD, and for appropriate to source data on all participants. measures to detect these outcomes. The findings that both groups improved exercise capacity and Jennifer Alison quality of life, and reduced hospital admissions and healthcare Discipline of Physiotherapy, The University of Sydney, Australia ID$[F]u5_T tilisation, with no between-group differences, casts doubt on the need to include a formal education program during pulmonary References rehabilitation, even when elements of D_IF]bT$[1 ehaviour change are included. The clinical implications are that people involved in 1. Spruit M, et al. Am J Resp Crit Care Med. 2013;188:e13–e64. pulmonary rehabilitation programs that are unable to offer a distinct 2. Zwerink M, et al. Cochrane Database Syst Rev. 2014;19:CD002990. education and T[$D6_IF]behavioural change component will not be disadvantaged in terms of major outcomes. However, it is http://dx.doi.org/10.1016/j.jphys.2015.02.002 important to note that both groups in the study had access to experienced health professionals through the exercise training 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 61–67 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review Katharine Scrivener a, Taryn Jones a, Karl Schurr b, Petra L Graham c, Catherine M Dean a a Department of Health Professions, Macquarie University; b Physiotherapy Department, Bankstown-Lidcombe Hospital; c Department of Statistics, Macquarie University, Sydney, Australia KEY WORDS ABSTRACT Rehabilitation Question: In adults undergoing inpatient rehabilitation, does additional after-hours rehabilitation Physical activity decrease length of stay and improve functional outcome, activities of daily living performance and Outcome physical activity? Design: Systematic review with meta-analysis of randomised trials. Participants: After hours Adults participating in an inpatient rehabilitation program. Intervention: Additional rehabilitation Weekend provided after hours (evening or weekend). Outcome measures: Function was measured with tests such as the Motor Assessment Scale, 10-m walk test, the Timed Up and Go test, and Berg Balance Scale. Performance on activities of daily living was measured with the Barthel index or the Functional Independence Measure. Length of stay was measured in days. Physical activity levels were measured as number of steps or time spent upright. Standardised mean differences (SMD) or mean differences (MD) were used to combine these outcomes. Adverse events were summarised using relative risks (RR). Study quality was assessed using PEDro scores. Results: Seven trials were included in the review. All trials had strong methodological quality, scoring 8/10 on the PEDro scale. Among the measures of function, only balance showed a significant effect: the MD was 14 points better (95% CI 5 to 23) with additional after- hours rehabilitation on a 0-to-56-point scale. The improvement in activities of daily living performance with additional after-hours rehabilitation was of borderline statistical significance (SMD 0.10, 95% CI 0.00 to 0.21). Hospital length of stay did not differ significantly (MD –1.8 days, 95% CI –5.1 to 1.6). Those receiving additional rehabilitation had significantly higher step counts and spent significantly more time upright. Overall, the risk of adverse events was not increased by the provision of after-hours or weekend rehabilitation (RR 0.87, 95% CI 0.70 to 1.10). Conclusion: Additional after-hours rehabilitation can increase physical activity and may improve activities of daily living, but does not seem to affect the hospital length of stay. Review registration: PROSPERO CRD42014007648. [Scrivener K, Jones T, Schurr K, Graham PL, Dean CM (2015) After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review. Journal of Physiotherapy 61: 61–67] Crown Copyright ß 2015 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). Introduction Inpatient rehabilitation participants are more inactive on the weekend than during the week.15,16 Furthermore, less therapeutic Inpatient rehabilitation programs are commonly required for activity is observed in the evenings and on the weekend.17 In many people with poor mobility and functional performance as a result rehabilitation hospital settings, therapists are rostered to work of many health conditions.1–3 These rehabilitation programs from Monday to Friday, within usual working hours. Consequently, should contain repetitive practice of functional tasks and exercise little or no therapeutic activities occur in the evenings and on the in order to improve fitness.1,4,5 Increasing the intensity of weekend. In addition, therapy areas are usually closed when rehabilitation programs elicits greater improvement in partici- therapists are not present. Therefore, for rehabilitation, increasing pants’ mobility and functional outcomes, as well as a reduction in physical activity opportunities out of traditional working hours is a the length of hospital stay.6–9 Despite this, inpatients undergoing major challenge. In 2006, a systematic review analysed trials of rehabilitation programs are inactive for large amounts of time additional physiotherapy outside of traditional working hours during the day.10–12 During weekdays, the amount of therapy provided to acute hospital inpatients but did not show a benefit occurring in hospital varies greatly. In rehabilitation after hip from the additional therapy.18 fracture, for example, 2 hours of physiotherapy and occupational therapy have been observed to be completed each weekday,13 Various strategies have been investigated to provide opportu- whereas in stroke rehabilitation, as little as 16 minutes of therapy nities for exercise out of the typical therapy times and time has been observed each weekday.14 environment. For example, one of these strategies included the provision of supplementary arm exercise programs that the http://dx.doi.org/10.1016/j.jphys.2015.02.017 1836-9553/Crown Copyright ß 2015 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
62 Scrivener et al: After-hours rehabilitation for hospital inpatients rehabilitation participant completes independently in the ward Risk of bias was assessed using the PEDro scale21 and the Cochrane environment.19 This program demonstrated a positive outcome Collaboration’s Risk of Bias tool.22 All included trial reports were with very minimal burden on therapy staff. located on the PEDro database to confirm their PEDro scale score. If a disagreement arose between the authors about the risk of bias The aim of this systematic review was to summarise current scores, the trial was discussed with a third author in order to reach evidence about the effect of additional in-hospital rehabilitation consensus. out of traditional working hours. This is in contrast to other reviews of more intensive therapy after stroke, which predomi- Participants, interventions, outcomes nantly included studies of additional therapy during the working Two authors independently examined the full-text version of day.6,7 Therefore, the research questions for this systematic review were: the trial reports included in the review to extract data. Where necessary, authors of articles included in the review were 1. Does additional rehabilitation occurring after hours or on contacted to provide additional data to allow the comparison of weekends improve the functional outcomes of rehabilitation results. Participants in the included studies could have any participants? clinical condition, provided they were receiving rehabilitation as inpatients. The after-hours physical rehabilitation could occur in 2. Does providing additional rehabilitation after hours or on any form (eg, arm exercise, mobility training) and could be weekends decrease the length of stay in rehabilitation? unsupervised (ie, self-monitored programs) or supervised by anyone (eg, therapists, families, assistants, nursing staff). Trials 3. Does providing additional rehabilitation after hours or on examining additional therapy during regular working hours were weekends increase daily physical activity among hospital ineligible. Data were extracted for the following outcomes: inpatients? functional outcomes (eg, Motor Assessment Scale, Berg Balance Scale, 10-m walk test); activities of daily living (eg, Barthel index, 4. Does providing additional rehabilitation after hours or on Functional Independence Measure); length of hospital stay; weekends increase the risk of adverse events? physical activity (eg, activity monitors, behavioural mapping data); and adverse events. Methods Data analysis Identification and selection of studies To obtain pooled estimates of the effect of the intervention, This systematic literature review was conducted according to a DerSimonian and Laird random-effects meta-analyses were used. protocol that was registered a priori and reported according to the The effect of additional after-hours rehabilitation was estimated Preferred Reporting Items for Systematic Reviews and Meta- using: standardised mean differences (SMD) with 95% CI for the Analyses (PRISMA) statement.20 An electronic search for relevant functional outcomes and activities of daily living; mean differences articles was conducted in July 2014. The following databases were (MD) with 95% CI for the Timed Up and Go test, the 10-m walk test, searched: Ovid MEDLINE, Embase, AMED, CINAHL, Scopus and and length of hospital stay; and relative risk (RR) with 95% CI for PEDro. The search terms included those related to rehabilitation adverse events. Heterogeneity between studies was assessed using (physiotherapy, occupational therapy, exercise), additional rehabili- Cochrane’s Q, with p-values less than 0.05 indicating significant tation (weekend, after-hours, supplementary, six day, seven day, heterogeneity. Where results were reported as medians and Saturday, Sunday), inpatient (patient, hospital) and randomised interquartile ranges or ranges, the methods of Hozo and controlled trial (controlled, intervention group, random). Full details colleagues23 were used to convert results into means and standard of the search strategy used for each database are in Appendix 1 on deviations. While reporting of medians may indicate non- the eAddenda. normality, the sizes of the studies where this occurred suggested that it might be reasonable to assume that means would be Titles and abstracts were examined for relevance by one author normally distributed. Subgroup and sensitivity analyses were not (KS). Where appropriate, the full text of articles was sought to undertaken due to the small number of studies providing data for determine their relevance to the review. Where there was doubt, a any outcome. R statistical software24 with the meta package25 was second author (TJ) reviewed the full-text article to determine its used for all analyses. relevance to the review. The criteria for inclusion of studies in the review are presented in Box 1. Results Assessment of characteristics of studies Flow of studies through the review Quality The search identified 2559 papers, of which 25 were retrieved Two authors independently examined the full-text version of in full text and screened for eligibility. Of these, seven trials were included in the review (Figure 1). the trial reports included in the review to assess the risk of bias. A systematic review6 of augmented therapy time after stroke Box 1. Inclusion criteria. was identified by the search. Screening of the reference list identified 10 papers that were possibly relevant. Based on the Design abstracts, two papers were obtained in full text, but neither Randomised trial was eligible because the participants were outpatients.26,27 Published in English Another systematic review,18 investigating the effect of addi- Participants tional physiotherapy for hospital inpatients (in all phases of care) Adult inpatients in a subacute or rehabilitation setting provided outside of regular business hours, was identified by Intervention the search. Screening of the reference list identified five papers Additional after-hours physical rehabilitation that were possibly relevant. However, screening the abstracts Outcome measures indicated that none was eligible: two were not randomised, Functional outcome controlled trials;28,29 one assessed additional therapy that was Activities of daily living not delivered after hours;30 and two were conducted in the acute Length of hospital stay setting.31,32 A more recent systematic review investigating the Physical activity levels Adverse events
[(Figure_1)TD$IG] Research 63 Titles and abstracts screened (n = 2559) Papers excluded after screening titles/abstracts (n = 2534) Potentially-relevant papers retrieved for evaluation of full text (n = 25) Papers excluded after evaluation of full text (n = 18) • Research design not RCT (n = 6) • Intervention not after-hours (n = 7) • Not conducted in inpatient subacute or rehabilitation setting (n = 2) • No additional rehabilitation to intervention group (n = 1) • Protocol for article included in review (n = 1) • Commentary not original research (n = 1) Papers included in review (n = 7) Figure 1. Flow of studies through the review. Table 1 Characteristics of the included studies. Study Participants Intervention Outcome measures Brusco et al 2007 38 n = 262 Exp = 60 min physiotherapy on weekdays, plus 60 min Activity = 10-m walk test (m/s), Age (yr) = Exp 77 physiotherapy on Saturday TUG (s), MAS, FIM, Functional (SD 13), Con 77 (SD 13) Con = 60 min physiotherapy on weekdays Reach Test Setting – mixed Exp = Usual care, plus practice of activities supervised by Quality of Life = EQ-5D Davidson et al 2005 36 n = 41 nursing staff on the weekend. Activities included sitting, sit to Length of stay Galvin et al 2011 35 Age (yr) = Exp 69 (SD 14), stand, standing balance and stepping. Harris et al 2009 19 Con = 64 (SD 18) Con = Usual care Activity = Barthel Index, MAS Setting – stroke Length of stay Exp = Usual care, plus family-mediated lower limb exercise for n = 40 8 wk, 35 min daily in hospital ward (continued into home if Impairment = LL FMA Age (yr) = Exp 63 (SD 13), discharged). Individualised lower limb exercise prescribed. Activity = 6-min walk test (m), Con 70 (SD 12) Con = Usual care Setting – stroke Berg Balance Scale, Barthel Exp = Usual care, plus a self-administered homework-based Index n = 103 upper-limb exercise program for 4 wk. Participants were Age (yr) = Exp 69 (SD 12), trained in the program, provided with an exercise instruction Activity = Chedoke Arm and Con 69 (SD 15) booklet and equipment, and monitored weekly. Hand Activity Inventory Setting – stroke Con = Usual care plus educational booklet about stroke Peiris et al 2012 40 n = 105 Exp = Usual physiotherapy and occupational therapy on Physical activity = steps, time Peiris et al 2013 37 Age (yr) = 74 (SD 12) weekdays, plus one Saturday session of physiotherapy and upright (hrs) Said et al 2012 39 Setting – orthopaedic occupational therapy Con = Usual physiotherapy and occupational therapy on Activity = FIM, 10-m walk test n = 996 weekdays (m/s), TUG (s), Modified MAS Age (yr) = Exp 75 (SD 13), Con 74 (SD 13) Exp = Usual physiotherapy and occupational therapy on Quality of Life = EQ-5D Setting – mixed weekdays, plus Saturday Length of stay Con = Usual physiotherapy and occupational therapy on Activity = DEMMI, Barthel Index n = 47 weekdays Physical activity = upright time Age (yr) = Exp 81 (SD 5), Con 82 (SD 7) Exp = Usual care (multidisciplinary rehabilitation, including 1 to (% target time) Setting – aged care 2 individual or group physiotherapy sessions on weekdays), Length of stay plus standing and walking activities in the late afternoon and on weekends (individual program delivered by a physiotherapist or physiotherapy assistant) Con = Usual care (multidisciplinary rehabilitation, including 1 to 2 individual or group physiotherapy sessions on weekdays) Con = control group, DEMMI = de Morton Mobility Index, EQ-5D = EuroQoL questionnaire, Exp = experimental group, FIM = Functional Independence Measure, LL FMA = lower limb section of the Fugl-Meyer Assessment, MAS = Motor Assessment Scale, TUG = Timed Up and Go test.
64 Scrivener et al: After-hours rehabilitation for hospital inpatients Table 2 Additional amount of after-hours rehabilitation in intervention group. Study Intervention delivery Additional rehabilitation time (min) total per day Brusco et al 2007 38 Saturday physiotherapy service 246 11.6 Davidson et al 2005 36 72 0.8 Galvin et al 2011 35 Nurse-supervised activity practice 1816 32.4 Harris et al 2009 19 720 25.7 Peiris et al 2012 40 Family-mediated 144 20.6 Peiris et al 2013 37 159 7.6 Said et al 2012 39 Self-administered (Æ family support) 241 15.1 Saturday physiotherapy and occupational therapy service Saturday physiotherapy and occupational therapy service Physiotherapist or assistant ]GI[(Figur_3)TD$e effect of extra physiotherapy on people with acute or subacute Study SMD conditions was also identified.33 One paper in the reference list Brusco38 (95% CI) was obtained in full text, but it was ineligible because the Davidson36 additional therapy was provided within business hours.34 Galvin35 Peiris37 Characteristics of the included trials Said39 Pooled Seven articles met the inclusion criteria and were included in the review. The studies investigated a total of 1489 participants. –0.6 –0.3 0 0.3 0.6 Three studies were in a stroke rehabilitation setting,19,35,36 two Favours con Favours exp were in mixed rehabilitation37,38 and one was in mixed aged-care rehabilitation.39 The 2012 study by Peiris and colleagues40 was a Figure 3. Forest plot of the effect of additional after-hours or weekend subgroup analysis of the larger trial conducted by this group and rehabilitation on physical function, pooling data from five studies and presented published in 2013.37 This subgroup analysis focused on partici- as a standardised mean difference (95% CI). pants in the orthopaedic rehabilitation setting.40 Further details of the studies can be found in Tables 1 and 2. rehabilitation time varied significantly from 72 to 1816 minutes of rehabilitation over the study period, or an average of 0.8 to Quality 32.4 minutes of additional rehabilitation for each day in hospital. All seven studies included in the review scored 8/10 on the Effect of additional after-hours or weekend rehabilitation on PEDro scale. This suggests that they have high methodological function rigor. Figure 2 summarises the risk of bias of the included studies using the Cochrane Collaboration’s checklist. From Figure 2 it can Figures 3, 5, 7 and 9 outline the effect of additional after-hours be seen that the area of most risk is in non-blinding of participants or weekend rehabilitation on functional outcomes. and therapists to group allocation. Whilst it is understandably difficult to blind participants in studies where the intervention is Physical function obvious, some studies made no attempt to blind weekday treating Five of the studies assessed physical function using the de therapists to group allocation. This may have impacted the results, because weekday staff could alter the amount of usual therapy if Morton Mobility Index (DEMMI) or the standard or modified Motor they were aware that the study participant was receiving Assessment Scale (Figure 3, and see Figure 4 on the eAddenda for additional rehabilitation after hours or on the weekend. the detailed forest plot). There was no evidence of heterogeneity between studies (Q = 0.91, p = 0.92). Overall, there was no evidence The amount of additional rehabilitation time provided to the of an improvement in physical function due to additional weekend intervention group is presented in Table 2. The additional or after-hours rehabilitation (SMD –0.03, 95% CI –0.24 to 0.18). erugiF(_2)TD$IG][ )TD$FIG]_rige([5u Random sequence generaƟon Study WMD AllocaƟon concealment Brusco38 (95% CI) Blinding of parƟcipants Galvin35 Blinding of personnel Peiris37 Blinding of outcome assessors Pooled Incomplete outcome data SelecƟve reporƟng Other bias Brusco et al 2007 38 –0.4 –0.2 0 0.2 0.4 Davidson et al 2005 36 (m/sec) Galvin et al 2011 35 Favours con Favours exp Harris et al 2009 19 Peiris et al 2012 40 Figure 5. Forest plot of the effect of additional after-hours or weekend Peiris et al 2013 37 rehabilitation on walking speed, pooling data from three studies and presented as a weighted mean difference (95% CI). Said et al 2012 39 Low risk of bias Unclear risk of bias High risk of bias Figure 2. Summary of ratings on the Cochrane Risk of Bias tool.
(Fig[re_7)TD$IG]u Researc[(Figure_1TD$IG])h 65 Study WMD Study WMD Brusco38 (95% CI) Brusco38 (95% CI) Peiris37 Davidson36 Said39 Peiris37 Pooled Said39 Pooled –20 –10 0 10 20 –60 –30 0 30 60 (sec) (days) Favours con Favours exp Favours con Favours exp Figure 7. Forest plot of the effect of additional after-hours or weekend Figure 11. Forest plot of the effect of additional after-hours or weekend rehabilitation on the Timed Up and Go test, pooling data from three studies and rehabilitation on length of stay, pooling data from four studies and presented as presented as a weighted mean difference (95% CI). a weighted mean difference (95% CI). Walking borderline statistical significance (95% CI 0.00 to 0.21). There was Three studies investigated walking speed (Figure 5, and see no evidence of heterogeneity between studies (Q = 2.88, p = 0.58). Figure 6 on the eAddenda for the detailed forest plot). The effect of Effect of additional after-hours or weekend rehabilitation on additional rehabilitation on walking speed was not significant (MD length of stay 0.03 m/s, 95% CI –0.04 to 0.11) (Figure 5). There was no evidence of heterogeneity between studies (Q = 4.05, p = 0.13). A meta-analysis of four trials examining the effect of additional after-hours and weekend rehabilitation on hospital length of stay Three studies investigated the Timed Up and Go test (Figure 7, is presented in Figure 11 (see Figure 12 on the eAddenda for the and see Figure 8 on the eAddenda for the detailed forest plot). detailed forest plot). Overall, additional rehabilitation after hours Overall, there was no effect of additional rehabilitation on the time or on weekends had no significant effect on the length of the stay in taken to complete the test (MD 0.04 seconds, 95% CI –2.33 to 2.41). rehabilitation (MD –1.8 days, 95% CI –5.1 to 1.6). There was no There was no evidence of heterogeneity between studies (Q = 0.45, evidence of heterogeneity between studies (I2 = 0%, p = 0.88). p = 0.80). Balance Effect of additional after-hours or weekend rehabilitation on A study by Galvin and colleagues35 demonstrated a significant physical activity effect in favour of the intervention group on the Berg Balance Scale (range 0 ‘worst’ to 56 ‘best’) on discharge from hospital. The intervention group improved by 14 more points than the control group (95% CI 5 to 23). Arm function Two studies investigated physical activity, showing that The study by Harris and colleagues19 demonstrated a between- weekend or after-hours rehabilitation could increase physical group difference of 7 points (95% CI 3 to 10) in favour of the activity39 and, more specifically, steps taken and time spent intervention group on the Chedoke Arm and Hand Inventory; upright.40 In the study by Said and colleagues,39 physical activity scores can range from 0 to 63. levels in the intervention group were compared to activity levels Activities of daily living observed on the rehabilitation unit in a previous study.16 The The combined result of the five studies that measured activities activity levels were double those previously observed of an of daily living with the Barthel Index or Functional Independence Measure is presented in Figure 9 (see Figure 10 on the eAddenda evening (13.8 minutes) and weekend activity levels improved to be for the detailed forest plot). The mean result favoured additional equal to that observed on weekdays (additional 30 minutes, to aF(i]GI$DT)9_erug[ fter-hours or weekend rehabilitation (SMD 0.10) but this was of achieve a total of 1.6 hours upright time).16,39 In the 2012 study by Peiris and colleagues,40 an additional Saturday therapy session caused participants to take twice as many steps (MD 428 steps, 95% CI 184 to 673) and spend 50% more time upright (MD 0.5 hours, 95% CI 0.1 to 0.9) on that day. 1gu]GIF$DT)i3_e[(r Study SMD RR Brusco38 (95% CI) (95% CI) Davidson36 Galvin35 Study Peiris37 Brusco38 Said39 Harris19 Pooled Peiris37 Said39 Pooled 0.1 0.5 1 2 10 –1.0 –0.5 0 0.5 1.0 Favours exp Favours con Favours con Favours exp Figure 13. Forest plot of the effect of additional after-hours or weekend Figure 9. Forest plot of the effect of additional after-hours or weekend rehabilitation on activities of daily living, pooling data from five studies and rehabilitation on adverse events, pooling data from three studies and presented presented as a standardised mean difference (95% CI). as relative risk (95% CI). Note that no adverse events occurred in either group in the study by Harris et al.19.
66 Scrivener et al: After-hours rehabilitation for hospital inpatients Adverse events systematic review,39 may provide additional evidence regarding the efficacy of after-hours rehabilitation. A meta-analysis of four studies was conducted. Despite reporting data about adverse events, the 2012 study by Peiris et al40 was When interpreting results from the studies in the review, the excluded from this meta-analysis because it reports data on a actual dosage of additional rehabilitation that was provided needs subset of participants in their larger 2013 trial.37 The pooled relative to be considered. Providing more days of rehabilitation, for risk of experiencing adverse events is expressed in Figure 13 (see example, on the weekend, does not necessarily result in a Figure 14 on the eAddenda for the detailed forest plot). Overall, significantly larger amount of rehabilitation. For example, a trial there was no increased risk of adverse events with the provision of comparing 5-day versus 7-day physiotherapy in the acute after-hours or weekend rehabilitation (RR 0.87, 95% CI 0.70 to 1.10). orthopaedic setting found no difference in the number of There was no evidence of heterogeneity between studies (Q = 0.05, physiotherapy sessions the two groups received.42 Similarly, in p = 0.98). The reported adverse events included in the analysis the study by Davidson and colleagues in this review,36 which were more-serious events such as falls. Harris and colleagues19 investigated a nurse-run weekend exercise program, the addition- also reported that 15 participants in the intervention group (who al exercise provided to each participant was minimal, with an undertook an independent upper-limb exercise program) experi- average 13 minutes (SD 14) of additional exercise on each weekend enced shoulder pain, although it is unclear whether control group day. In this systematic review, we considered whether to examine participants were asked about this. The data from Peiris and the effect of the dose of the additional rehabilitation that was colleagues37 were obtained via correspondence with the author. provided; however, due to the limited number of studies reporting on each outcome measure, this was not possible. Discussion In conclusion, after-hours or weekend rehabilitation has This systematic review suggests that additional after-hours or beneficial effects on aspects of physical function, performance of weekend rehabilitation can improve aspects of physical function activities of daily living, and the amount of physical activity in the and performance of activities of daily living, as well as increase hospital. There was no effect shown for length of stay in hospital. physical activity levels in hospital. However, no significant effect on length of stay in hospital was identified. What is already known on this topic: Rehabilitation that involves repetitive practice of functional tasks and exercise to The results of this review support other studies suggesting that improve fitness is effective for people with poor mobility and increased intensity of rehabilitation leads to improved functional functional performance due to various health conditions. outcomes.6–9 Moreover, it supports the hypothesis that additional Rehabilitation inpatients perform few therapeutic activities rehabilitation can be delivered out of hours, including on the in the evening and on weekends. weekend. However, the results are in contrast to a previous What this study adds: Additional rehabilitation provided systematic review that investigated physiotherapy provided out of after hours or on weekends improves aspects of physical hours in hospitals13 and found no effect of the additional therapy. function, performance of activities of daily living, and the amount of physical activity undertaken in the hospital. Despite The studies in this review varied in the method of delivering the these benefits, length of stay in hospital was not significantly additional rehabilitation. One study used a self-administered affected. exercise program with weekly support from therapy staff,19 another study used family members to assist with an after-hours eAddenda: Figures 4, 6, 8, 10, 12 and 14 and Appendix 1 can be exercise program,35 whilst another study trained nursing found online at doi:10.1016/j.jphys.2015.02.017. staff to deliver exercise programs on the weekend.36 The remaining four studies used therapists or therapy assistants to provide Ethics approval: Not applicable. additional therapy session either after hours or on weekends.37–40 Competing interests: Nil. Both studies using independent or family-mediated training Source(s) of support: Nil. demonstrated a significant impact on function with minimal Acknowledgements: Nil. adverse events (eg, mild shoulder pain after arm exercise). Correspondence: Katharine Scrivener, Department of Health Professions, Macquarie University, Sydney, Australia. Email: kate. This review identified that providing additional rehabilitation [email protected] after hours is effective in improving some patient outcomes. From a hospital perspective, this intervention can be self-administered References by the patient, supported by family members or offered by existing members of nursing staff – meaning that it can be implemented at 1. Dobkin BH. Rehabilitation after Stroke. N Engl J Med. 2005;352(16):1677–1684. minimal or no cost. On the other hand, this review demonstrated 2. Halbert J, Crotty M, Whitehead C, Cameron I, Kurrle S, Graham S, et al. Multi- no reduction in length of stay; thus, not necessarily producing any cost savings for the organisation. For clinicians working in disciplinary rehabilitation after hip fracture is associated with improved outcome: rehabilitation, offering after-hours intervention may be a mecha- A systematic review. J Rehabil Med. 2007;39(7):507–512. nism for improving outcome without a significant increase in 3. Van Ross E, Larner S. Rehabilitation after Amputation. In: Boulton AJM, workload. This review also provides cautious support to the idea of Connor H, Cavanagh PR, eds. In: The Foot in Diabetes. New York: John Wiley & restructuring rehabilitation services to operate over extended Sons Ltd; 2002:309–321. hours, seven days a week. 4. Handoll HH, Sherrington C. Mobilisation strategies after hip fracture surgery in adults. Cochrane Database Syst Rev. 2011;(3):CD001704. This review contained high-quality randomised, controlled 5. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. trials; all with a PEDro score of 8/10. The studies contained Lancet Neurol. 2009;8:741–754. participants of similar ages – generally over 65 years. A variety of 6. Kwakkel G, van Peppen R, Wagenaar RC, Wood Dauphinee S, Richards C, Ashburn A, rehabilitation settings and diagnostic groups were included in the et al. 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Journal of Physiotherapy 61 (2015) 96 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers A tailored hand exercise program improves function of the rheumatoid hand Synopsis Summary of: Lamb SE, Williamson EM, Heine PJ, Adams J, Dosanjh S, participants were educated with a standardised protocol to progress or regress Dritsaki M, et al. Exercises to improve function of the rheumatoid hand the exercises, and received an exercise booklet, an exercise contract and a (SARAH): a randomised controlled trial. Lancet 2014 October, doi.org/ diary, and participated in a patient-led goal-setting process. Outcome 10.1016/S0140-6736(14)60998-3. measures: The primary outcome was the overall hand function subscale of the Michigan Hand Outcome Questionnaire (range 0 to 100, with 100 indicat- Question: For people with rheumatoid arthritis, does a tailored ing greatest function), which was assessed by a blinded assessor at 4 and strengthening and stretching hand exercise program in addition to usual 12 months. Results: A total of 438 participants (89%) completed the 12-month care lead to greater improvements in hand function than usual care alone? follow-up. The mean difference in improvement for hand function was Design: A multicentre, investigator-blind, parallel-group, randomised, 4.7 units (95% CI 2.3 to 7.1) at 4 months and 4.3 units (95% CI 1.5 to 7.1) at controlled trial with concealed allocation. Setting: Seventeen National Health 12 months; both favoured the exercise program. No serious adverse events Service hospital trusts across the United Kingdom. Participants: Inclusion associated with the treatment were recorded. Conclusion: A tailored hand criteria were: adults with rheumatoid arthritis who met the American College exercise program in addition to usual care resulted in greater hand function of Rheumatology clinical and immunological criteria, who reported active than usual care alone for people with rheumatoid arthritis. pain and dysfunction of their hands, and who were on stable drug treatment for 3 months or more. Key exclusion criteria included: upper limb surgery or Margreth Grotlea and Ka˚ re Birger Hagenb fracture in the previous 6 months, pregnancy, or waiting for upper limb aOslo and Akershus University College of Applied Sciences, FORMI, surgery. Randomisation allocated 244 to usual care and 246 to usual care plus the tailored hand exercise program. Interventions: Usual care was based on Clinic for surgery and neurology, Oslo University Hospital, international clinical guidelines, including joint-protection education and Ullevaal N-0407, Oslo, Norway functional splinting (when needed). In addition, as part of usual care, participants received information sheets and up to three sessions of outpatient bNational Advisory Unit on Rehabilitation in Rheumatology, therapy with a maximum of 1.5 hours contact time. In addition to usual care, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway the intervention group were prescribed an exercise program that consisted of seven mobility and four strength or endurance exercises to be performed daily http://dx.doi.org/10.1016/j.jphys.2015.02.007 at home for a minimum of 12 weeks, plus six sessions of face-to-face contact with a physiotherapist or occupational therapist. During the sessions, the ß 2015 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. Commentary the participants were probably more motivated than the general arthritis population. In order to be applicable to the majority of people with Rheumatoid arthritis is associated with impaired hand function, in terms rheumatoid arthritis, the balance between what may be considered as of joint deformities, pain, stiffness and reduced grip strength and joint ‘optimal’ versus ‘good enough’ regarding dosage should therefore be mobility. This may lead to activity limitations, participation restrictions and explored. reduced quality of life. In this well-designed and sufficiently powered study, the researchers investigated the effect of exercises for the rheumatoid hand. Concerning the selection of exercises, one may question whether the The results documented that a low-cost intervention led to additional and metacarpophalangeal flexion and finger pinch exercises may have the important functional improvements in participants on stable drug potential to enhance development of deformities in inflamed and unstable treatment. metacarpal joints and interphalangeal joints. Hence, more studies are needed to determine the optimal exercise selection and dosage. The development of the program was based on physiological consider- ations, research evidence, clinical expertise and client preference.1 It Nina Østera˚ s and Ingvild Kjeken adhered to the new Medical Research Council’s framework for design and National Advisory Unit on Rehabilitation in Rheumatology, evaluation of complex interventions. This thorough process may represent Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway an important factor that contributed to the positive results. Furthermore, the large number of centres and therapists involved indicate that the program is Reference applicable in a variety of settings. The next step would be to evaluate whether it may be successfully delivered in primary healthcare. 1. Heine PJ, et al. Physiotherapy. 2012;98:121–130. Current guidelines for exercise dosage are not specific regarding the http://dx.doi.org/10.1016/j.jphys.2015.02.008 optimal dosage for people with hand arthritis. Participants in the present study were instructed to exercise every day, while adherence to the program was reported as performing one to two (or more) sessions per week. Thus, there seems to be a gap between what the researchers considered to be the optimal frequency and what they expected participants to manage in their everyday life. Also, as in most studies, 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 96 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers A tailored hand exercise program improves function of the rheumatoid hand Synopsis Summary of: Lamb SE, Williamson EM, Heine PJ, Adams J, Dosanjh S, participants were educated with a standardised protocol to progress or regress Dritsaki M, et al. Exercises to improve function of the rheumatoid hand the exercises, and received an exercise booklet, an exercise contract and a (SARAH): a randomised controlled trial. Lancet 2014 October, doi.org/ diary, and participated in a patient-led goal-setting process. Outcome 10.1016/S0140-6736(14)60998-3. measures: The primary outcome was the overall hand function subscale of the Michigan Hand Outcome Questionnaire (range 0 to 100, with 100 indicat- Question: For people with rheumatoid arthritis, does a tailored ing greatest function), which was assessed by a blinded assessor at 4 and strengthening and stretching hand exercise program in addition to usual 12 months. Results: A total of 438 participants (89%) completed the 12-month care lead to greater improvements in hand function than usual care alone? follow-up. The mean difference in improvement for hand function was Design: A multicentre, investigator-blind, parallel-group, randomised, 4.7 units (95% CI 2.3 to 7.1) at 4 months and 4.3 units (95% CI 1.5 to 7.1) at controlled trial with concealed allocation. Setting: Seventeen National Health 12 months; both favoured the exercise program. No serious adverse events Service hospital trusts across the United Kingdom. Participants: Inclusion associated with the treatment were recorded. Conclusion: A tailored hand criteria were: adults with rheumatoid arthritis who met the American College exercise program in addition to usual care resulted in greater hand function of Rheumatology clinical and immunological criteria, who reported active than usual care alone for people with rheumatoid arthritis. pain and dysfunction of their hands, and who were on stable drug treatment for 3 months or more. Key exclusion criteria included: upper limb surgery or Margreth Grotlea and Ka˚ re Birger Hagenb fracture in the previous 6 months, pregnancy, or waiting for upper limb aOslo and Akershus University College of Applied Sciences, FORMI, surgery. Randomisation allocated 244 to usual care and 246 to usual care plus the tailored hand exercise program. Interventions: Usual care was based on Clinic for surgery and neurology, Oslo University Hospital, international clinical guidelines, including joint-protection education and Ullevaal N-0407, Oslo, Norway functional splinting (when needed). In addition, as part of usual care, participants received information sheets and up to three sessions of outpatient bNational Advisory Unit on Rehabilitation in Rheumatology, therapy with a maximum of 1.5 hours contact time. In addition to usual care, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway the intervention group were prescribed an exercise program that consisted of seven mobility and four strength or endurance exercises to be performed daily http://dx.doi.org/10.1016/j.jphys.2015.02.007 at home for a minimum of 12 weeks, plus six sessions of face-to-face contact with a physiotherapist or occupational therapist. During the sessions, the ß 2015 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. Commentary the participants were probably more motivated than the general arthritis population. In order to be applicable to the majority of people with Rheumatoid arthritis is associated with impaired hand function, in terms rheumatoid arthritis, the balance between what may be considered as of joint deformities, pain, stiffness and reduced grip strength and joint ‘optimal’ versus ‘good enough’ regarding dosage should therefore be mobility. This may lead to activity limitations, participation restrictions and explored. reduced quality of life. In this well-designed and sufficiently powered study, the researchers investigated the effect of exercises for the rheumatoid hand. Concerning the selection of exercises, one may question whether the The results documented that a low-cost intervention led to additional and metacarpophalangeal flexion and finger pinch exercises may have the important functional improvements in participants on stable drug potential to enhance development of deformities in inflamed and unstable treatment. metacarpal joints and interphalangeal joints. Hence, more studies are needed to determine the optimal exercise selection and dosage. The development of the program was based on physiological consider- ations, research evidence, clinical expertise and client preference.1 It Nina Østera˚ s and Ingvild Kjeken adhered to the new Medical Research Council’s framework for design and National Advisory Unit on Rehabilitation in Rheumatology, evaluation of complex interventions. This thorough process may represent Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway an important factor that contributed to the positive results. Furthermore, the large number of centres and therapists involved indicate that the program is Reference applicable in a variety of settings. The next step would be to evaluate whether it may be successfully delivered in primary healthcare. 1. Heine PJ, et al. Physiotherapy. 2012;98:121–130. Current guidelines for exercise dosage are not specific regarding the http://dx.doi.org/10.1016/j.jphys.2015.02.008 optimal dosage for people with hand arthritis. Participants in the present study were instructed to exercise every day, while adherence to the program was reported as performing one to two (or more) sessions per week. Thus, there seems to be a gap between what the researchers considered to be the optimal frequency and what they expected participants to manage in their everyday life. Also, as in most studies, 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 95 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Constraint-induced movement therapy early after stroke improves rate of upper limb motor recovery but not long-term motor function Synopsis Summary of: Thrane G, Askim T, Stock R, Indredavik B, Gjone R, assessment, the Nine-Hole Peg Test, the arm use ratio, and the Stroke Erichsen A, et al. Efficacy of constraint-induced movement Impact Scale. Results: Primary outcome data were obtained from therapy in early stroke rehabilitation: A randomized controlled 85% of the participants at 6 months. Intention-to-treat analyses of multisite trial. Neurorehabil Neural Repair. 2014; DOI:10.1177/ the primary outcome variable showed no differences between the 1545968314558599. groups on log-transformed Wolf Motor Function Test time at 6 months (mean difference = –0.07, 95% CI –0.16 to 0.02), although Question: Does modified constraint-induced movement therapy the constraint-induced movement therapy group had a significantly improve arm motor function in people within 4 weeks after stroke? greater improvement in log-transformed Wolf Motor Function Test Design: Multisite, randomised, controlled trial with blinded time at the end of the 2-week intervention (mean difference = –0.14, outcome assessment at baseline, after 2FD1]I_[T$ weeks of intervention 95% CI –0.26 to –0.02). There were significant within-group and at 6-month follow-up. Setting: Five hospitals in Norway. improvements in all secondary variables, but no differences Participants: Inclusion criteria were: individuals within 5-26 days between groups. Conclusion: It is feasible and safe to provide a after stroke with unilateral arm or hand paresis, and being able to lift modified constraint-induced movement therapy protocol within two fingers or extend the wrist at least 10 2TdD_[$]FI eg from full flexion. Key the first 4 weeks after stroke. While constraint-induced movement exclusion criteria were: a Modified Rankin Scale > 4, a prior stroke therapy early after stroke may improve the rate of upper limb affecting the upper extremity, and a life expectancy < 1 year. recovery compared to standard care, it does not improve long-term Randomisation of 47 participants allocated 24 to the intervention function. group and 23 to the control group. Interventions: The intervention group received constraint-induced movement therapy for 3 hours/ [95% CIs calculated by the CAP Editor.] day for 10 consecutive workdays; a mitt was worn on the unaffected upper limb for up to 90% of waking hours. The control group received Prudence Plummer standard care according to guidelines. Participants in both groups Department of Allied Health Sciences, The University of North Carolina received other multidisciplinary care as needed. Outcome mea- sures: The primary outcome measure was the Wolf Motor Function at Chapel Hill, USA Test of arm function at 6-months post intervention. Secondary outcome measures were: the Fugl-Meyer upper extremity motor http://dx.doi.org/10.1016/j.jphys.2015.02.004 Commentary In spite of strong research showing positive effects of constraint- function and impairment during current early phase rehabilitation? induced movement therapy on impairments and function, it is not We do need more research to understand the factors contributing to clear how much has been adopted into mainstream clinical practice. recovery during this early phase and how to select the interventions I think we are all aware of missed opportunities to take advantage of that are most beneficial for patient subgroups. The inability of this the profound ability for neuroplasticity during early phase study to recruit an adequate sample for an overall well-designed rehabilitation. This article is timely, in that it focuses on study that followed the Extremity Constraint Induced Therapy constraint-induced movement therapy during this early rehabilita- Evaluation (EXCITE) protocol quite closely3 should be a wake-up call tion phase. According to a recent meta-analysis,1 the results of this for researchers. I suggest we take a different approach to participant study reinforce previous findings that there is no consensus of the selection for these studies and broaden our selection criteria to effects of constraint-induced movement therapy in the acute phase. produce a larger sample – then we can stratify accordingly. Otherwise, we will continue to produce evidence that cannot It is important to understand the effects of constraint-induced adequately answer these important questions. movement therapy during this acute phase and to identify which protocols and doses are most effective, if any. The effect pendulum Carol Giuliani swings from constraint-induced movement therapy produces Department of Allied Health Sciences, better function and reduces impairments compared to ‘standard’ The University of North Carolina at Chapel Hill, USA therapy, to it is detrimental to recovery if the dose is too high.2 The authors suggest that there may be short-term effects on the Wolf References Motor Function Test and the Nine-Hole Peg Test two weeks after constraint-induced movement therapy but no difference between 1. Thrane G, et al. J Rehabil Med. 2014;46:833–842. groups at six months; therefore, ‘application of constraint-induced 2. Dromerick AW, et al. Neurology. 2009;73:195–201. movement therapy in early stroke rehabilitation is not warranted 3. Wolf SL, et al. JAMA. 2006;296:2095–2104. because of limited evidence of lasting effect.’ What evidence do we have of the lasting effects of interventions for stroke upper limb http://dx.doi.org/10.1016/j.jphys.2015.02.005 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 95 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Constraint-induced movement therapy early after stroke improves rate of upper limb motor recovery but not long-term motor function Synopsis Summary of: Thrane G, Askim T, Stock R, Indredavik B, Gjone R, assessment, the Nine-Hole Peg Test, the arm use ratio, and the Stroke Erichsen A, et al. Efficacy of constraint-induced movement Impact Scale. Results: Primary outcome data were obtained from therapy in early stroke rehabilitation: A randomized controlled 85% of the participants at 6 months. Intention-to-treat analyses of multisite trial. Neurorehabil Neural Repair. 2014; DOI:10.1177/ the primary outcome variable showed no differences between the 1545968314558599. groups on log-transformed Wolf Motor Function Test time at 6 months (mean difference = –0.07, 95% CI –0.16 to 0.02), although Question: Does modified constraint-induced movement therapy the constraint-induced movement therapy group had a significantly improve arm motor function in people within 4 weeks after stroke? greater improvement in log-transformed Wolf Motor Function Test Design: Multisite, randomised, controlled trial with blinded time at the end of the 2-week intervention (mean difference = –0.14, outcome assessment at baseline, after 2FD1]I_[T$ weeks of intervention 95% CI –0.26 to –0.02). There were significant within-group and at 6-month follow-up. Setting: Five hospitals in Norway. improvements in all secondary variables, but no differences Participants: Inclusion criteria were: individuals within 5-26 days between groups. Conclusion: It is feasible and safe to provide a after stroke with unilateral arm or hand paresis, and being able to lift modified constraint-induced movement therapy protocol within two fingers or extend the wrist at least 10 2TdD_[$]FI eg from full flexion. Key the first 4 weeks after stroke. While constraint-induced movement exclusion criteria were: a Modified Rankin Scale > 4, a prior stroke therapy early after stroke may improve the rate of upper limb affecting the upper extremity, and a life expectancy < 1 year. recovery compared to standard care, it does not improve long-term Randomisation of 47 participants allocated 24 to the intervention function. group and 23 to the control group. Interventions: The intervention group received constraint-induced movement therapy for 3 hours/ [95% CIs calculated by the CAP Editor.] day for 10 consecutive workdays; a mitt was worn on the unaffected upper limb for up to 90% of waking hours. The control group received Prudence Plummer standard care according to guidelines. Participants in both groups Department of Allied Health Sciences, The University of North Carolina received other multidisciplinary care as needed. Outcome mea- sures: The primary outcome measure was the Wolf Motor Function at Chapel Hill, USA Test of arm function at 6-months post intervention. Secondary outcome measures were: the Fugl-Meyer upper extremity motor http://dx.doi.org/10.1016/j.jphys.2015.02.004 Commentary In spite of strong research showing positive effects of constraint- function and impairment during current early phase rehabilitation? induced movement therapy on impairments and function, it is not We do need more research to understand the factors contributing to clear how much has been adopted into mainstream clinical practice. recovery during this early phase and how to select the interventions I think we are all aware of missed opportunities to take advantage of that are most beneficial for patient subgroups. The inability of this the profound ability for neuroplasticity during early phase study to recruit an adequate sample for an overall well-designed rehabilitation. This article is timely, in that it focuses on study that followed the Extremity Constraint Induced Therapy constraint-induced movement therapy during this early rehabilita- Evaluation (EXCITE) protocol quite closely3 should be a wake-up call tion phase. According to a recent meta-analysis,1 the results of this for researchers. I suggest we take a different approach to participant study reinforce previous findings that there is no consensus of the selection for these studies and broaden our selection criteria to effects of constraint-induced movement therapy in the acute phase. produce a larger sample – then we can stratify accordingly. Otherwise, we will continue to produce evidence that cannot It is important to understand the effects of constraint-induced adequately answer these important questions. movement therapy during this acute phase and to identify which protocols and doses are most effective, if any. The effect pendulum Carol Giuliani swings from constraint-induced movement therapy produces Department of Allied Health Sciences, better function and reduces impairments compared to ‘standard’ The University of North Carolina at Chapel Hill, USA therapy, to it is detrimental to recovery if the dose is too high.2 The authors suggest that there may be short-term effects on the Wolf References Motor Function Test and the Nine-Hole Peg Test two weeks after constraint-induced movement therapy but no difference between 1. Thrane G, et al. J Rehabil Med. 2014;46:833–842. groups at six months; therefore, ‘application of constraint-induced 2. Dromerick AW, et al. Neurology. 2009;73:195–201. movement therapy in early stroke rehabilitation is not warranted 3. Wolf SL, et al. JAMA. 2006;296:2095–2104. because of limited evidence of lasting effect.’ What evidence do we have of the lasting effects of interventions for stroke upper limb http://dx.doi.org/10.1016/j.jphys.2015.02.005 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 93 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Trial Protocol Efficacy of the addition of positive airway pressure to conventional chest physiotherapy in resolution of pleural effusion after drainage: protocol for a randomised controlled trial Elinaldo da Conceic¸a˜o dos Santos a,b, Adriana Claudia Lunardi a,c a Master’s and Doctoral Programs in Physical Therapy, Universidade Cidade de Sa˜o Paulo; b Department of Biological and Health Sciences, Universidade Federal do Amapa´; c Department of Physical Therapy of School of Medicine, University of Sa˜o Paulo, Sa˜o Paulo, Brazil Abstract on chest radiography, as assessed by a blinded physician. Duration of chest drainage, length of hospital stay, and any pulmonary Introduction: Chest drainage for pleural effusion can cause pain complications diagnosed during hospitalisation will be recorded. and changes in respiratory function. It can also increase the risk of Analysis: Intention to treat using: survival analysis for duration of pulmonary complications and impair functional ability, which may chest drainage, and length of hospital stay; analysis of variance for increase length of hospital stay and the associated costs. For these chest-tube output, lung function and peripheral oxygen saturation; reasons, surgical and clinical strategies have been adopted to and chi-square tests for comparing the incidence of pulmonary reduce the duration of chest drainage. Objectives: To evaluate the complications between groups. Discussion: Conventional chest efficacy of the addition of intermittent positive airway pressure physiotherapy and intermittent positive airway pressure breathing applied by the Muller reanimator via a rubber facial mask versus are widely indicated for people with pleural effusion and chest conventional physiotherapy on the duration of chest drainage drains; however, no studies have evaluated the real benefit of this (primary objective), and its effect on the recovery of respiratory type of treatment. Our hypothesis is that optimised lung expansion function, length of hospital stay and incidence of pulmonary achieved through the application of intermittent positive airway complications (secondary objectives). Design: Randomised, con- pressure will accelerate the reabsorption of pleural effusion, trolled trial. Participants and setting: Inpatients with pleural decrease the duration of chest drainage and respiratory system effusion, aged over 18 years, who have had chest drainage in situ impairment, reduce the length of hospital stay, and reduce the for < 24 hours will be recruited from two university hospitals. incidence of pulmonary complications. Patients will be excluded if they have any contraindication for the use of non-invasive positive airway pressure. Intervention and Trial registration: ClinicalTrials.gov. Registration number: control groups: After initial assessments of lung function, NCT02246946. Was this trial prospectively registered: Yes, date: 156 patients will be randomised into a positive airway pressure 16 September 2014. Funded by: Conselho Nacional de Desenvolvi- group (positive airway pressure at 15 cmH2O plus conventional mento Cientı´fico e Tecnolo´ gico-CNPq. Funder approval number: chest physiotherapy), a conventional chest physiotherapy group 442709/2014-5. Anticipated completion: September 2016. Corre- (conventional chest physiotherapy plus non-therapeutic positive spondence: Dr Adriana Claudia Lunardi, Master’s and Doctoral Pro- airway pressure at 4 cmH2O) or a control group (non-therapeutic grams in Physical Therapy, Universidade Cidade de Sa˜o Paulo, Sa˜o positive airway pressure at 4 cmH2O). All groups will receive Paulo, Brazil. Email: [email protected] treatment three times per day for 7 consecutive days. Measure- ments: A blinded assessor will conduct all assessments. Peripheral Full protocol: Available on the eAddenda at doi:10.1016/j.jphys. oxygenation and chest drainage output will be measured over 2014.11.016 7 consecutive days. Lung function will be re-assessed on Day 4 and Day 8. The criteria for removal of the chest drain will be a transudate output 200 ml over 24 hours and full lung expansion http://dx.doi.org/10.1016/j.jphys.2014.11.016 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 97 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Gait improves after 12 weeks of intensive resistance and functional training in people with mild to moderate dementia Synopsis Summary of: Schwenk M, Zieschang T, Englert S, Grewal G, Najafi B, while seated. Outcome measures: The primary outcome was gait Hauer K. Improvements in gait characteristics after intensive resistance performance (speed, cadence, stride length, double support time, step and functional training in people with dementia: a randomised width and step time variability), measured using an electronic gait controlled trial. BMC Geriatrics 2014; 14:73. analysis system (GAITRite) at baseline and 12 weeks. Results: Forty- nine participants (80%), with a mean age of 82 years (SD 8) and a Mini- Question: Does an intensive progressive resistance and functional Mental State Examination average of 21 points (SD 3), completed the exercise program improve gait characteristics in people with demen- study. There was greater than 90% adherence to the program in both tia? Design: Randomised, controlled trial with concealed allocation and groups. Results significantly favoured the high-intensity exercise group blinding of participants and assessors. Setting: A geriatric hospital and at 12 weeks, with differences of: 18 cm/second for gait speed (95% CI outpatient nursing care service in Germany. Participants: Inclusion 10 to 27); 11 steps/minute for cadence (95% CI 4 to 18); 8 cm for stride criteria were: adults aged at least 65 years with a confirmed dementia length (95% CI 2 to 14); –0.08 seconds for stride time (95% CI –0.12 to – diagnosis, cognitive impairment (Mini-Mental State Examination score 0.03); and –2.9% for double support as a percentage of stride time (95% 17 to 26), and able to walk 10 m or more without a walking aid. A key CI –4.5 to –1.3). There were no significant differences between the exclusion criterion was living more than 15 km from the study centre. groups for step width and step time variability. A lower functional Randomisation allocated 26 people to the exercise intervention and performance at baseline, but not cognitive status, was independently 35 people to the control group. Interventions: The exercise group associated with improvements in gait speed. Conclusion: A 12-week participated in two 2-hour sessions each week for 12 weeks. A qualified high-intensity resistance and functional exercise program improved instructor supervised the exercise sessions, which comprised resis- temporal and spatial characteristics of gait for older people with mild tance and functional training. Resistance training targeted functionally to moderate dementia. relevant muscle groups at an intensity of 70 to 80% of one repetition maximum. Functional training focused on tasks like sit to stand and Nicholas Taylor walking, with progression by altering speed, amplitude or accuracy of Section Editor, Journal of Physiotherapy performance. The control group met twice per week for 1 hour of low- intensity supervised training; they performed activities that were not http://dx.doi.org/10.1016/j.jphys.2015.02.009 expected to affect walking, such as flexibility exercises and ball games Commentary referral to rehabilitation occurring only after multiple falls and referrers being unaware of effective gait rehabilitation programs. Gait problems that are associated with dementia include slowing and While the study findings may not generalise to those with more severe increased step-to-step variability, and are present from the earliest dementia, it is worth noting that the greatest benefit of the training was disease stages. They are related to decreased executive function, are risk in participants with the greatest functional impairment. It should also factors for falling1 and diminish functional independence.2 Given the be noted that despite the clinically meaningful improvement in rapidly increasing prevalence of dementia, there is substantial value in velocity, there was a lack of improvement in gait variability, which is a developing methods of improving or maintaining gait function in this risk factor for falling. This will need to be addressed in future research. population. The study by Schwenk and colleagues is important, in that it is a well-designed trial that provides strong evidence of the effectiveness Joanne Wittwer of a training program to improve walking in older people with dementia. School of Allied Health, La Trobe University, Australia The high adherence rates and lack of serious adverse events in a relatively frail group increase the clinical applicability of the training program. References A key aspect for translation into clinical practice is the combination of 1. Nakamura T, et al. Gerontology. 1996;42:108–113. resistance training and practice of functional activities, which supports 2. Hebert LE, et al. Am J Alzheimers Dis Other Demen. 2010;25:425–431. previous findings that multi-component interventions may be more 3. Blankevoort CG, et al. Dement Geriatr Cogn Disord. 2010;30:392–402. effective than single-component interventions.3,4 Other important 4. Potter R, et al. Int J Geriatr Psychiatry. 2011;26:1000–1011. program elements are the progressive modification of training activities according to individual performance and the systematic use of strategies http://dx.doi.org/10.1016/j.jphys.2015.02.010 tailored for people with cognitive impairment to facilitate adherence. An issue for clinicians may be the need for early intervention. The study group included people with mild to moderate dementia. Unfortunately, there are a number of potential barriers to early referral for gait rehabilitation for people with dementia. These include 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 97 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Gait improves after 12 weeks of intensive resistance and functional training in people with mild to moderate dementia Synopsis Summary of: Schwenk M, Zieschang T, Englert S, Grewal G, Najafi B, while seated. Outcome measures: The primary outcome was gait Hauer K. Improvements in gait characteristics after intensive resistance performance (speed, cadence, stride length, double support time, step and functional training in people with dementia: a randomised width and step time variability), measured using an electronic gait controlled trial. BMC Geriatrics 2014; 14:73. analysis system (GAITRite) at baseline and 12 weeks. Results: Forty- nine participants (80%), with a mean age of 82 years (SD 8) and a Mini- Question: Does an intensive progressive resistance and functional Mental State Examination average of 21 points (SD 3), completed the exercise program improve gait characteristics in people with demen- study. There was greater than 90% adherence to the program in both tia? Design: Randomised, controlled trial with concealed allocation and groups. Results significantly favoured the high-intensity exercise group blinding of participants and assessors. Setting: A geriatric hospital and at 12 weeks, with differences of: 18 cm/second for gait speed (95% CI outpatient nursing care service in Germany. Participants: Inclusion 10 to 27); 11 steps/minute for cadence (95% CI 4 to 18); 8 cm for stride criteria were: adults aged at least 65 years with a confirmed dementia length (95% CI 2 to 14); –0.08 seconds for stride time (95% CI –0.12 to – diagnosis, cognitive impairment (Mini-Mental State Examination score 0.03); and –2.9% for double support as a percentage of stride time (95% 17 to 26), and able to walk 10 m or more without a walking aid. A key CI –4.5 to –1.3). There were no significant differences between the exclusion criterion was living more than 15 km from the study centre. groups for step width and step time variability. A lower functional Randomisation allocated 26 people to the exercise intervention and performance at baseline, but not cognitive status, was independently 35 people to the control group. Interventions: The exercise group associated with improvements in gait speed. Conclusion: A 12-week participated in two 2-hour sessions each week for 12 weeks. A qualified high-intensity resistance and functional exercise program improved instructor supervised the exercise sessions, which comprised resis- temporal and spatial characteristics of gait for older people with mild tance and functional training. Resistance training targeted functionally to moderate dementia. relevant muscle groups at an intensity of 70 to 80% of one repetition maximum. Functional training focused on tasks like sit to stand and Nicholas Taylor walking, with progression by altering speed, amplitude or accuracy of Section Editor, Journal of Physiotherapy performance. The control group met twice per week for 1 hour of low- intensity supervised training; they performed activities that were not http://dx.doi.org/10.1016/j.jphys.2015.02.009 expected to affect walking, such as flexibility exercises and ball games Commentary referral to rehabilitation occurring only after multiple falls and referrers being unaware of effective gait rehabilitation programs. Gait problems that are associated with dementia include slowing and While the study findings may not generalise to those with more severe increased step-to-step variability, and are present from the earliest dementia, it is worth noting that the greatest benefit of the training was disease stages. They are related to decreased executive function, are risk in participants with the greatest functional impairment. It should also factors for falling1 and diminish functional independence.2 Given the be noted that despite the clinically meaningful improvement in rapidly increasing prevalence of dementia, there is substantial value in velocity, there was a lack of improvement in gait variability, which is a developing methods of improving or maintaining gait function in this risk factor for falling. This will need to be addressed in future research. population. The study by Schwenk and colleagues is important, in that it is a well-designed trial that provides strong evidence of the effectiveness Joanne Wittwer of a training program to improve walking in older people with dementia. School of Allied Health, La Trobe University, Australia The high adherence rates and lack of serious adverse events in a relatively frail group increase the clinical applicability of the training program. References A key aspect for translation into clinical practice is the combination of 1. Nakamura T, et al. Gerontology. 1996;42:108–113. resistance training and practice of functional activities, which supports 2. Hebert LE, et al. Am J Alzheimers Dis Other Demen. 2010;25:425–431. previous findings that multi-component interventions may be more 3. Blankevoort CG, et al. Dement Geriatr Cogn Disord. 2010;30:392–402. effective than single-component interventions.3,4 Other important 4. Potter R, et al. Int J Geriatr Psychiatry. 2011;26:1000–1011. program elements are the progressive modification of training activities according to individual performance and the systematic use of strategies http://dx.doi.org/10.1016/j.jphys.2015.02.010 tailored for people with cognitive impairment to facilitate adherence. An issue for clinicians may be the need for early intervention. The study group included people with mild to moderate dementia. Unfortunately, there are a number of potential barriers to early referral for gait rehabilitation for people with dementia. These include 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 100 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinical Practice Guidelines Knee osteoarthritis Osteoarthritis Research Society International (OARSI) guidelines for the non-surgical management of knee osteoarthritis Date of latest update: March 2014. Date of next update: Not expert-consensus guidelines for the management of people with indicated. osteoarthritis of the knee. Evidence was reviewed for a variety Patient group: Individuals diagnosed with osteoarthritis of the of treatment modalities, including: biomechanical interventions; knee. Intended audience: The guidelines are intended for exercise (land-based, water-based, strength training); self- physicians, allied health professionals and patients worldwide. management and education; weight management; medication Additional versions: The current guidelines are an update of the (eg, paracetamol, intra-articular corticosteroids, oral and topical Osteoarthritis Research Society International (OARSI) recommenda- non-steroidal anti-inflammatory drugs (NSAIDs), duloxetine, tions for the management of hip and knee osteoarthritis (2010). The diacerein, intraarticular hyaluronic acid, opioids); compounds OARSI website also includes two-page summaries for the physician (chondroitin, glucosamine, capsaicin, avocado and soybean unsa- and patient. Expert working group: The guideline development ponfiables, rosehip); walking aids; acupuncture; balneotherapy; group comprised a patient advocate and a 13-member committee of and electrotherapy. Treatments were recommended as either experts from the fields of rheumatology, physiotherapy, orthopae- appropriate for all individuals, appropriate for specific clinical dics, primary care, physical medicine and rehabilitation, and clinical sub-phenotypes, of uncertain appropriateness, or inappropriate. A trials. The experts represented the USA, UK, France, Netherlands, useful flow diagram on page 4 outlines a summary of the core Belgium, Australia, Japan, Netherlands, Denmark and Sweden. treatments that are appropriate for all individuals, and recom- Funded by: OARSI. Consultation with: The guidelines were mended treatments for specific clinical sub-phenotypes. The bulk of disseminated for public comment. Approved by: OARSI. Location: the guidelines consists of a summary of each treatment modality, The guidelines and additional documents are available at: where the recommendation, rationale, and quality of evidence http://oarsi.org/education/oarsi-guidelines. They are also published underpinning the recommendation are presented. References are as: McAlindon TE, et al. OARSI guidelines for the non-surgical provided at the end of the document. management of knee osteoarthritis. Osteoarthritis and Cartilage 2014; 22: 363-388. Sandra Brauer Description: These guidelines are published in a 26-page research The University of Queensland, Australia article and aim to provide patient-focused, evidence-based, http://dx.doi.org/10.1016/j.jphys.2015.02.018 1836-9553/ß 2015 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association.
Appraisal Journal of Physiotherapy 61 (2015) 101 Media Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Living well to the end Taylor J, Simader R, Nieland P, eds. Potential and Possibility: unable to exercise in the gym. He became frustrated and angry Rehabilitation at end of life. Physiotherapy in Palliative Care. with himself, his disease and the therapist, returning from the gym Munich: Elsevier, Urban & Fischer; 2013. ISBN: 978-0-7020- to his room and locking himself in his bathroom’. The inclusion of 5027-5. reflective questioning within each section challenges the reader; for example, ‘What does death mean to you? And how is this For many, the topic of death and dying is uncomfortable and, concept of death translated in your work?’ These features make the until now, the role of the physiotherapist in this area has not been book an excellent teaching tool. clearly articulated. This comprehensive book is an essential first text for understanding the meaning and value of care delivered by The section on clinical reasoning and goal setting is particularly physiotherapists for people at the end of life. In the first chapter, helpful for making sense of the conundrum between maintaining contributing author Nigel Sykes emphasises the important role realistic and achievable goals without diminishing hope. It that physiotherapists play in enabling people ‘to live well until acknowledges that ‘goal setting can be a valuable part of the they die’; this theme is explored throughout, providing a detailed rehabilitation process if therapists are able to manage the tension framework for interventions in both physical and psychosocial between affirming life and preparing for death’. Providing a domains. Because of the changing health landscape in which framework with which to identify appropriate goals and imple- improved treatments enable people in palliative care to live longer, ment a treatment strategy that is respectful of the diagnosis, albeit often with impaired function, and the benefits of palliation disease trajectory and, most importantly, the individual, will assist extending beyond a cancer diagnosis, there are increasing numbers in allaying the fear that can be a barrier to accessing best practice. of physiotherapists involved with people who are facing end-of- This marries well with the chapter that covers communication and life issues. Therefore, this resource is timely and invaluable. deals with the strong emotions that can arise in palliative care, and is an example of how the structure of the book balances and The book is divided into five chapters, which cross-reference reinforces concepts and skill development throughout. My only and build on each other, making it a well-structured and accessible suggestion for future editions is to consider exercise as a separate read. Emphasis on empathic patient-centred care resonates topic, rather than a subsection of ‘Fatigue and Weakness’. The throughout the different sections, which cover content such as extensive reach of exercise across the physical, psychosocial and defining palliative care, professional identity, patients’ perspec- spiritual domains of care warrants this. tives, the management of specific symptoms, ethics and self-care. It is well-referenced, reflects the growing evidence base in this Described as a ‘dream realised’ by the three editors, this book field, and covers a broad scope of practice; this is due, in part, to the achieves its aims to support clinical practice and stimulate contribution of 29 authors from nine countries, including Australia. discussion. It provides insight and accessibility to the lived world Whilst the health systems under which the different sections are of people at the end of life and is certain to become an essential written vary, the information is consistent and applicable. The text across the spectrum of clinical practice, management and colour coding of content, which is arranged in boxes to easily education – challenging the individual therapist and the profession identify points of caution (red) and key strategies (green), is to consider the potential and possibility of what we have to offer. particularly helpful. A significant number of case studies are included, which provide powerful insights into people’s lived Roslyn Savage experiences. The case studies are particularly valuable for the Senior Palliative Care Physiotherapist, Calvary Health Care, Sydney, honesty and vulnerabilities that are illustrated. For example, ‘On one occasion, David (diagnosed with motor neurone disease) was Australia http://dx.doi.org/10.1016/j.jphys.2015.02.001 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
52 Editorial exponential increase in randomised, controlled trials in physio- a lasting one. She cared about patients’ outcomes before therapy.4 patient-centred care was articulated. Her contribution was ahead of its time, in that it was in line with the contemporary In the preface of the second edition of Neurological Rehabilita- view of healthcare systems, which are now best conceptualised as tion: Optimizing Motor Performance,5 published in 2010, Janet and learning systems where healthcare delivery, education and Roberta reflect on the progress of the profession and their research coexist to improve patient outcomes at individual and optimism for the future: societal levels. Physiotherapists are making a major change away from method- Janet entered the physiotherapy profession in 1954, at a time ologies developed in an earlier time for which there is no when the average working life of a physiotherapist was 5 years – evidenciary support, and increasingly using methods that are she went on to devote close to 60 highly productive years to congruent with current knowledge and for which there is her profession. Janet never retired; until her death she held an encouraging evidence. The results of suitably rigorous clinical honorary position of Associate Professor in the Faculty of trials eventually contribute to evidence-based practice. The current Health Sciences, The University of Sydney. On hearing of Janet’s interest in rehabilitation research and the quality of that research illness, the physiotherapy staff at the F]uTDI_3[$ niversity sent Janet are grounds for optimism. flowers and promptly received a response from her: ‘I have fond memories of working at the School of Physiotherapy, The Janet felt that bridging the gap between science and practice University of Sydney in its golden years – we thought we could was an overwhelming task for the clinician and was, therefore, change the world’. a critical driver in writing textbooks throughout her career. Collaboratively with Roberta, Janet authored/edited 13 books from Janet did change the world, she made it a better place, and she 1976 to 2010, which have inspired generations of physiotherapists. will be greatly missed. She inspired and empowered generations of These books have been translated into most European languages physiotherapists. and many Asian languages including Korean, Chinese, Japanese, Arabic and Farsi. The books have stimulated many passionate Ethics approval: Not applicable. Health debates and the development of ideas within the broad physiother- Competing interests: Nil. apy community, and between physiotherapy and other professions. Source(s) of support: Nil. To engage in these debates, Janet travelled, collaborated with Acknowledgements: Nil. international scientists, taught and presented conference papers in Correspondence: _[]CFD$I4T olleen DF[IC_T$5] anning, Faculty of over 30 different countries. Janet and Roberta worked, discussed, Sciences, The University ofI[$T]_DF6 Sydney, Sydney, Australia. argued and conducted their own research and scholarly work, while Email: F$DcIT_7[] olleen.FcI[8_]TD$ [email protected] encouraging and mentoring young researchers and clinicians. Although Janet’s major contribution was in neurological rehabilita- References tion, the way she conceptualised the profession and moved it forward applied to other areas of rehabilitation. The breadth of her 1. Carr JH, Shepherd R. Physiotherapy in Disorders of the Brain. London: Heinemann; influence and mentorship is exemplified by the Foundations for 1980. Physiotherapy Practice Series, commissioned by Janet and Roberta, and published in the early 1990s: Key Issues in Cardiopulmonary 2. Carr JH, Shepherd R. The Motor Relearning Programme for Stroke. 1st ed. London: Physiotherapy,6 edited by Elizabeth Ellis and Jenny Alison; Key Issues Heinemann; 1982. in Musculoskeletal Physiotherapy,7 edited by Jack Crosbie and Jenny McConnell; and Key Issues in Neurological Physiotherapy,8 edited by 3. Carr JH, Shepherd R. Neurological Rehabilitation: Optimizing Motor Performance. Louise Ada and Colleen Canning. The editors of each of these volumes 1st ed. Oxford: Butterworth Heinemann; 1998. were, at the time, all Janet’s junior colleagues who were inspired by her mentorship and guidance. 4. http://www.pedro.org.au/english/downloads/pedro-statistics/. Accessed February 3, 2015. It is important for us to acknowledge our debt to those who inspire and lead us. Janet will be remembered as a tirelessly 5. Carr JH, Shepherd R. Neurological Rehabilitation: Optimizing Motor Performance. inquiring academic who was a trailblazer, and her legacy will be 2nd ed. London: Churchill Livingstone Elsevier; 2010. 6. Ellis E, Alison J. Key Issues in Cardiopulmonary Physiotherapy. Oxford: Butterworth Heinemann; 1992. 7. Crosbie J, McConnell J. Key Issues in Musculoskeletal Physiotherapy. Oxford: Butter- worth Heinemann; 1993. 8. Ada L, Canning C. Key Issues in Neurological Physiotherapy. Oxford: Butterworth Heinemann; 1990. Papers of the Year 2014 The Editorial Board is pleased to announce the 2014 Paper of the exacerbating lymphoedema.2–4 This may have contributed to the Year Award. The winning paper is judged by a panel of members of reduced physical function – particularly upper limb strength – in the International Advisory Board who do not have a conflict of women during and after treatment for breast cancer.5 The interest with any of the papers under consideration. They vote for systematic review by Paramanandam and Roberts1 demonstrated the paper published in the 2014 calendar year which, in their with meta-analyses that weight training does not increase the opinion, has the best combination of scientific merit and onset or severity of lymphoedema in women after breast cancer. application to the clinical practice of physiotherapy. This process Weight training also improves upper and lower limb strength and resulted in a tied vote. improves aspects of quality of life related to physical function. The first winning paper is Weight training is not harmful for The second winning paper is Treadmill training provides women with breast cancer-related lymphoedema: a systematic greater benefit to the subgroup of community-dwelling people review by Vincent Paramanandam from Tata Memorial Hospital in after stroke who walk faster than 0.4 m/s: a randomised trial by India and Dave Roberts from Oxford Brookes University in the Catherine Dean from Macquarie University and Louise Ada and United Kingdom.1 In the past, clinical practice guidelines for breast Richard Lindley from the University of Sydney, Australia.6 Despite cancer have advised against strenuous activity or exercises with regaining the ability to walk, many survivors of stroke do not the arm on the affected side in order to reduce the risk of causing or regain their original walking speed or distance. Overall, treadmill
Announcement 53 training has moderately beneficial effects on walking speed and 3. Harris SR, Hugi MR, Olivotto IA, Niesen-Vertommen SL, Dingee CK, Eddy F, et al. distance in stroke survivors.7 The trial by Dean et al6 shows that Upper extremity rehabilitation in womden with breast cancer after axillary dissec- treadmill training typically provides greater benefits in walking tion: Clinical practice guidelines. Critical Reviews in Physical and Rehabilitation speed and distance in stroke survivors whose comfortable walking Medicine. 2001;13:91–103. speed before training is over 0.4 m/s. Clinicians can therefore confi dently use comfortable walking speed to predict the potential for 4. Spratt JS, Donegan WL. Surgical Management. In: Donegan WL, Spratt JS, eds. In: improvement with treadmill training. Cancer of the Breast. 4th ed. WB Saunders: Philadelphia; 1995:443–504. References 5. Neil-Sztramko SE, Kirkham AA, Hung SH, Niksirat N, Nishikawa K, Campbell KL. Aerobic capacity and upper limb strength are reduced in women diagnosed 1. Paramanandam VS, Roberts D. Weight training is not harmful for women with with breast cancer: a systematic review. Journal of Physiotherapy. 2014;60: breast cancer-related lymphoedema: a systematic review. Journal of Physiotherapy. 189–200. 2014;60:136–143. 6. Dean CM, Ada L, Lindley RI. Treadmill training provides greater benefit to the 2. Cheifetz O, Haley L. Management of secondary lymphedema related to breast subgroup of community- dwelling people after stroke who walk faster than cancer. Canadian Family Physician. 2010;56:1277–1284. 0.4 m/s: a randomised trial. Journal of Physiotherapy. 2014;60:97–101. 7. Polese JC, Ada L, Dean CM, Nascimento LR, Teixeira-Salmela LF. Treadmill training is effective for ambulatory adults with stroke: a systematic review. Journal of Physio- therapy. 2013;59:73–80.
Journal of Physiotherapy 61 (2015) 81–86 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research Parents of children with physical disabilities perceive that characteristics of home exercise programs and physiotherapists’ teaching styles influence adherence: a qualitative study Carmen Lillo-Navarro a, Francesc Medina-Mirapeix b, Pilar Escolar-Reina b, Joaquina Montilla-Herrador b, Francisco Gomez-Arnaldos c, Silvana L Oliveira-Sousa d a Department of Pathology and Surgery, Physiotherapy Area, Miguel Herna´ndez University, San Juan de Alicante; b Department of Physiotherapy, Regional Campus of International Excellence ‘Campus Mare Nostrum’, University of Murcia; c Therafis Clinic; d Department of Physiotherapy, Catholic University San Antonio of Murcia, Spain KEY WORDS ABSTRACT Parents Question: What are the perceptions of parents of children with physical disabilities about the home Adherence exercise programs that physiotherapists prescribe? How do these perceptions affect adherence to home Exercise exercise programs? Design: Qualitative study using focus groups and a modified grounded theory Qualitative research approach. Participants: Parents of children with physical disabilities who have been prescribed a home Physiotherapy exercise program by physiotherapists. Results: Twenty-eight parents participated in the focus groups. Two key themes that related to adherence to home exercise programs in young children with physical disabilities were identified: the characteristics of the home exercise program; and the characteristics of the physiotherapist’s teaching style. In the first theme, the participants described their experiences regarding their preference for exercises, which was related to the perceived effects of the exercises, their complexity, and the number of exercises undertaken. These factors determined the amount of time spent performing the exercises, the effect of the exercises on the family’s relationships, and any sense of related burden. In the second theme, participants revealed that they adhered better to prescribed exercises when their physiotherapist made an effort to build their confidence in the exercises, helped the parents to incorporate the home exercise program into their daily routine, provided incentives and increased motivation. Conclusion: Parents perceive that their children’s adherence to home-based exercises, which are supervised by the parents, is more successful when the physiotherapist’s style and the content of the exercise program are positively experienced. These findings reveal which issues should be considered when prescribing home exercise programs to children with physical disabilities. [Lillo- Navarro C, Medina-Mirapeix F, Escolar-Reina P, Montilla-Herrador J, Gomez-Arnaldos F, Oliveira- Sousa SL (2015) Parents of children with physical disabilities perceive that characteristics of home exercise programs and physiotherapists’ teaching styles influence adherence: a qualitative study. Journal of Physiotherapy 61: 81–86] ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction include: the complexity of the prescribed regimen, the parents’ knowledge of the therapeutic regimen, and relations and inter- For children with physical disabilities, the participation of their actions with health professionals.2,10 However, there is a families in home activity programs is key for successful therapy recognised need for qualitative research in order to understand interventions. Moreover, the active participation of parents during the complexities of treatment adherence.8 these activities has demonstrated positive effects on the children’s outcomes,1–4 such as gains in motor skill attainment.2–4 Several qualitative studies have assessed factors that affect adherence among children with disabilities,11–13 but these Despite the positive effects of adherence on functional studies have not researched the influence of the interactions outcomes, many studies have shown that children with dis- with physiotherapists who prescribe home exercise programs abilities are at risk of low levels of adherence.5–7 This problem is for very young children, where parents are necessarily involved. especially relevant for children with long-term conditions.6,8 A recent systematic review and synthesis of qualitative papers Depending on the differences in the definition of adherence on treatment adherence, which focused on children with chronic and its measurement, estimates of how many parents actually long-term conditions,8 found that healthcare professionals were complete exercises with their children, according to prescription, seen as sources of support in overcoming adherence challenges. vary; they average around 50%.7,9 Although the existing literature provides some insight into parents’ perceptions of healthcare providers who apply chronic Quantitative research has identified a number of potential therapeutic regimens, these perceptions could differ widely barriers to treatment adherence in children with disabilities; these http://dx.doi.org/10.1016/j.jphys.2015.02.014 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
]GIF$DT)1_eugi([r82 Lillo-Navarro et al: Children’s adherence to home exercise programs Figure 1. Flow of participant recruitment. when physiotherapists provide exercises for children with Data collection disabilities. The present study was designed to examine the perceptions of parents who supervise exercises prescribed by Two researchers, who were unknown to the parents, conducted physiotherapists for children with disabilities. Thus, the research the focus groups with the help of a topic guide with predetermined questions for this study were: questions (Box 1). This guide was based on a review of literature in this area. Additional questions were included, according to themes 1. What are the perceptions of parents of children with physical that started to emerge from the initial focus groups.17 During the disabilities about the home exercise programs that physiothera- focus groups, an audiotape, a videotape and field notes were used pists prescribe? for data collection. 2. How do these perceptions affect adherence to home exercise Parents were reassured of confidentiality before the beginning programs? of their focus group session. Six focus groups were formed because categories were consolidated after these six groups.17 The size of Method the focus groups varied from four to seven participants, and sessions lasted from 40 to 80 minutes. Design Data analysis The qualitative design of this study involved focus groups, because group interaction can trigger responses and build insights The sessions were transcribed verbatim. Each participant was that may not arise during interviews.14 Focus groups have been assigned a number code for data entry. The following steps were used in previous studies to identify experiences related to parents’ used in the analysis process: a first reading of all transcripts to adherence.15 obtain an overall impression of content; segmentation of the sentences or paragraphs and codification of categories in the Participants transcripts; and generation of themes.18 This data analysis was undertaken using a modified grounded theory approach,17 This study included parents of children with physical dis- incorporating data collection, coding and analysis, and using a abilities who had been prescribed a home exercise program by physiotherapists from three early intervention centres in south- Box 1. Thematic guide for focus group discussions. east Spain. The inclusion criteria were: parents of children aged between six months and six years, and who had been prescribed a Aim: To encourage the participants to speak freely about home exercise program by a physiotherapist. Subjects were whatever they think is relevant to the study and their excluded if they presented with communication impairments experiences from the onset of their children’s disorders. that rendered participation in the focus groups impossible. Considering the home exercise program in which your child is involved: A purposive sampling strategy16 was used to include the Do you usually perform the program? Why? Why not? parents of children in different age groups, genders, and clinical How did your learn to perform the program? conditions. Although the final sample size was dependent on the What benefits and problems do you find in applying the saturation of information, 37 subjects were initially selected. An program? assistant researcher from each centre sent a letter to the eligible What encourages you to do it? parents to invite them to participate in the focus group discussion. How could the program be made easier to incorporate? A week later, the research assistants called the parents to What things could help you to do the program? determine their willingness to participate, and to clarify any Do you want to talk about something else related to the questions. When several parents declined to participate, other program or your experience at the centre? parents who met the appropriate criteria were sourced (Figure 1).
Research 83 process of constant comparison without the theory development Table 2 component.19 Three authors (FMM, PER, CLN) independently Characteristics of the home exercise programs. coded segments of phrases that contained meaningful incidents and labelled these into categories using emerging codes. The Characteristic Programs (n = 28) categories were then combined into key themes. The authors reviewed and compared their findings to reach a consensus on all Type of exercises, n (%) 15 (54) steps. Three rounds of coding and discussion took place; this was stretching 22 (79) aimed at enhancing credibility of the analysis used, and developing manual skills 13 (46) clear themes and categories. This process was iterative with data locomotion 28 (100) collection and allowed new categories or themes to be inserted functional skills 21 (75) from the data of subsequent group transcripts. No new themes or postural stabilisation 16 (57) categories emerged at the end of the sixth focus group, which sensory stimulation implied that saturation was reached. 4 (14) Frequency (d/wk), n (%) 9 (32) To check consistency of the final themes and categories, two 1 to 3 15 (54) researchers cross-checked their results via a blind review using 4 to 6 codes for the same passages of two transcripts.20 Any disagree- 7 12 (43) ments between the two researchers were resolved by discussion. 16 (57) At every step, an independent researcher reviewed whether Number of exercises, n (%) the analysis was systematically supported by the data, with the 1 to 5 intention of enhancing dependability.17 Confirmability was 6 to 10 enhanced when the same categories emerged from the data of subsequent groups’ transcripts. average, participants completed less than half of the prescribed exercise sessions and less than 50% of the stretching exercises Results required. According to participants, these problems were influ- enced by specific characteristics of both the prescribed home Flow of participants through the study exercise program and the physiotherapist’s performance during treatment at the early intervention centre (Box 2). From the initial sample of 37 eligible participants, a final sample of 28 participants was included in this study. Six focus Theme 1: Characteristics of the home exercise program groups were formed, with two groups of fathers and four groups of mothers. The progress of the selection stages for the focus Within this theme, the following subthemes were identified: groups and reasons for non-participation are presented in preference for exercises developed through experience, and Figure 1. The reasons for non-attendance at a scheduled focus amount of exercises. group were unknown. Non-participants presented similar char- acteristics to participants. The characteristics of the participants Preference for exercises developed through experience and their children are shown in Table 1. Participants reported that their adherence differed between Characteristics of the participants exercises, and admitted to developing preferred exercises over time within their home exercise program. Based on their own Participants reported that their children received between one experiences, they were able to identify personal likes and dislikes, and three weekly sessions of 30 to 45 minutes of treatment at the both on their part and on behalf of their children. Overall, centre, and that they also routinely received prescribed home participants preferred exercises that worked and were fun and exercise programs for their children to perform. These home enjoyable for their children. exercise programs varied between children. The frequencies of the main characteristics of the home exercise programs are shown in When I see that an exercise is effective and it works, I do it. (Mother Table 2. Participants recognised problems of adherence either to of a 13-month-old boy) the whole program or to specific types of exercises. For instance, on I think playing with my daughter is the best way to help her. This is Table 1 my experience. (Mother of a 10-month-old girl) Characteristics of participanting parents and their children with disabilities. In contrast, participants were less likely to be engaged when Characteristic Participants (n = 28) exercises were perceived either as producing adverse effects or being too complex. Adverse effects were related to the children’s Parents 21 (75) reactions to pain or discomfort, and perceptions of complex Age over 30 yrs, n (%) 20 (71) exercises were associated with the level of technical skills the Female gender, n (%) parents needed to perform the exercises. Stretching and passive Number of children, n (%) 12 (43) range of motion exercises were mostly referred to as ‘complex 1 16 (57) exercises’. During these exercises, parents experienced feelings of 2 or 3 uncertainty regarding the final range of motion and the risks for 18 (64) their child. There was a consensus that physiotherapists at the Children centre should perform complex exercises. Aged over 2 yrs, n (%) 8 (27) Medical diagnosis, n (%) 5 (18) At the beginning, I didn’t like doing exercises that were painful for cerebral palsy 8 (29) my son. I didn’t understand and it bothered me to do exercises that congenital disease a 2 (7) were painful. (Mother of a 12-month-old boy) developmental delay b 5 (18) obstetric brachial plexus injury It was more difficult in the beginning, when the baby was little and encephalopathy of prematurity 19 (68) not knowing how far I could safely move his neck. (Mother of an 8- Impairment, n (%) 15 (54) month-old boy) GMFCS level 3 10 (36) cognitive impairment I am afraid to do the exercises, because I think I might break his leg visual impairment or arm while doing the exercise. I am afraid, because I’m not a professional and I do not know how far or how much to do the GMFCS = Gross Motor Function Classification System. exercises. (Mother of a 12-month-old boy) a Includes muscular torticollis, Duchenne muscular dystrophy, arthro- gryposis multiplex congenita, and chromosome motor disorder, b without specific diagnosis.
84 Lillo-Navarro et al: Children’s adherence to home exercise programs Box 2. Summary of factors perceived to influence adherence to home exercise programs. Theme Subtheme Categories of coded statements Characteristics of Preference for exercises exercises and Exercises that improve outcomes home programs Amount of exercises Enjoyable exercises Exercises without adverse effects (pain, discomfort) Physiotherapist’s Building parents’ Non-complex exercises (without the need for technical skills) teaching style confidence in implementing the Time consumption exercise program Disruption of the affective or recreational family relationship Helping incorporation Excessive burden, according to the real needs of family into daily routines Incentivising adherence Demonstrating exercises with the child Providing feedback Monitoring and giving Providing written instructions support to adherence Providing information and support to parents Giving reminders to incorporate into daily routines Perception of achievements Incentives based on goals Changes in the child’s exercise performance Gaining peace of mind Perception of regular monitoring of home program Amount of exercise least once per month; observing exercise practice while providing Often, participants reported that they initially wanted to feedback and making subsequent corrections in technique; giving written instructions and explanations in a way that is accurate, perform the recommended amount of exercises, but they tended understandable and convincing; and providing opportunities for to reduce these over time. They reported two reasons. The first the exchange of information and for resolving uncertainties reason was that participants felt that doing a lot of exercises was regarding home exercise programs. These aspects were important problematic, as this either required excessive time taken from their for skill acquisition at the beginning of treatment and for providing daily activities or it restricted their time for recreational or reassurance in subsequent sessions. affective relationships with their children. She (the therapist) teaches me the exercises while she is actually I do not do all exercises every day, it’s too much and I’m not able to doing them with my daughter. Seeing how she performs the find enough time in my daily routine. (Mother of a 20-month-old exercises during each session gives you more confidence to do boy) them. (Mother of a 6-month-old girl) My son receives a lot of physiotherapy at the centre. I believe my She (the therapist) explained to me what she was doing with the job is to be a mum first and not a physiotherapist. (Mother of a child. Then she said to me: let’s see how you do it; let’s see if it’s 2-year-old boy) done correctly. (Mother of a 12-month-old girl) The second reason was that participants felt that executing the For me it was very useful to have a worksheet, because at the whole program could be an excessive burden for the children. beginning you feel lost and you don’t know what to do with the child. (Father of a 1-year-old girl) I do not do all the exercises every day because I think it’s too much effort and stimulation for my child. (Mother of a 10-month-old Our physiotherapist is always available. If I have any questions or girl) want to talk or ask about an exercise, she clearly explains and this helps me to understand. Then I can perform the treatment with Theme 2: The physiotherapist’s teaching style confidence. (Father of an 11-month-old boy) The way that the physiotherapist taught parents to acquire Helping parents to incorporate the home exercise program into their skills for their child’s treatment influenced adherence to the home daily routine exercise program. The following subthemes were identified: building parents’ confidence in exercise performance; helping Participants reported that adherence was also low when they parents to incorporate the home exercise program into their daily had difficulties incorporating home exercises into their daily routine; providing incentives to maintain adherence; and moni- routine. They reported that fitting exercises into their daily routine toring and giving support to adherence. was a problem due to lack of time and forgetting to do the home exercises. Participants appreciated receiving cues within their Building parents’ confidence in exercise performance daily routines, especially adherence reminders to avoid omissions Participants reported that adherence was difficult when they or slips. They felt that, in general, they accept reminders, especially when professionals explain that cues and reminders are aids for lacked confidence in ensuring that exercises were performed performing the desired behaviour. correctly at home. They also reported that when the therapist helped to build that confidence, it had a positive influence on I do not do exercises every day, because I’m not able to fit these adherence to the home exercise program. According to the into my daily routine. Perhaps I would have more success if she participants, several actions by the physiotherapist promoted had given me instructions about when to do them. (Mother of a their confidence. These included: demonstrating the exercises 4-year-old boy) while the parents watch their child during physiotherapy treatment; asking the parents to demonstrate the exercises at
Research 85 Providing incentives to maintain adherence children who did not enjoy taking part in some home exercises, Participants agreed that an important incentive for reinforcing and argued that the imposition of a prescribed exercise may increase the treatment-related burden and, thus, decrease adher- adherence was the perception of achieving progress in their child’s ence. The present study also suggests that the presence of pain functional health status. However, participants reported that during exercise plays a crucial role in the application and changes in their child’s functioning were often slow and difficult to maintenance of a child’s home exercise program. Child pain has perceive over time. Participants tended to lose motivation and also been cited as a relevant issue for parental stress.23 decrease adherence when they did not see any functional changes in their child’s status over a long time period. In the present study, the amount of exercises was also noted to be a problem that developed over time. Some studies performed When I see my son move a little more, I believe it’s the exercises with parents of children with long-term conditions have also I have done with him that have helped him. This motivates me suggested that it is difficult to maintain adherence to home to do the exercises. (Mother of a 20-month-old boy) programs over time. However, the literature regarding home exercise programs specifically varies concerning the relevance of When I don’t see improvements in my child, I am not motivated to the amount of exercises: some authors have suggested that do the exercises. (Mother of a 2-year-old girl) extensive programs often result in poor adherence,12 while others have found this aspect to be irrelevant.9 Participants agreed that incentives, beyond the child’s func- tional changes, are also important and seldom used by phy- Building confidence in exercise performance had an impact on siotherapists. They appreciate receiving goal-based incentives the parents’ ability to cope with their adherence. Three factors that such as changes in the exercise performance (child’s tolerance, were particularly important for confidence-building were: regular number of repetitions) or gaining peace of mind; this last item was contact with parents; allowing parents to watch the physiothera- a relevant incentive for parents. Participants were afraid of being pist interact with their child; and physiotherapists’ involvement in regarded as bad parents, in the future, if they could not take reviewing the home exercises and providing information regarding advantage of all the opportunities to care for their child. their child’s illness and treatment. Regular contact with healthcare providers has also been identified as a support strategy for learning At first, my son hardly held on at all, but now I see him much better home-based care.8 The opportunity to receive information about a at holding after the exercises and that motivates me to continue child’s illness and treatment has been identified as a relevant doing them. (Mother of a 22-month-old boy) resource to help parents cope with the situation of having a child with health problems.24 In the present study, feelings of I did the exercise to benefit my child, but I also did it for me. It was uncertainty and fear were common and constantly shaped the an incentive for me to say that I did all that I could to help my child. parents’ need for information. (Mother of an 8-month-old boy) These findings suggest that parents appreciate professional Monitoring and giving support to adherence suggestions for incorporating home exercises into their daily routine Adherence monitoring by the physiotherapists was important, and for overcoming challenges to adherence. This is consistent with a recent systematic review of qualitative papers on adherence, in order to encourage participants to follow the prescribed home which focused on children with chronic long-term conditions.8 exercise program. Participants reported that regular adherence Parents also value the role of the therapist in encouraging adherence, monitoring by health professionals allowed them to voice the by providing information about achieving objectives and seeing problems that they had complying with the exercise program. their child’s development in response to the treatment. According to Most parents spoke about receiving solutions to their problems some authors, parents’ knowledge of improvements seems to have a from physiotherapists, which helped them to improve their paradoxical effect: on the one hand, the perception of results in adherence. When participants failed to receive any new sugges- children can encourage parents to continue treatment, and on the tions, they felt frustrated. other, it could cause parents to relax and decrease their adherence.25 He recommended that we put the child to sleep on her side. After a The experiences presented by parents in this study may be while we told him that we could not get her on her side, so he different from those presented by parents of children with other suggested changing the pillow to the side. Now the child sleeps disorders. However, within the physical disabilities presented in on the side we want. The solution has been successful. (Father of a the present study, several pathologies were represented, such as 6-month-old girl) cerebral palsy and different types of congenital syndromes and diseases. She asked if we were doing the exercise that she had recommended. We discussed that we could not and although she told us to try, she The present study was cross-sectional and the participants’ gave us no alternatives. (Father of a 1-year-old girl) recollection of events was retrospective, relying on their memory of past events. Therefore, longitudinal and prospective studies that Discussion include parents of children with different health conditions and that follow the children throughout the entire rehabilitation process may This study supports previous research showing that children offer additional information. Also, the perceptions of the children with, or at risk of, developmental disorders are susceptible to low performing the exercises were not taken into account, although this levels of adherence to home exercises.7,10 The results of this study would have been difficult with the very young children involved in indicate that the characteristics of the home exercise program and the study. Another limitation is that a systematic analysis of the physiotherapist’s teaching style may influence adherence. This differences in the type of responses received from subgroups of study also provides experiential knowledge that may be used as a parents was not performed (eg, by gender or the children’s ages). starting point for healthcare providers to consider the tasks and strategies that may be used to develop and implement a home Given the sample size and the fact that the focus groups were exercise program with adequate levels of adherence. conducted in only three early-intervention centres, caution should be taken when generalising the results. More research is required In this study, some parents rarely performed the whole home for this purpose, as well as for researching parent-related factors, exercise program, instead only performing the exercises that they because the findings were limited to factors related to exercises preferred. The finding that parents preferred enjoyable and and therapists that contribute to poor adherence. simple exercises for themselves and their children is supported by previous research.21,22 Boas identified cases of parents and This study identified factors that might help physiotherapists to recognise early signs of poor adherence. Examples of these are concerns over correct techniques, fear of causing harm, difficulties incorporating the exercises into daily routines, boredom, and feelings of uncertainty. Therapists should remain alert for the
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Compliance with home rehabili- tation therapy by parents of children with disabilities in Jews and Bedouin in Israel. What is already known on this topic: Home exercise Dev Med Child Neurol. 2001;43:261–268. programs have positive effects on the functional outcomes of children with disabilities. However, adherence to home 8. Santer M, Ring N, Yardley L, Geraghty A, Wyke S. Treatment non-adherence in exercise programs is difficult to achieve. pediatric long-term medical conditions: systematic review and synthesis of quali- What this study adds: Parents of children with physical tative studies of caregivers’ views. BMC Pediatr. 2014;14:63. disabilities who have been prescribed home exercise pro- grams by physiotherapists perceive that some characteristics 9. Chappell F, Williams B. Rates and reasons for non-adherence to home physiother- of the programs and the physiotherapist’s teaching style can apy in paediatrics. Physiotherapy. 2002;88:138–147. influence their adherence. In order to promote adherence, physiotherapists should consider these factors when develop- 10. Gajdosik CG. Issues of parent compliance. What the clinician and researcher should ing and teaching home exercise programs. know. Phys Occup Ther Pediatr. 1991;11:73–88. Ethics approval: The University of Murcia’s Ethics and Research 11. Piggot J, Hocking C, Paterson J. Parental adjustment to having a child with Cerebral Committee approved this study. All participants gave written, Palsy and Participation in home therapy programmes. Phys Occup Ther Pediatr. informed consent before data collection began. 2003;23:5–29. Competing interests: Nil. 12. Taylor NF, Dodd KJ, McBurney H, Graham HK. Factors influencing adherence to a Source(s) of support: This study was supported by a research home-based strength-training programme for young people with cerebral palsy. grant from the Ministry of Health and Consumer Affairs (PI052418) Physiotherapy. 2004;90:57–63. Spain. Acknowledgements: Nil. 13. 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Journal of Physiotherapy 61 (2015) 68–76 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review Aoife Synnott a, Mary O’Keeffe a, Samantha Bunzli b, Wim Dankaerts c, Peter O’Sullivan b, Kieran O’Sullivan a a Department of Clinical Therapies, University of Limerick, Limerick, Ireland; b School of Physiotherapy, Curtin University, Perth, Australia; c Department of Rehabilitation Sciences, University of Leuven, Leuven, Belgium KEY WORDS ABSTRACT Physiotherapy Question: What are physiotherapists’ perceptions about identifying and managing the cognitive, Qualitative psychological and social factors that may act as barriers to recovery for people with low back pain (LBP)? Systematic review Design: Systematic review and qualitative metasynthesis of qualitative studies in which physiothera- Metasynthesis pists were questioned, using focus groups or semi-structured interviews, about identifying and Low back pain managing cognitive, psychological and social factors in people with LBP. Participants: Qualified physiotherapists with experience in treating patients with LBP. Outcome measures: Studies were synthesised in narrative format and thematic analysis was used to provide a collective insight into the physiotherapists’ perceptions. Results: Three main themes emerged: physiotherapists only partially recognised cognitive, psychological and social factors in LBP, with most discussion around factors such as family, work and unhelpful patient expectations; some physiotherapists stigmatised patients with LBP as demanding, attention-seeking and poorly motivated when they presented with behaviours suggestive of these factors; and physiotherapists questioned the relevance of screening for these factors because they were perceived to extend beyond their scope of practice, with many feeling under-skilled in addressing them. Conclusion: Physiotherapists partially recognised cognitive, psychological and social factors in people with LBP. Physiotherapists expressed a preference for dealing with the more mechanical aspects of LBP, and some stigmatised the behaviours suggestive of cognitive, psychological and social contributions to LBP. Physiotherapists perceived that neither their initial training, nor currently available professional development training, instilled them with the requisite skills and confidence to successfully address and treat the multidimensional pain presentations seen in LBP. Registration: CRD 42014009964. [Synnott A, O’Keeffe M, Bunzli S, Dankaerts W, O’Sullivan P, O’Sullivan K (2015) Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. Journal of Physiotherapy 61: 68–76]. ß 2015 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction many other healthcare professionals (eg, chiropractors, osteo- paths, medical doctors).6 Management of physical factors, such as Low back pain (LBP) is no longer accurately viewed as a purely structural, anatomical or biomechanical disorder of the lumbar guarded movement patterns and muscle tension, and lifestyle spine. Research in recent decades has highlighted that LBP is a complex disorder, which can be influenced by a wide range of other factors, such as sedentary behaviour and deconditioning, have factors.1,2 These include cognitive (eg, catastrophic thoughts and beliefs, unhelpful expectations, poor motivation), psychological been a focus of physiotherapy training for many decades. However, (eg, depression, anxiety), social (eg, low job satisfaction, interper- sonal relationship stress, cultural factors), physical (eg, guarded the need to incorporate consideration of cognitive, psychological and restricted movement patterns), and lifestyle (eg, physical inactivity) factors.2 These factors are seen to act as catalysts for and social factors in LBP management may pose a greater challenge chronicity, contributing to poorer recovery and prolonged for physiotherapists.7–9 disability in at least some people with LBP.3,4 Physiotherapy students have been found to have relatively Guidelines for LBP treatment generally acknowledge a shift towards a biopsychosocial management approach.3,5 However, evidence-based attitudes and beliefs about pain compared to other physiotherapists have mostly received training of a more healthcare students.10–12 However, even recently graduated phy- biomedical nature, at least in their initial education, similar to siotherapists demonstrate some attitudes and beliefs about pain that are not fully in line with LBP guidelines and contemporary research findings.10,12,13 Physiotherapists increasingly receive training in treatment packages that take into account cognitive, psychological and social factors in LBP;14–18 however, it is unclear as to whether such training adequately equips them with the requisite skills to change patient management and outcomes.19 A recent review of http://dx.doi.org/10.1016/j.jphys.2015.02.016 1836-9553/ß 2015 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Research 69 several different study designs concluded that whilst physiothera- Box 1. Eligibility criteria. pists theoretically support a biopsychosocial approach to LBP, in practice, very few are doing so adequately, despite training in Design cognitive behavioural principles.20 However, that review20 focused Qualitative studies primarily on return to work rather than the wider population of Published in English people with LBP. Furthermore, that review included only a limited Participants number of qualitative studies that offered useful methodology to Physiotherapists with experience in treating LBP investigate physiotherapists’ perceptions and identify potential Outcomes barriers, and facilitators to incorporate such factors into clinical Physiotherapists’ perceptions regarding identifying and practice. Gaining a detailed insight of physiotherapists’ perceptions about these factors could be very useful in order to evaluate whether managing the cognitive, psychological and social factors such factors are considered in LBP assessment and management. that may act as barriers to recovery in people with non- Qualitative metasynthesis is ‘an interpretive integration of qualita- specific LBP tive findings that are themselves interpretive syntheses of data’ 21 that may contribute to clinically oriented theory.22 searched for references. The primary authors of the studies that were initially shortlisted were contacted to identify any additional Therefore, the research question for this systematic review and studies of potential relevance. The eligiblity criteria are detailed in metasynthesis was: Box 1. Mixed-method studies were included if the qualitative analysis could be isolated. Studies investigating the perceptions of What are physiotherapists’ perceptions about identifying and physiotherapists and other healthcare professionals or patients managing cognitive, psychological and social factors that may were only included if the physiotherapists’ data could be isolated. act as barriers to recovery in people with LBP? The physiotherapists’ perceptions had to relate to non-specific LBP or chronic LBP but not specific diagnoses such as cauda equina Method syndrome, radicular syndrome, infection, inflammatory disorders, tumour, fractures, osteoporosis or pregnancy. Identification and selection of studies Assessment of characteristics of studies This review has been reported in accordance with the enhancing transparency in reporting the synthesis of qualitative research The Critical Appraisal Skills Programme (CASP) qualitative (ENTREQ) guidelines;23 the checklist for the synthesis of qualitative assessment tool was applied by two authors working indepen- data is detailed in Appendix 1 on the eAddenda. The databases dently to evaluate the trustworthiness of the eligible articles. EbscoHost (Academic Search Complete, AMED, Biomedical Articles were not excluded on the basis of the CASP criteria. The Reference Collection, CINAHL, Medline, PsychArticles, PsychInfo, trustworthiness criteria evaluated within CASP are listed in SportDiscus), Embase, Scopus and Web of Science were searched Table 1, with more detailed explanation in Appendix 3 on the between March 2014 and May 2014 by two independent reviewers. eAddenda. For each article, the reasoning for the unfulfilled CASP criteria is detailed in Appendix 4 on the eAddenda. The search strategy was developed by the authors and key words were compiled based on systematic searches of key words Data extraction and synthesis utilised in systematic reviews20,24 performed in this area. The strategy used four groups of key words, to ensure that the selected The data extracted using a purpose-designed format were: a studies included: qualitative research methodologies; phy- description of the participants, the sample sizes, the methods of siotherapists as the treating healthcare professional; cognitive, data collection, the aims of the studies, and the main findings psychological and social factors; and LBP as the condition of related to the metasynthesis. interest. The specific key words had to be included in the abstract to be shortlisted for this review. The full search strategy is detailed Data synthesis was conducted by the first author (AS), an in Appendix 2 on the eAddenda. undergraduate physiotherapy student. The analytic process described by Sandelowski and Barroso21 was adapted for the The search was limited to English-language papers involving review. The first stage of the process was the extraction of findings humans; no year limits were applied. Titles and abstracts were and coding of findings for each article. The second stage was screened by two independent reviewers. Full-text versions of grouping of findings according to their topical similarity to potentially eligible articles were retrieved. Manual searches of determine if findings confirm, extend or refute each other. The reference lists of the shortlisted articles were also performed third stage was abstraction of findings – analysing the grouped by two independent reviewers. Recent systematic reviews of findings to identify additional patterns, overlaps, comparisons and qualitative literature on LBP 20,24 were also shortlisted and Table 1 Achievement of the Critical Appraisal Skills Programme criteria by the included studies. Study Clear Qualitative Appropriate Sampling Data Researcher Ethical Appropriate Clear Research statement methodology research collection reflexivity consideration data analysis statement value Billis et al 200525 appropriate design N of findings Bond et al 201229 of aim Y N Y Y Y Y Coˆ te´ et al 200931 Y N Y Y N Y N N Y Daykin et al 200413 Y Y N Y N N Y Y N Y Dean et al 200526 Y Y Y N Y N Y Y N Y Jeffrey and Foster 201232 Y Y Y N N Y N Y N Y Josephson et al 201134 Y Y Y N N Y Y Y Y Y Josephson et al 201336 Y Y Y N N Y N Y N Y Sanders et al 201330 Y Y N Y N Y N Y N Y Sanders et al 201437 Y Y N Y Y N Y Y N Y Slade et al 201235 Y Y N Y Y N Y Y N Y Wynne-Jones et al 201433 Y Y N Y Y N Y Y N Y Y Y Y Y N Y Y N Y Y Y N Y Y Y = yes, N = no.
70 Synnott et al: Low back pain and psychosocial factors redundancies to form a set of concise statements (themes), Description of studies which capture the content of all findings. The three stages were completed simultaneously rather than sequentially. The emerging Confounding factors groupings of early codings were cross-checked with on-going Two studies in this review interviewed physiotherapists who codes and were used to inform future codes. Final groupings were reviewed by all authors to ensure homogeneity of the primarily had experience in treating an acute LBP population.25,26 codes between groups, and to ensure no potential groupings were Physiotherapists rarely use validated outcome measures to screen overlooked during the analysis. To ensure that the findings for psychosocial issues in acute LBP patients,27 due to the traditional were grounded in primary data and to guide the interpretive thinking that acute episodes of LBP resolve rapidly,28 with outcome process, the coding and thematic analysis was presented to, measures often reserved solely for those who present with poor discussed with, and critiqued by two co-authors (KOS, MOK both clinical improvement. As a result, physiotherapists in the two clinical and research physiotherapists). The suitability of the fit studies that primarily had experience with an acute LBP caseload of the final themes to early codes/grouping was further reviewed may not have had a comparable awareness of the cognitive, by another author (SB) with experience in qualitative analysis. psychological and social factors that physiotherapists treating chronic or non-specific LBP may have had in the remaining studies. Results One study29 recruited physiotherapists who were employed Identification and selection of studies within a military setting and were involved in treating a non- specific LBP population. It is not clear how this military setting and The identification and selection of studies for analysis is experience influenced these physiotherapists and if their experi- summarised in Figure 1. In total, 6338 articles were found in the ences were comparable to those of the physiotherapists treating databases. After 1133 duplicates were removed, 5205 titles and LBP recruited by the remaining studies. Participants in the abstracts were scanned. Thirteen articles were retrieved, with four remaining studies were all based within either public or private articles being excluded because they did not fulfil the inclusion health settings. criteria. One study was deemed suitable from hand searching of relevant systematic reviews. Two articles recommended by Trustworthiness of results relevant authors in the LBP area fulfilled the inclusion criteria. The CASP criteria of trustworthiness met by each study are Twelve articles in total were included in the metasynthesis. A summary of the included articles is presented in Table 2. Nine presented in Table 1. Further details about the specific reasons that studies were located in Europe, two in Australia and one in Canada, individual studies failed to meet the criteria are presented in with the majority taking place between 2004 and 2013 in Appendix 4. For example, ten studies failed to fulfil criterion 9 due physiotherapy settings. A total of 182 participants were inter- to an absence of member checking, where the original data and study findings are cross-checked with the participants. Because v_erugiF1[)TD$IG]( iewed in the 12 studies. some studies did not meet some of the criteria, the completeness, interpretation and generalisability of the results may each have been affected. However, the studies all had clear aims research value, with consistent use of appropriate qualitative methodology and data analysis. Figure 1. Flow of studies through the review. Themes identified in the metasynthesis Table 3 provides an overview of the themes and subthemes identified. Table 4 presents the number of times each subtheme was identified by a study, and the total number of times it was supported by a statement in any of the included studies. Theme 1. Limited recognition by physiotherapists of the role that cognitive, psychological and social factors play in LBP Subtheme 1.1. Patients’ biomedical expectations Physiotherapists in several studies described how patients’ biomedical treatment expectations influenced their management approach. Some physiotherapists seemed to struggle when commu- nicating with patients in these situations, with a view that treatment should involve either education or passive treatment, but not both. You certainly get a gut feel of the ones that you’re wasting your time on. . . they perhaps think they’re coming to me for a massage or something to be done to make them feel better. . . so they are difficult and I have to say. . . well, look if you don’t want to follow what I’m saying I’m afraid I can’t help you.30 Let’s say you give them a nice little speech. . . it would surprise me if they were satisfied and if they would come back. You know they’re just going to think. . . there’s not much point in going for treatment.31 They don’t want to hear what you’re saying. They want you to make them better.32 Consequently, the default position of many physiotherapists seemed to involve yielding to these patient expectations and administering passive treatments.
Research 71 Table 2 Characteristics of the included studies. Study Participants Data collection Aim Main findings Billis et al 200525 Three focus To evaluate the clinical and PTs dealing with a LBP groups, each social factors that practising PTs readily recognised social factors such as marriage population containing 6 to PTs and post-graduate PTs and family life as contributors to the patient’s pain. N = 18 (22% female) 8 participants recognise as important in the However, PTs were less cognisant of the role that Qualified (yr) = 3 to 28 assessment and management cognitive and psychological factors may play in the Workplace = 83% private Semi- of LBP patients. patient’s pain presentation. Only a small group of PTs structured who had received post-graduate training paid Bond et al 201229 PTs dealing with LBP in a interviews To understand civilian PTs’ attention to these factors in their initial examination Coˆ te´ et al 200931 military population attitudes and beliefs towards of the patient. PTs were comfortable in utilising a N = 14 (60% female) Semi- assessing and managing LBP biomedical approach in treating this patient caseload Daykin et al 200413 Qualified (yr) = 5 to 30 structured in a military population. and often negatively stereotyped those presenting Dean et al 200526 Workplace = military interviews with non-specific LBP as attention seeking. Jeffrey and Foster 201232 To identify perceived barriers PTs dealing with a LBP Semi- and facilitators to PTs’ use of PTs recognised the influence of social factors on pain; population (> 25% of structured clinical practice guidelines in however, they often administered contradictory caseload) interviews management of LBP. biomedically-oriented treatment with weak N = 16 (gender n/s) evidence. Patients that were seen to have poor Qualified (yr) = half Semi- To explore PTs’ pain beliefs compliance and motivation for treatment were often < 10, half >10 structured and their influence on the referred onto other healthcare providers. Workplace = 50% private interviews management of patients with chronic LBP. PTs recognised that cognitive factors such as patient PTs dealing with a chronic Semi- expectations were barriers to recovery in LBP, as LBP population structured To explore PTs’ perceptions of many patients expected hands-on treatment and N = 6 (100% female) interviews LBP patient’s adherence to were intolerant of a hands-off approach. PTs lacked Qualified (yr) = 15 to 27 treatment. confidence in their training to implement the Workplace = 0% private Four focus recommended biopsychosocial approach clinically. groups, each To understand the personal PTs dealing with a LBP containing 4 to experiences and beliefs of PTs PTs labelled those presenting with behaviours population 6 participants that influence relevant suggestive of cognitive, social and psychological N = 8 (100% female) decision making and factors as difficult. The self-perceived inexperience, Qualified (yr) = 5 to 13 Four focus management of a LBP patient and lack of training of PTs, may have contributed to Workplace = 75% private groups, each population. this labelling. containing 4 to PTs dealing with a LBP 6 participants To explore PTs’ opinions PTs recognised cognitive factors such as unhelpful population about gaining the esssential patient expectations as barriers to both patient N = 11 Semi- knowledge or information to adherence and treatment. Gender = 45% female structured successfully manage LBP. Qualified (yr) = 10 to 39 interviews Even in the absence of a definitive mechanical Workplace = 36% private To learn how PTs describe diagnosis, PTs still classified patients purely on a Semi- reasoning behind their mechanical basis. Cognitive factors such as patient Josephson et al 201134 PTs dealing with LBP structured management interventions in expectations were barriers to successfully managing Josephson et al 201336 N = 21 interviews LBP patients, and how they LBP patients. PTs questioned the value of Sanders et al 201330 Gender = 17% female manage challenging patient intervention in patients that were perceived as Qualified (yr) = 6 to 40 Four focus presentations. passive or unmotivated, with some stigmatising such Workplace = 19% private groups, each patients. containing 4 to To learn how PTs incorporate PTs dealing with a LBP 6 participants a biopsychosocial approach PTs deemed those LBP patients that did not present population into LBP management, and with cognitive, psychological and social factors as N = 21 how they manage to balance ‘easy’. In contrast, those that did present with these Gender = 71% female the mechanical and factors were described as ‘complex’ and posed a Qualified (yr) = 6 to 40 psychosocial aspects of LBP challenge to clinical practice. Workplace = 19% private patient care. PTs believed that they had a responsibility to treat PTs dealing with a LBP To evaluate perceived barriers the easy cases. However, they were unsure of their population among PTs to the role in the management of more complex cases when N = 12 (50% female) implementation of a new patients presented with cognitive, psychological and Qualified (yr) = 4 to 33 biopsychosocial intervention social factors, describing limitations in their Workplace = 80% private in clinical practice. expertise and scope of practice when managing such cases. Sanders et al 201437 PTs dealing with a LBP To learn how PTs manage a Slade et al 201235 population LBP population in the absence Combining both a biomedical and biopsychosocial N = 26 (gender n/s) of a definitive mechanical approach in the management of this patient Qualified = n/s diagnosis. population posed a significant challenge amongst the Workplace = 0% private PTs. While many recognise the importance of cognitive, psychological and social factors, they PTs dealing with a chronic believe that addressing these factors extends beyond LBP population their scope of practice. N = 23 (56% female) Qualified (yr) = 1 to 37 PTs recognised LBP as a complex problem which Workplace = 43% private involves social and psychological contributions. However, PTs felt inadequately prepared by their biomedically-oriented training to successfully address these factors in practice and advocated the need for further training. PTs often lacked confidence or felt inadequately prepared to treat patients with non-specific LBP who did not have a clear biomedical diagnosis, due to their own biomedically-oriented training.
72 Synnott et al: Low back pain and psychosocial factors Table 2 (Continued ) Participants Data collection Aim Main findings Study Wynne-Jones et al 201433 PTs dealing with a LBP Semi- To explore both GPs’ and PTs’ While PTs routinely discussed work in the context of population structured views of managing LBP in the an assessment of a patient with LBP, their advice and N = 6 (100% female) interviews context of work. treatment was often functional and mechanical in Qualified = n/s nature, perceiving that their profession is limited in Workplace = 0% private instilling any change in the work environment. GP = general practitioner, LBP = low back pain, n/s = not stated, PT = physiotherapist. Table 3 Subthemes Overview of themes and subthemes. 1. Biomedical expectations of patients 2. Biomedical preferences of physiotherapists Themes No subthemes identified Limited recognition by physiotherapists of the roles that cognitive, 1. Limited willingness to discuss with patients that these factors may influence their LBP psychological and social factors play in LBP. 2. Concerns about training, expertise and exceeding professional scope of practice Some physiotherapists stigmatise patients whose behaviour indicates that cognitive, psychological or social factors are influencing their LBP. Limited role in managing cognitive, psychological and social factors. Table 4 Contributing statements (n) Contributing articles (n) Number of contributing statements and articles that identified subthemes. 13 6 Subthemes 18 7 15 5 Biomedical expectations of patient 17 7 Biomedical preferences of the physiotherapist 16 8 Stigmatising of behaviours suggestive of cognitive, psychological and social factors Limited willingness to identify factors as contributors to LBP Concerns about training, expertise and exceeding their scope of practice Most people come in and they’re looking for a diagnosis and In fact, some physiotherapists attributed a progression to therefore a click, crunch, and off they go they’ll be fine.26 chronicity solely to a lack of understanding or awareness of the biomedical and mechanical drivers of pain, with no acknowledge- Subtheme 1.2. Physiotherapists’ biomedical preferences ment of the cognitive, psychological and social drivers of chronicity Many physiotherapists believed that their role was mainly to in back pain. address the mechanical aspects of LBP. Whilst there are no details Especially since our role as physiotherapists is to make sure that on the training received by the physiotherapists, their own movement is restored, but we need to know what is preventing comments suggest that their preference for dealing with the movement. Giving exercises to promote activity is fine but not ‘mechanical’ aspects of LBP reflects their own previous training and enough. If you don’t resolve the physical or biomechanical their professional confidence. components, I think you will be heading towards chronicity.31 Everyone (of my patients) gets stability exercises cause that’s in Given the biomedically oriented preferences of patients and fashion at the moment, so it’s almost a case they get it whether they physiotherapists, it appeared that the cognitive, psychological and need it or not. . . so you are basing a lot of input on very little social factors were not widely recognised. Some physiotherapists evidence base and yet it seems to be in fashion.29 seemed to recognise the significant influence on LBP of certain life events, as well as social factors such as the patient’s family life and Even among patients who had been told that their LBP was non- occupational environment. Very little mention of psychological specific in nature, physiotherapists preferred to explore the factors was observed, apart from some mention of the role of fear in mechanical nature of LBP, either oblivious to the other dimensions LBP. Overall, there was little discussion of if, or how, these factors of LBP, or choosing not to address it. were considered in the treatment program. I would probably explain to her that it was most likely postural It could be a lot of life problems behind (LBP) as the most important strain. . . There could be an underlying facet joint degenerative factor.34 problem evident.32 . . . yea she may even need to switch jobs.34 Testament to this, amongst physiotherapists, there was an overwhelming preference for the biomedical pain presentation. Fear. Fear they might reproduce their symptoms, especially if they’re not completely pain free, erm, and I think also they’re I like clear pictures! It’s easier isn’t it, more straightforward.13 worried about taking sick time again, erm, from the employers’ perspective, losing their job if they keep taking sick leave.33 An uncomplicated back that feels well and allows someone to lead a rewarding life while still experiencing back pain is easy to treat.30 Theme 2. Some physiotherapists stigmatise patients whose behaviour indicates that cognitive, psychological or social factors Whilst physiotherapists recognised the implications of social are influencing their LBP issues, such as the influence of work-related factors on a patient’s pain disorder, their advice was often linked to the functional and Several physiotherapists described some LBP patients as poorly mechanical adaptations that patients can make in the context of work. motivated, demanding, attention-seeking and, in some cases, self- centred and not interested in helping themselves to recover. If it (work) comes up in the questioning, in terms of either why they’re off work, or the problems they’re having at work, then yes, Whether they’re (patients) motivated to actually do something for we’ll look at, you know, the postures and the function, and any sort themselves or they want you to, sort of. . . click your fingers; wave of ways round it or who they need to speak about it.33 your magic wand and the pain’ll be gone.32
Research 73 This group of people (chronic LBP patients) are very self-centred Physiotherapists expressed concerns about discussing with self-focused group of people who are very interested in themselves. patients the influences that cognitive, psychological and social They’re a self internal, internalizing group.30 factors have on the presentation of pain, for fear of it ‘going wrong’. Consequently, physiotherapists preferred it when Those extravagant pain people.30 patients brought up the certain cognitive, psychological or social factors related to their pain themselves, relieving the phy- Some do not get better with treatment due to their attention siotherapists from this responsibility and the fear of it ‘going seeking need usually the neglected by their husbands women.25 wrong’. Neglected women tend to moan I’m in pain. . . for attention.25 It was if I placed all the emphasis on the fact that she didn’t like her job. She didn’t like that; she really reacted then because I managed This suggests some recognition by physiotherapists of the to identify too clearly the fact that she didn’t like her job.31 cognitive, psychological and social factors that might influence the pain experience. This includes depression or low mood contribut- I prefer a person (LBP patient) who can vent for herself and tell me ing to low motivation, anxiety contributing to hypervigilance, low things herself without me asking questions. . . cause it can go self-efficacy and an external locus of control contributing to a wrong.36 desire for passive treatment, and catastrophising contributing to extravagant behaviours.1,2 However, physiotherapists neither Other physiotherapists described how experience from treating seemed to identify cognitive, psychological or social factors as similar LBP patient presentations facilitated them being willing, or underlying causes for these observed behaviours, nor considered able, to identify these factors. them as potentially modifiable factors for targeted intervention. From the language used in the above examples (‘those’ people, Just through experience, you know, is that there are some joints ‘that’ group), it appears that at least some physiotherapists in the that physios would call emotional joints.30 included studies had little empathy for the cognitive, psychological or social aspects of the pain experience. You’re going to get a lot more of the psychological side coming in and that’s why you need far more experienced physiotherapists, I Some physiotherapists alluded to the possibility that some LBP think, to cope with that.13 patients may be in receipt of financial aid or disability and, as a result, are driven by a financial incentive and consequently lack a Subtheme 3.2. Concerns about training, expertise and exceeding motivation for recovery. professional scope of practice I suppose, I mean, if you really went down to it, you could talk about Physiotherapists recognised the limitations of their profes- those people who are, or you know, poverty in patients, little sional training in dealing with influencing cognitive, psycholog- money, sometimes, is quite, you know, they’re quite willing to be ill, ical and social factors. Physiotherapists described a lack if you understand me?30 of adequate skill acquisition and were often unable to implement skills learned during training when working in Maybe their own benefits, they will be earning more through that clinical practice, which posed a barrier to addressing these way than going back to work. . . but although I’m saying that, it’s issues in practice. In many cases, where cognitive, psychological very hard to prove anything. You always have your own and social factors were implicated, there was considerable suspicions.30 pessimism about the potential for therapy to result in clinical improvement. Theme 3. Limited role in dealing with the cognitive, psychological and social factors I think that we are really not well equipped to give the right message across to these patients. . . I don’t think we have enough Subtheme 3.1. Limited willingness to discuss with patients that these training and background to maybe to know exactly what to say to factors may influence their LBP these people, to be positive but to be realistic. I think we need more input with that kind of thing, the right things to say and the wrong Physiotherapists recognised the need to provide a clear and things to say, would help.37 simple explanation for the patient’s pain and felt that a biomedical diagnosis offered the best framework for this, even amongst those There is a limitation to what I can achieve with regard to, say, my diagnosed as having non-specific LBP and where evidence for the counselling skills and my skills of helping them modify their pain explanation was lacking. behaviour and helping them with their cognitive, you know, construct if you like, regarding LBP.30 The explanation is tailored entirely. . . on how much you feel they can understand without scaring them.35 We can guide them as to ways of avoiding sitting all day, trying to encourage them to get up and move around regularly, as to make Simplistic (mechanical) explanations (for their back pain), so the sure that they’re sitting in a correct position as possible, but as far patients have something to hang their hat on. . . without saying as changing what they’re actually doing at work, I don’t think I that’s the absolute truth.35 have much influence at all really.33 It’s very easy to say, you’ve got a disc that’s bulging out this way, if Some physiotherapists described how their lack of expertise in you do this McKenzie technique that pushes it back in. . . and we these domains was so profound, there was no point even asking know that that’s probably not true, but it’s a simplistic way for about them, since they could not treat them. Furthermore, even patients to understand and you can give them a model.35 among those physiotherapists who recognised that these factors were important in LBP, many considered that the management of You have to give them some sort of diagnosis. . . even if I’m not a them was beyond their professional role and scope of practice, as hundred per cent sure that it’s facet I’ll just tell them it’s facet, tell they were not equipped with the knowledge or skills to have any them it’s a disc strain so they know it’s going to get better.35 successful input. Why would I give a questionnaire to my patient to identify whether he is afraid to move, if I don’t know what to do about it?31
74 Synnott et al: Low back pain and psychosocial factors If there’s a relationship issue and things like that, that’s stuff that I of promoting recovery.38 On the other hand, by ceding to patients’ won’t necessarily address, because I don’t think it’s my area. I expectations and providing biomedical explanations of pain and mean, I’m not going to start saying to patients, you know, how is treatments, physiotherapists may be perpetuating patients’ your relationship with your husband at the minute, because. . . biomedical beliefs and fears that pain indicates significant tissue what am I going to do about it, if you know what I mean? If they damage.39 It is possible that the perceived expectations of patients start bringing up those sort of issues?30 are heavily influenced by the beliefs and attitudes of their physiotherapists, and that patients may be more open to ‘non- That is where I feel I don’t have much to offer, only to lend a physical’ treatment, if high-quality two-way communication is listening ear and a bit of advice if I can, but I have no way of used. In addition, it may be more relevant to challenge patient knowing whether that advice is appropriate.37 beliefs around the overall range of factors involved in their LBP rather than worrying unduly about which specific treatment or This was often described in such a way as to absolve the exercise is used as part of treatment. profession from having any professional involvement. Conse- quently, the responsibility for treating patients presenting with Despite expressing frustration with patients expecting biome- cognitive, psychological and social factors is often shifted on to dically oriented treatment, many physiotherapists themselves other healthcare professionals. were more comfortable with LBP presentations that were deemed straightforward and did not involve complicating factors, allowing I mean, it can’t be our, we who fail (physiotherapy profession), and treatment to focus on ‘mechanical’ factors such as mobility and take the blame for it. I don’t think we’re barking up the wrong tree movement patterns. However, there is no evidence to suggest that either. You can’t dump it (patients’ psychosocial issues) over on even in ‘routine’ LBP presentations that an approach which only somebody else like that.36 addresses mechanical factors is optimal. Such conflicting manage- ment principles have been previously documented, with phy- Is that really what we think is better (physiotherapy) than just siotherapists recognising the influence of psychosocial factors on letting things take their natural course?36 outcome in LBP, yet advising patients to remain off work.7 Such an approach has previously been rationalised as indicative of In the event that such ‘difficult’ patients were offered pessimistic beliefs about pain, and an attempt to legitimise the treatment, physiotherapists reported feeling pessimistic about experience of pain for the patient and enhance patient satisfac- these interactions and expected patient outcomes, which in turn tion.40 reduced their own job satisfaction and their self-confidence about being capable of helping people. Apart from one study mentioning the importance of fear in LBP,33 there was little mention of specific psychological factors You can treat again until you’re blue in the face, but you’ll take two that are known barriers to recovery, including depression, anxiety steps forwards and the patient will go away, do whatever they and post-traumatic stress disorder. The lack of focus on some of want, and take two steps back. . . and this is when you get these factors may explain why previous research has suggested frustrating. . . unresolved cases.13 that clinicians are not as capable of identifying risk or complexity among LBP patients using questionnaires that examine these A physiotherapist who is treating a difficult patient may switch off factors in a standardised manner.41,42 Several such questionnaires, a little bit. . . I think you become less sympathetic.13 including the Orebro and Startback questionnaires, are now available and, based on these results, may be worth using in Difficult patients were not expected to have good treatment clinical practice.41,42 However, even the use of such questionnaires outcomes so the physiotherapist would write them off quickly.13 would not address the reported lack of competence and confidence among physiotherapists in influencing these factors. The sort of patient who you’ve been seeing for twice a week for 10 weeks, 12 weeks, 14 weeks, and yeah, when you say Mrs So- The second theme that was identified was that physiotherapists and-So’s coming in and you see Mrs So-and-So’s name on the stigmatised some behaviours that were suggestive of cognitive, books, your heart sinks down into your boots. You think ‘Oh no!’ psychological and social factors being involved in patients’ LBP That’s a ‘heart sink’ patient.13 experience. Many LBP patients had negative personal character- istics attributed to them. This included accusations of patients Discussion looking for attention, lacking motivation, being dependent of others, helping them rather than self-managing, and being The first theme that was identified in this review was that motivated by the prospect of financial gain. Similar findings have physiotherapists displayed limited recognition of the roles that been reported elsewhere, where LBP is attributed to personal cognitive, psychological and social factors play in LBP. Phy- weakness and a desire for secondary gain with manipulative, siotherapists appeared to be more comfortable with the concept of excessively demanding patients seen to be placing huge strain on LBP as a mechanical disorder of the spinal tissues. This is consistent healthcare services.43 As discussed, this may reflect a lack of with patients requesting passive ‘hands-on’ therapy for the spine, awareness that these behaviours may be indicative of underlying and physiotherapists being quite happy to provide advice on local cognitive, psychological and social factors. structural diagnoses, and exercise or manual therapies directed at a local mechanical spinal disorder. Another consideration is that physiotherapists often rely heavily on a structural diagnosis to inform their treatment.44 Some physiotherapists appeared to readily recognise and When a non-specific diagnosis is used, this diagnostic ambiguity discuss social factors, such as family life and work, as being poses a challenge to the physiotherapist. Consequently, this ‘non- relevant to LBP. The main cognitive barrier to recovery that was fitting’ scenario threatens their professional competence, with identified was patients’ biomedical treatment expectations. The physiotherapists attributing responsibility for poor patient out- issue of how to handle patients’ expectations, that are deemed by comes to the patient.45 Quinter and Cohen46 have recently physiotherapists to be unhelpful, is an interesting one. On the one discussed the stigmatisation of people with chronic pain by hand, it has been suggested that patients’ expectations and healthcare professionals, proposing that it can be explained by a preferences should be elicited and used in the clinical decision- lack of empathy towards pain patients who don’t ‘fit’ neatly into making process to help select treatments that have the best chance the healthcare professional’s biomedical perspective of pain. Attempts to enhance empathy may first need to come from educating physiotherapists about the underlying mechanisms of chronic LBP, as empathy is at least predicated on being able to understand what is going on with patients. Perceptions of stigmatisation by health professionals are common amongst
Research 75 people with LBP and may jeopardise the patient-therapist This review has several important clinical implications. The fact relationship, which is closely linked to patient compliance47 and that cognitive, psychological and social factors were only partially successful management.44,48 identified by physiotherapists as barriers to recovery factors in LBP supports the role for using short screening tools (eg, STarTBack41 It is possible that the factors perceived by physiotherapists to and Orebro42) to specifically highlight when such factors are reflect the negative personality characteristics of a patient are in present. The presence of these factors, the limited understanding of fact potentially modifiable barriers to recovery that require how they affect patient engagement with therapy, and a lack of targeted intervention. For example, rather than being a sign of confidence in exploring these factors may partly explain some of laziness or being unmotivated to help themselves, the search for a the stigmatising of patients with LBP that occurs among some ‘magic-bullet’ cure may reflect deeply held biomedical beliefs that, physiotherapists. Physiotherapists should consider whether some if left unchallenged, present a barrier to recovery. Equally, characteristics such as poor motivation, or dependence on passive repeatedly seeking passive care may indicate low self-efficacy therapies, may indicate the presence of other factors such as and poor coping strategies. Thus, in order to reduce perceptions of depression, anxiety or poor self-efficacy, which require greater stigmatisation amongst people presenting with LBP, it may be consideration. Furthermore, there may be a need for greater important to educate physiotherapists about identifying what is a appreciation by physiotherapists of how important it is to manage potentially modifiable factor. factors like patient expectations, because they are related to clinical outcomes.57,58 This may require expansion of the core The third, and final, theme that was identified was the limited range of clinical tools used by physiotherapists, which can be done perceived role for physiotherapists in managing cognitive, without reinforcing passive dependence on the physiotherapist. psychological and social factors among people with LBP. Patients Because some physiotherapists feel underprepared by their commonly report fear and anger, and mentioning the presence of traditional biomedically oriented education to adequately identify these factors in their lives may de-legitimise their LBP in the eyes of and address these factors, there is a need for additional training to their clinician.49,50 This appears to have been experienced by some ensure any additional knowledge and skills gained are transferra- of the physiotherapists, so that they often avoided even discussing ble to clinical practice. Consequently, it may be of benefit for a factor unless the patient brought it up. However, in contrast to physiotherapists involved in treating LBP to undergo training that this reluctance of physiotherapists to discuss these factors with specifically involves the assessment and treatment of ‘live’ patients, previous research has identified that acknowledgement patients, to enable physiotherapists to translate the skills they by a clinician of the impact of pain on a person’s psychological have learned into practice, with ease and confidence. This may lead health is considered to be very valuable by patients.51 In other to improved confidence and competence of physiotherapists, and words, patients may be quite happy to have the impact of pain on improved patient outcomes. It may also be necessary to carry out their lives discussed and acknowledged, as long as there is no research to establish the correct language to use when explaining suggestion that these factors mean that their pain is ‘psychoso- pain in order to legitimise patients’ pain and avoid stigmatisa- matic’ or imagined. tion.40,59 Guidance from professional organisations and/or statu- tory healthcare providers on how these issues can be dealt with by Many physiotherapists reported that they lacked the requisite a physiotherapist, including when onward referral to another skills and confidence to successfully discuss and address these professional or service is indicated, is currently lacking and may be factors among patients with LBP. In many ways, this probably very useful. reflects their biomedically oriented nature of their training, and the absence of explicit training in communication, such as the use of What is already known on this topic: Recovery from LBP role playing during training to enhance communication skills.13 In can be limited by cognitive factors (eg, catastrophic beliefs, some cases, this lack of skills and confidence seems to have been poor motivation), psychological factors (eg, depression, anx- used to absolve physiotherapists of their responsibility to help iety), and social factors (eg, low job satisfaction, relationship patients with these issues. Linton et al52 previously described the stress). physiotherapy profession as ‘fear-avoidant’ when confronted with What this study adds: While some physiotherapists recog- these issues in practice. This fear-avoidance may be employed as a nise the importance of these factors as important barriers to defence mechanism, in order to protect their professional recovery, most prefer to treat the mechanical aspects of LBP confidence and self-esteem, which can be threatened by repeated and some stigmatise patients who demonstrate such factors. encounters with patients whose ‘non-specific’ diagnosis is outside Many physiotherapists feel underprepared to treat these their clinical comfort zone. aspects of LBP. Physiotherapists may benefit from using screening tools with which to identify these factors and from Among the physiotherapists who reported a willingness to training to help discuss and manage these factors with engage with these factors, any currently available training courses patients. were deemed to be insufficient for developing their skills and enhancing their patient management. Instead, it was considered eAddenda: Appendices 1, 2, 3 and 4 can be found online at that substantial clinical experience was needed in order to develop doi:10.1016/j.jphys.2015.02.016. sufficient expertise to enable successful management of these patients. However, there is no evidence that healthcare profes- Ethics approval: Not applicable. sionals with greater clinical experience or even a special interest in Competing interests: Nil. LBP display better beliefs about LBP.15,53,54 These limitations might Source(s) of support: One author was supported by a Health be alleviated by attending biopsychosocially-oriented workshops on Research Board of Ireland studentship. Another author was LBP. However, while such training may succeed in changing beliefs supported by an Irish Research Council postgraduate scholarship. regarding pain, the skills and knowledge learned during these Acknowledgements: Nil. courses do not always translate into changes in physiotherapists’ Correspondence: Aoife Synnott, Clinical Therapies, University management and patient outcomes and satisfaction.15,19,55 One of Limerick, Limerick, Ireland. Email: [email protected] possible explanation is that physiotherapists who attend such courses know what they are expected to say after training, in terms References of identifying on a case vignette some important cognitive, psychological or social factors; however, this may not reflect their 1. Waddell G. Low back pain: a twentieth century health care enigma. Spine. actual practice. 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Journal of Physiotherapy 61 (2015) 54–60 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Invited Topical Review Physiotherapy in the prevention of falls in older people Catherine Sherrington, Anne Tiedemann The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia 5[K]F_DTI$ E Y W O R D S [Sherrington C, Tiedemann A (2015) Physiotherapy in the prevention of falls in older people. Journal of Physiotherapy 61: 54–60] Accidental falls ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article Physiotherapy Therapeutic exercise under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction Physiological function Falls in older people are a common and important problem that A range of body structures and functions are involved in can have devastating consequences for individuals and their maintaining the body in an upright position. The appropriate co- support networks. Falls are also important for health systems due ordination of these structures and functions is also crucial. To avoid to the burden they place on health services. Physiotherapists can falling, a sighted ambulant person needs adequate: vision to play a crucial role in the prevention of falls in older people.1 There observe environmental challenges (eg, uneven or slippery sur- is high-level evidence that appropriately prescribed interventions faces); proprioception (awareness of where body parts are in can prevent falls.2 This review overviews: the impact of falls; the space); reaction time to respond to unexpected perturbations; and physiological basis of falls; evidence for the prevention of falls, muscle strength to extend the legs against gravity, with spare with a focus on exercise-based interventions; implications for capacity to enable a stronger activation to regain an upright practice; and future directions for research. position in case of a trip. Adequate co-ordination of these functions enables the correct muscles to be activated at the correct times, The increasing problem of falls with the correct amount of force to successfully undertake tasks such as walking and stair climbing. Postural control (balance) At least one-third of people aged 65 years and over fall once or reflects the successful co-ordination of these functions. Adequate more annually. Thus, 1 million older Australians currently fall each cardiovascular and respiratory function also ensures oxygen year. Falls can result in injuries, loss of confidence, and a transport to the muscles and the brain to enable these functions subsequent reduction in activity levels and community participa- to occur. tion. Unless fall rates can be reduced at a population level, the impact of falls will grow substantially in the near future due to the Function of the various components of successful postural increased proportion of older people in the global population. The control can be adversely affected by physiological ageing and low proportion of Australians aged over 65 years is predicted to levels of appropriate physical activity (disuse). Diseases and increase from 13% (3 million people) in 2010 to around 24% medications may also have this impact. Postural control can also be (9 million people) by 2050.3 By 2050, around 2.7 million older adversely affected by acute medical problems such as infections, Australians will fall each year and national annual health costs chronic conditions such as diabetes, and progressive conditions from fall-related injury are predicted to increase almost threefold, such as Parkinson’s disease. The impact of medications on to AUD1.4 billion, if current fall rates cannot be reduced.4 successful postural control is also likely to vary according to dose, Therefore, health agencies internationally are increasingly invest- interactions and metabolism but psychoactive medications have ing in fall prevention initiatives. been particularly associated with falls. Understanding falls Fortunately, many of these functions can be improved by physiotherapy intervention, particularly with the implementation Daily life requires humans to undertake tasks in a range of of structured exercise interventions. Or course, people with environmental settings. Falls occur due to a mismatch between an impairments in one or more of these systems can also learn to individual’s physiological function, environmental requirements compensate for these with other strategies such as the use of a and the individual’s behaviour. Each of these components will be cane, for those with visual impairments, or walking aids, for those considered in turn. with insufficient leg muscle strength. Physiotherapists can also have an important role in the provision of compensatory strategies and the decision about when to attempt rehabilitation rather than compensation. http://dx.doi.org/10.1016/j.jphys.2015.02.011 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Invited Topical Review 55 Environmental context strength of this evidence, is provided in Table 1. This summary is based on the most recent update of the Cochrane Review on falls It is important to consider the interaction between the prevention in community-dwelling older people.2 environment in which an individual is undertaking tasks and his or her physiological functioning. An individual with a high level of Randomised, controlled trials with falls as an outcome typically functioning in the physiological systems that are crucial to falls compare the number of falls experienced by people randomised to avoidance is still likely to fall in very challenging environments. For the intervention group with the number of falls experienced by example, sportspeople often fall during competitions and young fit people randomised to the control group using a rate ratio. If there people may fall while hiking or walking on icy surfaces. The key were the same number of falls in both groups, the rate ratio would distinction is that an older person with impaired physiology may be 1. A rate ratio of 0.7 means there were 30% fewer falls in the fall in an unchallenging environment such as walking across a intervention group compared to the control group. Rate ratios are room. Physiotherapists should seek to understand the context of reported with 95% confidence intervals reflecting the certainty of falls reported by their clients rather than assuming that all older the effect estimate, with a smaller confidence interval indicating people have fallen in an unchallenging environment. more certainty. Trials also often compare the proportion of people experiencing one or more falls in each group (ie, ‘fallers’) using a Behavioural context risk ratio. Similarly, if there were the same proportion of fallers in both groups, the risk ratio would be 1. A risk ratio of 0.7 means A person’s behaviour is also crucial in the consideration of risk there were 30% fewer fallers in the intervention group compared to of falling. People can choose which tasks they undertake and how the control group. The Cochrane review2 thus reports pooled data they undertake them. Behaviour is likely to be influenced by for both the rate of falls and risk of falling. The present review will cognitive impairment, insight and level of support available. Some focus on rate of falling because this is likely to be more sensitive to individuals with a high physiological risk of falling may be able to intervention impacts, especially in higher risk populations. avoid falling by increased awareness and use of assistance when required. Individual variations in attitudes and behaviour probably Exercise interventions explain the differences between measured fall risk and actual falls experienced.5 There is now strong evidence for the effectiveness of exercise in the prevention of falls in community-dwelling older people.2,8 Fall prediction tools Exercise is an obvious choice as a fall prevention intervention because impaired muscle strength and poor postural control are Although individual falls are complex and multifaceted, a known to increase the risk of falling and are amendable to change number of tools have been developed that can quantify a person’s with exercise.9,10 Exercise is the most highly-researched fall risk of falling with reasonable accuracy. The choice of tool will prevention intervention; the 2012 Cochrane review identified depend on the purpose of the tool and the setting in which it is to 59 randomised, controlled trials of exercise as a fall prevention be used. intervention.2 The strongest single predictor of future falls is a history of Researchers have sought to establish optimal approaches to previous falls.6 This is probably because an individual’s reason for exercise by exploring effects from different types of exercise. The falling the first time is likely to recur. Assessment of physical Cochrane review2 concluded that ‘multiple-component’ exercise functioning is the next strongest predictor and so its inclusion is programs prevent falls when delivered in a group (rate ratio 0.71, likely to increase a tool’s predictive ability. In general, fall 95% CI 0.63 to 0.82; 16 trials; 3622 participants) or home-based prediction tools have greater predictive power if they include format (rate ratio 0.68, 95% CI 0.58 to 0.80; DFI]$_Ts8[ even trials; more components, but this needs to be traded off against the utility 951 participants). The multiple-component programs involved of performing a longer assessment. The QuickScreen7 fall risk exercise targeting several of the following categories: gait, balance, assessment tool has been developed and validated for use among functional tasks, strength, flexibility and endurance. The Cochrane community-dwelling older people. This tool involves assessments review2 concluded that for Tai Chi, the reduction in rate of falls of balance, peripheral sensation and vision, and questions about bordered on statistical significance (rate ratio 0.72, 95% CI 0.52 to past falls and medication use. The risk of falling increases 1.00; [T_fi]FI9D$ ve trials, 1563 participants) but Tai Chi did significantly dramatically for people with multiple risk factors on the tool. reduce risk of falling (risk ratio 0.71, 95% CI 0.57 to 0.87; F[10D_$Ts]I ix trials, People with zero or one risk factor had a 7% chance of experiencing 1625 participants). Classes that included just gait, balance or multiple falls in the year of follow-up, yet those with six or more functional training led to a reduction in the rate of falls (rate ratio risk factors had a 49% chance of multiple falls. 0.72, 95% CI 0.55 to 0.94; [F]1Tf$_DI our trials, 519 participants). Conversely, no significant reduction in falls was seen as a result of Fall prediction tools also need to be setting specific, because if strengthening exercise alone or walking groups, but fewer trials [6_TD$IF]most individuals in a particular setting have a particular risk factor have investigated these interventions. (eg, muscle weakness in stroke survivors), a tool that measures this risk factor won’t discriminate fallers from non-fallers. Yet, if the An earlier meta-analysis with meta-regression by the present purpose of using the tool is to raise awareness of risk, then a tool authors identified a focus on postural control as a crucial that classifies everyone in a particular population as being at risk component of exercise to prevent falls.8 We classified the may still be useful. interventions as including a high challenge to balance if the exercise was undertaken while standing and aimed to: narrow the It is important to understand the difference between a base of support (by standing with the feet closer together or on one prediction tool that simply aims to predict the probability of foot); include exercise done without the use of the arms to support falling and an assessment tool that can be used to guide the body; and involve controlled movement of the body in space. prescription of interventions. It is not necessarily the case that The impact on falls in trials that included a moderate (two of three addressing all risk factors identified on a prediction tool will criteria) or high (all three criteria) challenge to balance was 22%, prevent falls. 7F_$TE[D]I vidence that these risk factors are amenable to whereas there was no overall impact on falls from programs that change with particular interventions is required. did not include these components. Examples of exercises that challenge balance and how these can be progressed are given in Prevention of falls Box 1. We also found greater impacts from programs that were of a higher dose and did not include a walking program. We postulate A summary of fall prevention interventions supported by that walking programs may increase the exposure to environmen- evidence from randomised, controlled trials, along with the tal fall hazards and also walking programs do not focus specifically on improving balance. As a result of this work and the findings of
56 Sherrington and Tiedemann: Physiotherapy in falls prevention Table 1 Fall prevention interventions for community-dwelling older people. Intervention Pooled effects in community-dwelling Difference between pooled effects in subgroups defined populations. Pooled rate ratios from according to risk status or intervention delivery. Pooled Exercise Gillespie et al2 unless otherwise indicated. rate ratios and subgroup comparisons from Gillespie et al2 multiple component group-based exercisea 0.71 (0.63 to 0.82); 16 trials, No significant difference in effect size between subgroups 3622 participants defined by risk of falling (p = 0.86) selected for higher risk of falling, 0.70 (0.58 to 0.85); gait, balance or functional training in a group 0.72 (0.55 to 0.94); 4 trials, 519 participants multiple component at homea 9 trials, 1261 participants resistance training at home 0.68 (0.58 to 0.80); 7 trials, 951 participants not selected 0.72 (0.58 to 0.90); 7 trials, Tai Chi 0.95 (0.77 to 1.18); 1 trial, 222 participants 2361 participants 0.72 (0.52 to 1.00); 5 trials, Suggestion of greater impact in groups not selected for 1563 participants higher risk of falling (p = 0.06) selected for higher risk of falling 0.95 (0.62 to 1.46); 2 trials, 555 participants not selected for higher risk of falling 0.59 (0.45 to 0.76); 3 trials, 1008 participants Multifactorial interventionsa 0.76 (0.67 to 0.86); 19 trials, No evidence of difference in effect by risk of falls (p = 0.50) 9503 participants selected for higher risk of falls 0.77 (0.66 to 0.90); 17 trials, 5954 participants not selected: 0.57 (0.23 to 1.38); 2 trials, 3549 participants Intervention may be more effective in the subgroup that received an assessment and active intervention compared with the subgroup that received assessment followed by referral or provision of information (p = 0.05) for risk of falling but not for rate of falls (p = 0.36). assessment plus active intervention delivery 0.74 (0.61 to 0.89); 11 trials, 6338 participants assessment plus referral for intervention delivery 0.82 (0.71 to 0.95); 9 trials, 3376 participants Home safety interventions 0.81 (0.68 to 0.97); 6 trials, Home safety interventions were more effective in the 4208 participants higher risk subgroup (p = 0.0009) and when delivered by OT selected for higher risk of falling 0.62 (0.50 to 0.77); 3 trials, 851 participants not selected 0.94 (0.84 to 1.05); 3 trials, 3357 participants delivered by OT 0.69 (0.55 to 0.86); 4 trials, 1443 participants not delivered by OT 0.91 (0.75 to 1.11); 4 trials, 3075 participants Vision assessment and eye examination 1.57 (1.19 to 2.06); 1 trial, 616 participants plus intervention Medications/supplements nutritional supplementation Risk ratio 0.95 (0.83 to 1.08); 3 trials, 1902 participants vitamin D 1.00 (0.90 to 1.11); 7 trials, Greater impact in people with lower Vitamin D than 9324 participants unselected populations (p = 0.01) selected for low Vitamin D 0.57 (0.37 to 0.89); 2 trials not selected 1.02 (0.93 to 1.13); 5 trials, 9064 participants calcitriol versus placebo 0.64 (0.49 to 0.82); 1 trial, 213 participants hormone replacement therapy versus placebo 0.88 (0.65 to 1.18); 1 trial, 212 participants hormone replacement therapy 0.75 (0.58 to 0.97); 1 trial, 214 participants + calcitriol versus placebo medication review Risk ratio 1.03 (0.81 to 1.31); 2 trials, 445 participants GP prescription-modification program Risk ratio 0.61 (0.41 to 0.91); 1 trial, 659 participants Cognitive behavioural therapy 1.11 (0.80 to 1.54); 2 trials, 350 participants Increased knowledge 0.88 (0.75 to 1.03); 4 trials, 2555 participants Effect sizes are shown as rate ratios and 95% CI unless otherwise specified. Comparisons including less than 200 people are not reported. Shaded rows indicate interventions that lead to a statistically significant reduction in falls. a Please see text for more details on typical components of these interventions OT = occupational therapist
Invited Topical Review 57 Box 1. Examples of balance-challenging exercises suitable for Box 2. Recommendations for exercise to prevent falls among community-dwelling older people. Adapted from Sherrington prescription to older people and methods of progressing et al8 exercise intensity. Adapted from Tiedemann et alTI1D][F4$_ 1 Exercise must provide a moderate or high challenge to Exercise Progression balance. Graded reaching Narrower foot placement Exercises should aim to challenge balance in three ways: in standing Reaching further and in different reducing the base of support directions moving the centre of gravity Stepping in different Reaching for heavier objects reducing the need for upper limb support. directions Reaching down to a stool or the floor Walking practice Standing on a softer surface Exercise must be of a sufficient dose to have an effect. (eg, foam rubber mat) Exercise should be undertaken for at least 2 hours per week. Sit to stand Stepping while reaching Longer or faster steps Ongoing exercise is necessary. Heel raises Step over obstacle The benefits of exercise are rapidly lost when exercise is Pivot on non-stepping foot ceased. Step-ups: forward Decrease base of support and lateral (eg, tandem walk) Falls prevention exercise should be targeted at the general Half squats sliding Increase step length and speed community as well as those at high risk of falls. down a wall Walking in different directions There is a larger relative effect from programs offered to the Walking on different surfaces general community than programs offered to high-risk groups, Walk around and over obstacles yet, high-risk groups actually have more falls, so a greater Heel and toe walking number of falls can be prevented in this population. Don’t use hands to push off Lower chair height Falls prevention exercise may be undertaken in a group or Softer chair home-based setting. Add weight (vest or belt) Group sessions should be supplemented with additional Decrease hand support home-based exercise in order to obtain the recommended Hold raise for longer exercise dose. One leg at a time Add weight (vest or belt) Walking training may be included in addition to balance Decrease hand support training but high-risk individuals should not be prescribed Increase step height brisk walking programs. Add weight (vest or belt) Walking training may be included in a program as long as it is Decrease hand support not at the expense of balance training. Hold the squat for longer Move a short distance away from Strength training may be included in addition to balance the wall training. Add weight (vest or belt) Effective strength training overloads the muscles by providing One leg at a time an amount of resistance that ensures that an exercise can only be done 10 to 15 times before muscles fatigue. other trials we developed eight recommendations to guide the provision of exercise to prevent falls that are shown in Box 2. Exercise providers should make referrals for other risk factors to be addressed. While our review and the Cochrane review have taken different Older people who have fall risk factors not amenable to change approaches to the classification of exercise interventions, the with exercise (such as visual problems and certain results are not necessarily inconsistent because most multiple medications) should receive a full assessment at a falls clinic or component programs (found to be effective in the Cochrane ask their general practitioner for appropriate referrals. review) included a challenge to balance, and the Tai Chi intervention (found to be effective in the Cochrane review) was An interesting approach to exercise prescription that has also classified in our review as providing a challenge to balance. recently been found to be effective in the prevention of falls5FI1_[1D$T] 4 is the LiFE program developed by Clemson and colleagues, where There is little direct evidence about the differential impact of participants are taught how to integrate the exercises into their different approaches to exercise because most studies with falls as daily routine. For example, participants are taught to practise an outcome have not been large enough to detect the effects of standing on one leg while waiting for the jug to boil or while different intervention approaches. One notable exception is the cleaning their teeth, and are encouraged to perform squats while study by Kemmler and colleagues,D$IF]1T1[_2 2 which found greater impact bending to pick up washing from the washing basket. on falls of high versus lower intensity group exercise interventions (rate ratio from Cochrane review2 0.60, 95% CI 0.47 to 0.76). The role of exercise as a single intervention in populations defined by a particular risk factor not amenable to change by The intervention programs used in many of the trials included in exercise is less clear. The Otago Exercise Programme is clearly the reviews involved individualised exercise prescription based on effective in the prevention of falls in general community- assessment of an individual’s abilities and limitations. As a range of dwelling older people,4I1_1DFT[$] 3 yet, in factorial studies by its developers, programs have been found to prevent falls, the current evidence it did not appear to have the same impact in people with severe supports the availability of a range of programs and individualised visual impairment[16_1]$FIDT 5 or in people taking psychoactive medica- exercise prescription according to an individual’s physical function- tions.I]$7[F1DT1_ 6 In contrast, the TD$1I_F[]i8 nterventions tested in the non-exercise ing and interests. Several of the trials1[FTD]_I’$3 authors have published arms of these studies – a home safety intervention for people manuals to guide the implementation of the program tested in the with visual impairment and gradual reduction of psychoactive trial. For example, the Otago Exercise Programme is a home-based medications for those taking these medications – were effective. program that has been found in a meta-analysis of several trials to It may be that certain risk factors are ‘dominant’ in certain able to reduce the rate of falls by 35% in community-dwelling older populations and falls can only be prevented in such a population people recruited via general practice (GP).TD14]1IF_$[ 3 Its manual is now freely by addressing this risk factor. available online. Online training for the Otago Exercise Programme is offered through the North Carolina Area Health Education Center. Similarly, the role of exercise as a single intervention in people that are at a very high risk of falls is less clear. It is often assumed that people at greater risk of falls will obtain greater benefits from interventions. Certainly, an intervention of similar relative
58 Sherrington and Tiedemann: Physiotherapy in falls prevention effectiveness will prevent more falls in high-risk populations who evidence to support FI]Di[T2_9$ nterventions, including: a multifaceted experience a greater absolute number of falls. However, our meta- podiatry intervention for people with disabling foot pain; insertion analysis actually found smaller relative benefits from exercise as a of a cardiac pacemaker for people with cardioinhibitory carotid single intervention in higher-risk people.8 This differs from the sinus hypersensitivity; cataract removal for those with operable finding of the Cochrane review that multiple component exercise cataracts; and gradual reduction in psychoactive medications. was equally effective in trials that selected people at an increased There is also evidence that Vitamin D can prevent falls in those risk of falls and trials in the general unselected population. This with low Vitamin D (but not in an unselected population)2 and that difference between the findings of the two reviews may be because a review of person’s medications by a GP can prevent falls. our meta-analysis also included people in residential care, so had a greater spectrum of risk, and because we included Tai Chi in the Multifactorial interventions same analysis as other forms of group exercise. Tai Chi was found in the Cochrane review to be less effective in higher-risk As a range of risk factors can cause falls, another common populations. The caution about the application of exercise as a approach is to assess for the presence of risk factors and target single intervention to high-risk groups is also emphasised by our interventions to the risk factors identified. It is difficult to draw recent trials in which those in the intervention groups showed conclusions about the optimal approach from meta-analyses of enhanced mobility but no significant reduction in falls. This was multifactorial interventions because the many trials in this area have the case in: frail older people with a program targeting frailty included a range of approaches. Two examples of p_TF3D0[$]I articularly rather than falls that included home exercise (incidence rate ratio successful multifactorial interventions are from earlier trials.1TD2[$]_F3I 4,25 (IRR) 1.12, 95% CI 0.78 to 1.63, p = 0.53);1T]F9ID_[$1 7,18 long-term stroke The study by Tinetti and colleaguesI_DT[2F]$32 4 included community-dwelling survivors with a weekly exercise class (IRR 0.96, 95% CI 0.59 to people aged over 70 who were independently ambulant but had at 1.51);1]F20ID[_T$ 9 and older people recently discharged from hospital with a least one of the targeted risk factors for falling (postural hypoten- home exercise program.F]2ID[$21T_ 0 In the latter trial, there was a sion, sedative/hypnotic use, use of more than four medications, significantly higher rate of falls in the exercise group (IRR 1.43, inability to transfer, gait impairment, strength or range of motion 95% CI 1.07 to 1.93, p = 0.017).2D$1I_F2][T 0 It may be that the increase in loss, and domestic environmental hazards); it did not include people mobility led to enhanced confidence, which in turn led to increasedDIF2_T$[] who were able to undertake vigorous activity. The intervention risk taking and more falls. Perhaps the post-hospital population is program targeted these risk factors in a systematic way by using one in which people have not adjusted to T$D_Fa[]32I recently increased risk adjustment of medications, behavioural instructions, and/or exer- of falls, so are prone to increased risk with increased mobility. It cise programs. There was a 30% lower fall rate in the intervention may be that a more intensive, supervised exercise intervention is compared to the control group (adjusted IRR 0.69, 95% CI 0.52 to required in these high-risk groups. Previous trials with intensive 0.90). In another early trial, Close and colleaguesD$FI]2T_3[ 5 recruited centre-based programs have shown benefits for older people with community-dwellers aged 65 years and older who presented to a recent history in injurious fallsF][24_2TD$I 1 and hip fractures.DITF]2_$2[5 2 an accident and emergency department with a fall. Intervention group participants underwent a detailed medical and OT assessment It would also be worth investigating the addition of a safety with referral to relevant services if indicated, which resulted in intervention to a home exercise program that is shown to enhance marked reductions in the risk of falling and of recurrent falls, as well mobility. Greater education about falls and safe mobility may as significantly lower risk of hospitalisation and functional decline. enable mobility to be enhanced without falls being increased. The Stepping On program focuses on empowering the individual to take D3I_$ST4F[] everal more recent multifactorial interventions have been less responsibility for falls prevention by encouraging better under- successful. For example, Elley and colleaguesF]2I_53$[TD 6 assessed a GP- standing about environmental hazards and other risk factors for based program for previous fallers, which involved a home-based falls, as well as the importance of exercise. This program has been falls risk assessment by a nurse with referral to community found to reduce the rate of falls by 31% when delivered [F2DT6_$i]I n seven services and exercise where indicated, and found that it didn’t sessions FD$_72u[T]I sing a group discussion-based format for community- prevent more falls than usual care (IRR 0.96, 95% CI 0.70 to 1.34). It dwelling older people that also involved exercise with the addition may be that intervention effects have become diluted over time as of an occupational therapy (OT) home visit.[D$2IF]2_8T 3 This approach fall prevention interventions get applied more commonly to informed our current trial with people after fall-related fracture control groups, so between-group differences are less stark. There (ACTRN12610000805077). is also some evidence that interventions provided as part of studies have greater impacts than referral-based programs,_6D$IF]2[T3 7 presumably Interventions targeted at single risk factors due to better adherence to interventions. As outlined in Table 2, several trials have found that single The best approach to the delivery of multifactorial interventions interventions can prevent falls when targeted at people with is controversial. It has been suggested that single interventions are particular risk factors addressed by the intervention. There is as effective as multiple interventions at a population level and are cheaper to deliver._D2T$F[37I] 8 It has also been suggested that tailoring may Table 2 Fall prevention interventions for community-dwelling older people targeting specific risk factors. Intervention Effects in community-dwellers with a particular risk factor or condition. Medication review From Gillespie et al2 unless otherwise indicated. Home healthcare patients aged 70+ taking one of four high-fall-risk medications 1.12 (0.58, 2.13); 1 trial, 317 participants Cataract removal People with operable cataracts 1st eye: 0.66 (0.45 to 0.95); 1 trial, 306 participants 2nd eye: 0.68 (0.39 to 1.17); 1 trial, 239 participants Replacing bifocal, trifocal, or progressive lens glasses People who wear bifocal, trifocal, or progressive lens and walk outdoors 3 x per week with single lens glasses when walking outdoors Subgroup who regularly leave the house 0.60 (0.42 to 0.87); 1 trial, 261 participants Podiatry (foot exercises, orthoses, shoes) People with disabling foot pain 0.64 (0.45 to 0.91); 1 trial, 305 participants Pacemaker People with carotid sinus hypersensitivity 0.73 (0.57 to 0.93); 3 trials, 349 participants Effect sizes are shown as rate ratios and 95% CIs unless otherwise specified. Comparisons including less than 200 people are not reported. Shaded rows indicate interventions that lead to a statistically significant reduction in falls.
Invited Topical Review 59 not be essential because multiple intervention programs (ie, where or more of: individualised prescription of home-based programs; more than one intervention is delivered to groups of people without referral to community group programs known to be suitable; screening and targeting) can also be successful.TD_$83IF[]29 offering group programs in a private practice or hospital department; and raising community awareness by educating A fall prevention approach that physiotherapists may find about the importance of exercise in the prevention of falls (eg, talks useful is to start with exercise prescription for _9$]TFD3[aI ll older clients, to groups of older people or fellow health professionals, and given the importance of exercise as a risk factor for falls, but add articles for local newspapers). additional interventions where4[_T]FID$0 fall risk factors not amenable to exercise intervention are detected. As other interventions, which are not usually delivered by physiotherapists, have also been found to prevent falls for people Hospital and residential care with particular risk factors, physiotherapists can also screen patients for these risk factors and refer for specialised intervention The 2012 Cochrane systematic review of interventions to (ie, medication management, podiatry, OT home visits for high-risk prevent falls in care facilities and hospitals included 60 trials (60 people, cataract removal, assessment of suspected carotid sinus 345 participants).]3$T1F4[ID_ 0 In relation to exercise interventions in care hypersensitivity). facilities (13 trials), the results were inconclusive. The authors suggested that exercise programs might increase falls in frail Implications for future research residents and reduce falls in less frail residents, leading to no overall effect. The review authors also concluded that vitamin D Further research is needed to establish the optimal approaches supplementation is effective in reducing the risk of falls in care to fall prevention in people with particular conditions (eg, stroke, facilities and that multifactorial interventions may reduce the frailty) and people after hospital discharge. The effectiveness and number of falls. cost-effectiveness of the delivery of fall prevention interventions in the context of usual health services also requires more investiga- A particularly successful intervention in residential care involved tion. The impact of fall prevention interventions on fractures also staff and resident education on fall prevention, advice on environ- requires urgent investigation. mental adaptations, progressive balance and resistance training, and hip protectors.2$4D_T3]FI[ 1 This program also appeared to prevent femoral Conclusions fractures when disseminated across the state of Bavaria.I[D_3$4TF3] 2 A group in New Zealand attempted to replicate this program without increasing Current evidence indicates that: group exercise, home safety staff levels and did not find it to be effective. In fact, they found an and multifactorial interventions prevent falls in community- increase in falls in the intervention group and concluded that, at low dwelling older people at an increased risk of falls; and group intensity, the program may actually be worse than usual care.4FI_D][3T$ 3 This and home-based exercise and multifactorial interventions also suggests that real investment is required to prevent falls and prevent falls in unscreened groups. Therefore, falls assessment fractures in residential aged care. tools can be used to predict who will fall and to tailor interventions but may not be needed in order to decide who should do groupTI$F_3D[] or In longer-stay subacute hospital settings, multifactorial inter- FI[D49]_Th$ ome D[_F0TI]e$5 xercise because all older people are likely to obtain benefits ventions appear to reduce the rate of falls.IFD5T[_4]$34 In more acute hospital from these interventions. settings, patient education interventions seem to be the most effective interventions in those without cognitive impairment.F]D_[4I3$T6 5 More falls are prevented in high-risk people with interventions One study4T$D[]7F_I36 found a one-on-one patient education program, of the same relative effectiveness, but it is not necessarily the case targeted at those without cognitive impairment, to be effective in that high-risk people will benefit more from interventions. This preventing falls in a rehabilitation settings and some carryover of can be considered when prioritising limited resources. Single this impact to fall prevention in people with cognitive impairment, interventions targeting cataracts, foot pain and psychoactive presumably due to changes in staff behaviour and awareness_D$[2I.]TF 4_8[T$DIF3] 7 medications can prevent falls in people with these risk factors. Greater understanding of fracture prevention in all groups and of Prevention of fractures optimal fall prevention strategies in high-risk groups is needed. Physiotherapists are very well placed to make an important Falls that lead to fractures and other serious injuries are usually contribution to the urgent global challenge of preventing falls in of greater concern to individuals than non-injurious falls. Low bone older people. mineral density has been identified as a risk factor for fractures and there is evidence that fractures can be prevented by medications Ethics approval: Not applicable that enhance bone mineral density. Of course, many fractures are Competing interests: Nil caused by falls so it is also likely that interventions known to Sources of support: The first author receives salary funding prevent falls can also prevent fractures. Unfortunately, confirmation from an Australian National Health and Medical Research Council of this would require trials of many thousands of people and such a Senior Research Fellowship. trial is yet to be completed; however, at least one is underway. Acknowledgements: Nil There is evidence from meta-analyses that exercise interventions Correspondence: Cathie Sherrington, Musculoskeletal Division, can prevent fractures. A meta-analysis of the Otago Exercise The George Institute for Global Health, Sydney, Australia. Email: Programme trialsD[1]F1I$T_ 3 found a similar impact on injurious falls (IRR [email protected] 0.65, 95% CI 0.53 to 0.81) than on all falls (IRR 0.65, 95% CI 0.57 to 0.75). The Cochrane review found that the impact of exercise References interventions on fractures was substantial (RR 0.34, 95% CI 0.18 to 0.63; _D$01IF[s]T ix trials, 810 participants). It is possible that the true effect is 1. Martin JT, Wolf A, Moore JL, Rolenz E, DiNinno A, Reneker JC. The effectiveness of smaller than this, because selective outcome reporting influences physical therapist-administered group-based exercise on fall prevention: a sys- this estimate. Thus, in future, all trials of interventions to prevent tematic review of randomized controlled trials. J Geriatr Phys Ther. 2013;36(4): falls should report fractures as well as fall outcomes. 182–193. Implications for practice 2. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, et al. 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Effect of a prevent falls among older hospital inpatients: a randomized controlled trial. Arch multifactorial interdisciplinary intervention on mobility-related disability in frail Intern Med. 2011;171(6):516–524. older people: randomised controlled trial. BMC Medicine. 2012;10. 36. Hill AM, Waldron N, Etherton-Beer C, McPhail SM, Ingram K, Flicker L, et al. A 18. Fairhall N, Sherrington C, Lord SR, Kurrle SE, Langron C, Lockwood K, et al. Effect of a stepped-wedge cluster randomised controlled trial for evaluating rates of multifactorial, interdisciplinary intervention on risk factors for falls and fall rate in falls among inpatients in aged care rehabilitation units receiving tailored multi- frail older people: a randomised controlled trial. Age Ageing. 2014;43(5):616–622. media education in addition to usual care: a trial protocol. BMJ Open. 2014;4(1): e004195. 19. Dean CM, Rissel C, Sherrington C, Sharkey M, Cumming RG, Lord SR, et al. Exercise to enhance mobility and prevent falls after stroke: the community stroke club 37. Hill A-M, McPhail SM, Waldron N, Etherton-Beer C, Ingram K, Flicker L, Bulsara M, randomized trial. Neurorehabil Neural Repair. 2012;26(9):1046–1057. Haines TP. Reducing falls in rehabilitation hospital units using individualised patient and staff education: a pragmatic stepped-wedge cluster randomised 20. Sherrington C, Lord SR, Vogler CM, Close JC, Howard K, Dean CM, et al. A post- controlled trial. Lancet. 2015. (in press). hospital home exercise program improved mobility but increased falls in older people: a randomised controlled trial. PLoS One. 2014;9(9):e104412. Further reading 21. Hauer K, Rost B, Rutschle K, Opitz H, Specht N, Bartsch P, et al. Exercise training for Otago Exercise Program www.acc.co.nz/PRD_EXT_CSMP/groups/external_ rehabilitation and secondary prevention of falls in geriatric patients with a history providers/documents/publications_promotion/prd_ctrb118334.pdf of injurious falls. J Am Geriatr Soc. 2001;49(1):10–20. North Carolina Area Health Education Center 22. Binder EF, Brown M, Sinacore DR, Steger-May K, Yarasheski KE, Schechtman KB. www.aheconnect.com/newahec/cdetail.asp?courseid=cgec3 Effects of extended outpatient rehabilitation after hip fracture: a randomized controlled trial. JAMA. 2004;292(7):837–846. 23. Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The effectiveness of a community-based program for reducing the incidence of falls in the elderly: a randomized trial. J Am Geriatr Soc. 2004;52(9):1487–1494.
Journal of Physiotherapy 61 (2015) 87–92 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research Physiotherapy students and clinical educators perceive several ways in which incorporating peer-assisted learning could improve clinical placements: a qualitative study Samantha Sevenhuysen a, Melanie K Farlie b, Jennifer L Keating c, Terry P Haines b, Elizabeth Molloy d a Allied Health; b Allied Health Research Unit, Monash Health; c Faculty of Medicine, Nursing and Health Sciences; d Health Professions Education and Educational Research Unit, Monash University, Melbourne, Australia KEY WORDS ABSTRACT Education Question: What are the experiences of students and clinical educators in a paired student placement Professional model incorporating facilitated peer-assisted learning (PAL) activities, compared to a traditional paired Students teaching approach? Design: Qualitative study utilising focus groups. Participants: Twenty-four Learning physiotherapy students and 12 clinical educators. Intervention: Participants in this study had experienced two models of physiotherapy clinical undergraduate education: a traditional paired model (usual clinical supervision and learning activities led by clinical educators supervising pairs of students) and a PAL model (a standardised series of learning activities undertaken by student pairs and clinical educators to facilitate peer interaction using guided strategies). Results: Peer-assisted learning appears to reduce the students’ anxiety, enhance their sense of safety in the learning environment, reduce educator burden, maximise the use of downtime, and build professional skills including collaboration and feedback. While PAL adds to the clinical learning experience, it is not considered to be a substitute for observation of the clinical educator, expert feedback and guidance, or hands-on immersive learning activities. Cohesion of the student-student relationship was seen as an enabler of successful PAL. Conclusion: Students and educators perceive that PAL can help to position students as active learners through reduced dependence on the clinical educator, heightened roles in observing practice, and making and communicating evaluative judgments about quality of practice. The role of the clinical educator is not diminished with PAL, but rather is central in designing flexible and meaningful peer- based experiences and in balancing PAL with independent learning opportunities. Registration: ACTRN12610000859088. [Sevenhuysen S, Farlie MK, Keating JL, Haines TP, Molloy E (2015) Physiotherapy students and clinical educators perceive several ways in which incorporating peer- assisted learning could improve clinical placements: a qualitative study. Journal of Physiotherapy 61: 87–92] Crown Copyright ß 2015 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). Introduction consider implementing peer-assisted learning (PAL). Reviewers in Health services that provide clinical education are feeling this field have concluded that PAL models enhance placement significant strain as university programs and student numbers grow1 in response to health professional workforce shortages.2 outcomes and carry the additional benefit of addressing capacity Approaches to clinical education are also being examined for issues.9,10 quality and sustainability.3,4 Clinical educators report that student education can be burdensome and stressful.5,6 Students report that Peer-assisted learning has been defined as ‘the acquisition of placement experiences can provoke high levels of anxiety,7 and sometimes do not provide adequate learning experiences.3 knowledge and skill through active helping and supporting among status equals or matched companions’.8 The company of another Universities have adopted student-centred, collaborative learn- ing models, supported by research;8 however, education in the student on placement appears to reduce student anxiety and aid clinical setting has largely retained traditional models. In physio- learning.9,10 Advantages for the clinical educator, such as reduced therapy clinical education, a clinical educator can supervise one burden, have also been reported,11,12 but without high-quality student, or more than one student concurrently. Where students work together in pairs or larger groups, clinical educators can evidence, the 2:1 model cannot be confidently recommended over the 1:1 approach.13 How PAL placement models are enacted in practice might differ with placement environment, the effectiveness of the peer relationship, and the beliefs and preparation of the student and educator.11,14,15 Peer interactions can vary from social http://dx.doi.org/10.1016/j.jphys.2015.02.015 1836-9553/Crown Copyright ß 2015 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
88 Sevenhuysen et al: Peer-assisted learning in clinical education support to formalised peer-assisted patient-based learning acute, subacute and community settings) with student supervision tasks. responsibilities as part of their role. A recent randomised, controlled trial, comparing a formalised Data analysis PAL model with a traditional approach for pairs of physiotherapy students, found similar student performance outcomes.16 Howev- Qualitative analysis was based on Thematic Analysis techni- er, both students and clinical educators reported dissatisfaction ques.20 Three researchers (SS, MF, EM) independently ‘open’ coded with the rigidity of the prescribed PAL model. They reported plans the data for themes and subthemes. An extended analysis to use more flexible PAL models in the future. A qualitative study framework was developed, based on these triangulated codes, utilising focus groups to enable an in-depth investigation of cross-checked against the transcripts, circulated to all researchers, educator and student experience of PAL may provide insights into discussed, and adjusted to reflect any key themes in the data. the aspects of PAL that are more satisfactory to incorporate into paired student placement models, which will support further Results refinement of the PAL model. Twenty-two students and 12 educators participated in the Therefore, the research question for this study was: focus groups. Their demographic characteristics are presented in Table 2. What are the experiences of students and clinical educators in a paired student placement model incorporating facilitated peer- Qualitative analysis assisted learning activities, compared to a traditional paired teaching approach? Three overarching themes emerged: what PAL can do, what PAL cannot replace, and cohesion of the student-student relationship. Method The subthemes relating to these broader themes are bolded within the text and summarised in Boxes 1 to 3. Design Participants in this study had participated in a prospective, Theme 1. What peer-assisted learning can do cross-over, randomised trial16 that compared two models of Students described clinical education as a stressful experience, physiotherapy clinical education: a traditional paired model and a PAL paired model.17 Students were randomly paired and allocated but the presence of a peer alleviated some of the perceived to either the traditional or PAL model for their 5-week pressure. Participants used the term ‘PAL’ as an umbrella term to cardiorespiratory and neurology placements. Student pairs describe many forms of peer interaction, from informal peer remained the same for both placements. support in the lunchroom to formalised patient-based peer learning tasks. Students considered that informal peer support The PAL model17 included PAL-specific standardised activities during both PAL and the traditional model, and structured support (Table 1), in addition to typical learning activities such as during PAL, reduced anxiety associated with clinical education. involvement in patient care, team meetings, tutorials and administration. PAL activities could be aligned to student learning Instead of just being thrown in the deep end, to do a subjective needs, but a minimum number of activities was mandated [history taking] on your own, complete an assessment on your own, (Table 1). The traditional model involved the usual practice of it was good to have that person there to bounce ideas off. We could clinical educators supervising students in pairs. In the traditional write out a plan together and we followed through together. Just model, the design of the placement activities was at the discretion having the confidence, reliance on someone else, made it easier of the educator and PAL activities were not specifically facilitated (student, FG2). or scheduled. The notion of learning through informal conversations was A physiotherapist, who was external to the research team, articulated by students. health service and university, facilitated three focus groups of students (FG1, FG2, FG3), after they had participated in both I think I learnt more [in PAL]. We helped each other to reflect. You models, to investigate their experiences. A member of the research could talk about what you did and how you could do it differently. team, who was employed by the university but had no relationship We would sit down and debrief with each other and go ‘how can we with the health service, facilitated two focus groups of clinical be different tomorrow?’ (student, FG2). educators (FG4, FG5). Both facilitators had extensive experience in leading focus groups. The opening focus group questions were Students perceived that the presence of a peer enabled a safe broad and designed to invite participants to describe their learning environment. Students could question and debrief with experiences. The questions then progressively focused on how their peer without fear of this impacting on their summative PAL was utilised and how it contributed to, or detracted from, the assessment, in contrast to discussions with a clinical educator. This educational experience in both models. Focus groups were 60 to was reported to have occurred informally in both the PAL and 90 minutes in duration and were audio-recorded and transcribed traditional models. verbatim. Even just asking silly questions you don’t want to ask your Participants supervisor because you think you might get marked down. It holds you back from asking some questions (student, FG1). The third-year students were studying for a 4-year undergrad- uate physiotherapy degree. The clinical educators were phy- Clinical educators perceived that their burden was reduced siotherapists from a tertiary metropolitan health service (including when students in either the PAL or traditional model provided this level of support to one another, instead of always turning to the educator. Table 1 The peer-assisted learning model.17 Domain Feedback Clinical reasoning Risk identification Tool Peer feedback book Educator feedback book Peer observation form Verbal feedback triad SNAPPS 18 Complexity-Risk Matrix 19 Structure Unstructured Unstructured Structured Unstructured Structured Structured Minimum frequency 2/student/wk 2/student/wk 2/student/wk 1/pair/wk 3/pair/wk 2/pair/placement
Research 89 Table 2 traditional model. PAL was perceived to perform a ‘double duty’ Characteristics of clinical educators and students. through both adding to the learning experience and aiding the logistics of placement organisation. Characteristic Educators (n = 12) Students (n = 22) They can give each other feedback and work together on problems. Gender, n female (%) 10 (83) 12 (55) I think that is useful rather than sending someone away to do a task Age (yr), n (%) and coming back with very little. It’s easier when they can bounce 0 (0) 15 (68) ideas off each other. I think they get more out of it and you feel like 18 to 20 2 (17) 7 (32) they’ve used their half hour of downtime for something productive, 20 to 25 8 (67) 0 (0) as opposed to disappearing to the library on their own and you’re 25 to 30 2 (17) 0 (0) not sure what’s been done (educator, FG5). > 30 Clinical experience (yr), n (%) 0 (0) PAL activities used in ‘downtime’ were seen as helpful in <1 5 (42) involving additional staff in clinical education. 1 to 3 3 (25) 3 to 5 3 (25) It worked well with part-time staff. In the past, staff that weren’t 5 to 10 1 (8) there from 8 am till 5 pm couldn’t supervise students. We have staff > 10 that are 8 am till 3 pm and then we could use that extra time to do some PAL activities and discuss it with the senior the next day ... It gives the students someone else to go to as well. If you haven’t things we couldn’t do with the traditional model that we could do had a lot of experience it takes the pressure off a little bit because now with PAL (educator, FG5). they don’t necessarily come to you with every single thing (educator, FG4). The prescribed PAL activities were also perceived to maximise the efficiency of the learning experience by helping students to ‘get Students felt positive about this perceived reduction in reliance more’ out of each patient interaction. The notion that PAL on the educator for support. Their comments demonstrated that supported structured reflection was raised by educators, and they were acutely aware of imposing on, or adding strain to, their praised by students for helping to generate reflective capacities. educators. I think it pushed them to reflect more on each individual It’s just being able to bounce things off each other. Our supervisor experience. Because there were so many PAL activities to complete mentioned that she likes that we could work together, and we felt and they picked a different situation for each, they were forced to good about being able to rely on each other (student, FG2). think about what they were doing and why, what they did well or not so well. Often I think if they didn’t have to do those things they The time burden associated with educator driven feedback would just do it, be done with it and that’s kind of it (educator, was also reduced, as student peers were able to provide feedback FG4). to one another. This was enhanced in the prescribed PAL model, as students were scheduled times for this to take place each week, The teamwork and co-operation required of students in the resulting in greater frequency of peer feedback. Educators in both prescribed PAL model was perceived as an authentic representa- focus groups described being legitimately surprised that student tion of skills required as a health professional. Students and peers would be willing and able to have constructive feedback educators reported that PAL helped students to develop skills in dialogue with each other. collaboration. It could save some time from the [educators] point of view when I It’s reflective of real life. You’re always going to be working with am not telling students ‘can you make sure the patient is well people that are less experienced or bring different things to the spoken to’ (educator, FG5). table. You need to be able to act accordingly; it’s part of your professionalism (educator, FG4). One of the things I observed when I did verbal feedback with PAL- model students was the students I observed were quite forthcoming Students perceived that the prescribed PAL model helped them with constructive feedback. The reason it surprised me [was to develop skills in feedback interactions, and stated explicitly because] when I was a student I would never say something bad that the mandated feedback as part of the PAL model had ‘spilt’ into about someone I was in placement with because I thought ‘that’s habits, even when they were not monitored. Again, educators going to highlight the negative aspect of my peer’s performance to reported that the ability to watch others, and make and my supervisor’. I was actually quite pleased that that didn’t seem to communicate judgments on performance was important in the be a barrier to providing constructive criticism (educator, FG4). workplace. Students recognised this additional feedback from different We got used to giving each other feedback and now we still do that parties as adding to the overall learning experience. even though we don’t have to ... So I guess sometimes you might think you don’t want to tell them, offend them, but because we had I really appreciated when my peer gave me feedback. It’s just a to in the beginning now we just keep giving each other feedback different perspective from the supervisor as well (student, FG3). (student, FG2). Using activities mandated in the prescribed PAL model to If you’ve got a junior staff member and you’ve asked them to give maximise ‘downtime’ in the clinical setting was identified as a feedback to a student, they would often argue ‘I don’t know how to significant positive for the clinical educators, compared with the give feedback’. If we’re skilling our students to give feedback to each other, I think it’s a good skill to have when they are coming to Box 1. Summary of subthemes within Theme 1: what peer- clinical practice (educator, FG4). assisted learning can do. Theme 2. What peer-assisted learning cannot replace Reduces student anxiety In both education models, students described the importance Helps to create a safe learning environment for students Reduces clinical educator burden of observing the clinical educator in order to establish the Maximises use of ‘downtime’ performance benchmark. This expert role modelling was consid- Develops collaborative skills ered to be something that could not be provided by peers, and was Increases feedback capability particularly important not only in improving the students’ own performance, but also in providing appropriate feedback to peers.
90 Sevenhuysen et al: Peer-assisted learning in clinical education You want to mimic, to some extent, what your [clinical educator] is I think, as someone who hasn’t done a lot of clinical supervising ... doing. To you, that’s the standard. If you can do what they do, then [the prescribed PAL model] gives a lot more structure as to how you’re going to be hopefully a good physio and get good marks. to supervise students and what to do with students (educator, Early on, to know how to go see a patient, the process you do things, FG4). and where they put things when they’re getting patients up [out of bed]. I think all those things early on through demonstration are so Students described that the value of the activities in the critical (student, FG3). prescribed PAL appeared to diminish towards the end of their clinical placements. Despite both educators and students acknowledging the value of peer feedback, both parties placed substantially higher value on Initially, when we were doing it the first couple of weeks, I found it educator feedback in both models. Some perceived that peer pretty good just to set out the information, what I wanted to assess feedback could lack depth, because students lacked clinical with the patients and get my head around what I was going to do expertise. Students also raised the notion that educator feedback ... After a few weeks that benefit wasn’t quite as obvious because I is more important because the educator is also the assessor. was a lot more confident in myself and what I wanted to do (student, FG3). It [feedback from the clinical educator] ... was more in depth and ... more relevant. It might have been that I respect the opinion of the The clinical educators agreed that in the future they would use [educator]. Not that I don’t of my peer, but you respect your PAL activities early in the placement and then progress towards [educator] a lot more because they have the experience and really independent practice. know what they’re talking about (student, FG1). I would choose the PAL model, starting the students together and [Students] want to know they’re doing well from their [educator] then [the] second or third week separating them, working together because they’re the ones that are going to assess them (educator, on some patients that need more physical assistance (educator, FG5). FG5). Both educators and students recognised that clinical education Students and educators privileged ‘hands on’ learning is complex and that learning needs and, therefore, task sequencing experiences (ie, doing) over the activities mandated in the PAL change depending on the student, educator and setting. The model (ie, observation, feedback, reflection, planning). This rigidity of the prescribed PAL model was a source of dissatisfaction; phenomenon of ‘doing is better than watching’ was framed as participants perceived the need for flexible PAL activities that an overall philosophy of good clinical education, rather than responded to changes throughout the placement. The students reflecting the experience of the alternate activities being of less highlighted the value of the clinical educator’s guidance in value. selecting and facilitating incrementally complex PAL activities tailored to the individual student’s progress, rather than strictly You do learn from observing but I feel like the idea of placement is following scheduled PAL tasks. more to get hands-on experience, so therefore seeing patients the whole time, whether it’s by yourself or with the assistance of your Say your peer was seeing the same patient every day and doing peer (student, FG1). similar stuff, giving them feedback every day on the one thing you’re doing is just going to be overkill. First time it might be ‘try I think in their mind, the idea of a clinical placement is doing it on a doing this, or try doing this’ but then by the fourth or fifth day real person. It’s not just watching, they’ve done that at university you’re watching them do pretty much the same thing. I think that (educator, FG4). seemed like a waste of time sitting, watching and not giving much feedback (student, FG1). Theme 3. Key variables for peer-assisted learning success: cohesion of the student relationship The clinical educators reported being challenged by the mandated frequency of tasks in the prescribed PAL model. Many The clinical educators and students referred to the success of described their plans to use a flexible model in the future. the PAL strategies being dependent on the cohesion of the student relationship. To be successful, it was important for students to I think if you had the flexibility to realise when it’s not working and proactively initiate PAL activities. to change things. With this [the prescribed PAL model] it got difficult because there wasn’t the flexibility to say this is not I think it depended on the student ... that’s a comment I have in working (educator, FG1). general. It really depends on which student you had. Some students were really good, took a lot of initiative and we didn’t have to ask a I really think some of the tools were beneficial and I would lot of questions at all. We had others that needed more prompting incorporate them into a model that was more flexible without the (educator, FG4). onus of ‘we have to do this’ (educator, FG2). My partner and [I] were quite different [in] the way we worked, the However, the clinical educators identified some positives in style of learning. It was hard to co-ordinate that because I would having a prescribed structure for clinical education. learn a different way to how he would. Working together wasn’t so easy (student, FG2). I think feedback can ... [be] forgotten ... It [the prescribed PAL model] prompted me to do that and also ... [prompted] the two Despite these reservations, some students described building students to give each other feedback (educator, FG5). effective peer relationships in both models, despite interpersonal differences. Educators considered that a student’s ability to Box 2. Summary of subthemes within Theme 2: what peer- interact productively with peers was a marker of overall assisted learning cannot replace. capability in practice. Educators perceived that students who were able to get along and complete work, despite personality Observing the practice of the clinical educator differences, demonstrated effective behaviours in communication, Individualised feedback from the clinical educator teamwork, and professionalism. Expert guidance Hands-on learning experiences I was told my students didn’t get along all that well outside of the clinical placement, but I didn’t see that reflected when I supervised them. If that was the case they were both very professional (educator, FG5).
Research 91 Box 3. Summary of subthemes within Theme 3: cohesion of in PAL. Skilled educators remain a key component to placement the student relationship. success by designing effective learning experiences. Earlier studies11,17,25 have suggested that supervising multiple students Can affect the frequency and success of peer-assisted requires specific educator skills. Educators successfully facilitating learning PAL are required to model target performances, set expectations and rationale for how PAL interactions might be useful to extend Is seen as a marker of students’ overall capability in learning, select and scaffold relevant and appropriate patient- practice based learning experiences/tasks, guide learners through complex social interactions, model reflective practice and provide individ- I think it [the poor peer relationship] was really reflective of ualised feedback. this student because his team work and the way he spoke to other staff was horrible ... The rapport was never as good as it was Both students and educators valued practical or hands-on with me because he knew I was the one marking him (educator, learning in the clinical environment. Although feedback and FG4). reflection are considered to be crucial for learning, both students and educators reported ‘learning by doing’ or ‘seeing patients’ as Discussion the cornerstone of clinical education. Peer-assisted learning models may help educators to increase feedback and reflection The results of this study reinforce the view that 2:1 into a culture of ‘doing’. Students and educators reported that PAL (student:supervisor) placement models can enhance clinical tasks were more useful early on in placements, which is learning experiences for physiotherapy students9,10 because consistent with the principles of scaffolding learning tasks to many benefits were described in both paired placement enable independent practice. Student preference for PAL earlier models. Participants reported that while PAL occurred in the in the placement has been previously reported; students tend to traditional and PAL models, the ‘prescribed PAL model’ was want to demonstrate independence as they approach placement influential in establishing positive habits that promoted oppor- completion.26 tunities for learning, such as active observation and peer feedback. Students and educators also reported that the PAL model Both students and educators described student ‘compatibility’ enhanced the use of ‘downtime’ that typically frustrated as a key enabler of successful PAL. In the 2:1 model, the student- students. Students perceived that the informal PAL, which student relationship has been identified by students as a stronger occurred in both models, reduced anxiety associated with clinical influence on learning than the educator-student relationship.26 education. Students perceived that the educators played a key role in creating an environment where collaboration was encouraged and compe- This qualitative analysis explains an outcome of our random- tition was minimised. In preparing educators to apply PAL models, ised trial:16 that some participants would continue with a ‘flexible it may be important to include related content. No evidence was PAL model’ despite greater satisfaction with the traditional model. found of peer relationships that were damaging or destructively The in-depth analysis of participant experience also provides competitive. This aligns with previous research, where compati- insights into aspects of PAL that were perceived as favourable. Both bility and competition has frequently been raised as a concern but educators and students reported benefits of informal PAL and has rarely been observed.11 additional benefits of a prescribed PAL model. A flexible model would counter challenges related to the rigidity of the prescribed The present study was conducted in one health service, with activities and mandated data collection associated with a formal one group of students and educators, which limits the generali- research project. sability of the findings. However, students and educators experi- enced at least two different placements within the year across five Peer support in both the PAL and traditional models reduced different sites, each with unique workplace cultures, and no site- dependence on the educator. PAL may help position students as specific differences emerged in the data. Educator participants active learners who are less reliant on the ‘expert’ educator for were volunteers and, therefore, a self-selecting group. Issues may feedback and direction. Nevertheless, students emphasised the have been missed that related specifically to educators who did not pivotal role that experienced educators play in modelling clinical volunteer. For example, educators who have a particularly negative performance. This direct observation of ‘experts’ provided a view of paired student placements and/or PAL may have chosen benchmark against which students could evaluate their own not to volunteer for the study. performance and the performance of others. Once the benchmark had been established, the efficacy of peer observation and feedback Conclusion was enhanced. Utilising PAL to develop important skills such as observation and feedback may have a positive effect on students’ Students reported that the learning environment created by willingness and ability to teach/supervise when they enter the PAL enabled honest discussion without fear of negative educator workplace. assessment. Educators reported that PAL reduced educator burden and that the prescribed PAL model maximised use of The educators reported that maximising use of ‘downtime’ was downtime and helped students to build professional skills. Both a significant benefit of the PAL model. Creating opportunities for students and educators considered that PAL supports clinical self-directed learning has been identified as important in effective learning, but cannot replace educator modelling, feedback and engagement of students in clinical education.21 Gordon and guidance. Cohesion of the student-student relationship was seen colleagues22 urged educators to ‘turn downtime into clinical as an enabler of successful PAL. Both students and educators learning time’ and ‘make maximal use of whatever the environ- described how PAL enabled active learning and reduced ment can offer’. Empowering educators to design targeted PAL dependence on the educator. Students reported that the activities to replace unstructured ‘independent learning’ has the prescribed PAL model ‘forced them’ to actively observe practice potential to improve the efficacy and efficiency of clinical and learn to communicate evaluative judgments to peers. The learning. role of the educator is not redundant in PAL, but central in designing flexible and meaningful professional practice experi- Students and educators in this study described clinical ences. In alignment with the results of our randomised trial,16 education elements that cannot be ‘replaced’ by PAL. One of the both parties reported resistance to the mandated activities and perceived dangers of PAL is that the educator will be made frequencies in the PAL model. Therefore, a flexible implementa- redundant and the ‘blind will be leading the blind’.23,24 The data tion of activities, to be negotiated by student and educator, is from the present study do not support that educators are sidelined recommended.
92 Sevenhuysen et al: Peer-assisted learning in clinical education What is already known on this topic: Peer-assisted learning 6. Sevenhuysen S, Haines TP. The slave of duty: why clinical educators across the in physiotherapy clinical education involves students under- continuum of care provide clinical education in physiotherapy. Hong Kong Physi- taking some paired tasks (eg, observing each other’s patient other J. 2011;29:64–70. management and giving feedback). This has the potential to maximise the learning opportunities without the direct in- 7. Alzayyat A, Al-Gamal E. A review of the literature regarding stress among nursing volvement of the clinical educator. In a recent trial, a traditional students during their clinical education. Int Nurs Rev. 2014;61:406–415. model of clinical education was preferred over a model that included mandatory peer-assisted learning tasks. 8. Topping K, Ehly S. Peer-assisted learning. London: Lawrence Erlbaum Associates; What this study adds: Students and educators each reported 1998. positive aspects of peer-assisted learning (such as reduced educator burden, greater productivity, and fostering of profes- 9. Briffa C, Porter J. A systematic review of the collaborative clinical education model sional skills), although there were aspects of educator-facilitated to inform speech-language pathology practice. Int J Speech Lang Pathol. learning that it could not replace. Flexible use of peer-assisted 2013;15:564–574. learning tasks may allow their advantages to be attained. 10. Secombe J. A systematic review of peer teaching and learning in clinical education. Ethics approval: The Monash Health and Monash University J Clin Nurs. 2008;17:703–716. Human Research Ethics Committees approved this study. All participants gave written, informed consent before data collection 11. Baldry-Currens JA, Bithell CP. The 2:1 clinical placement model: perceptions of began. clinical educators and students. Physiother. 2003;89:204–218. Competing interests: Nil. 12. Martin M, Morris J, Moore A, Sadlo G, Crouch V. Evaluating Practice Education Source(s) of support: Monash Health Allied Health Research Models in Occupational Therapy: Comparing 1:1, 2:1 and 3:1 Placements. Br J Unit. Occup Ther. 2004;67:192–200. Acknowledgements: Monash Health physiotherapy clinical educators and students. 13. Lekkas P, Larson T, Kumar S, Grimmer K, Nyland L, Chipchase L, et al. No model of Correspondence: Samantha Sevenhuysen, Allied Health, clinical education for physiotherapy students is superior to another: a systematic Monash Health, Melbourne, Australia. Email: sam.sevenhuysen@ review. Aust J Physiother. 2007;53:19–28. monashhealth.org 14. Dawes J, Lambert P. Practice Educators’ Experiences of Supervising Two Students References on Allied Health Practice-based Placements. J Allied Health. 2010;39:20–27. 1. Universities Australia. An agenda for Australian higher education 2013-2016. 15. Bartholomai S, Fitzgerald C. The Collaborative Model of Fieldwork Education: 2012. http://www.voced.edu.au/content/ngv55503. Accessed October 28, 2014. Implementation of the model in a regional hospital rehabilitation setting. Aust Occup Ther J. 2007;54:S23–S30. 2. World Health Organization. Working Together for Health, The World Health Report; 2006. http://www.who.int/whr/2006/whr06_en.pdf. Accessed September 16. Sevenhuysen S, Skinner EH, Farlie MK, Raitman L, Nickson W, Keating JL, et al. 19, 2014. Educators and students prefer traditional clinical education to a peer-assisted learning model, despite similar student performance outcomes: a randomised 3. Rodger S, Webb G, Devitt L, Gilbert J, Wrightson P, McMeeken J. Clinical education trial. J Physiother. 2014;60:209–216. and practice placements in the allied health professions: An international per- spective. J Allied Health. 2008;37:53–62. 17. Sevenhuysen S, Skinner EH, Farlie MK, Raitman L, Nickson W, Keating JL, et al. The development of a peer-assisted learning model for the clinical education of 4. Strohschein J, Hagler P, May L. Assessing the need for change in clinical education physiotherapy students. J Peer Learn. 2013;6:30–45. practices. Phys Ther. 2002;82:160–172. 18. Kneebone RL, Nestel D, Vincent C, Darzi A. Complexity, risk and simulation in 5. Bearman M, Molloy E, Ajjawi R, Keating J. ‘Is there a Plan B?’: clinical educators learning procedural skills. Med Educ. 2007;41:808–814. supporting underperforming students in practice settings Teach High Educ. 2012; 18:531–544. 19. Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: A learner-centered model for outpa- tient education. Acad Med. 2003;78:893–898. 20. Miles M, Huberman AM, Saldan˜ a J. Qualitative data analysis: A methods sourcebook. 3rd ed. Los Angeles: Sage; 2014. 21. Richards J, Sweet L. 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Journal of Physiotherapy 61 (2015) 77–80 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research Primary-contact physiotherapists manage a minor trauma caseload in the emergency department without misdiagnoses or adverse events: an observational study Matthew Sutton a, Adam Govier b, Sebastian Prince c, Mark Morphett c a School of Health Sciences, Flinders University; b Central Adelaide Local Health Network; c Flinders Medical Centre, Adelaide, Australia KEY WORDS ABSTRACT Physical therapy Questions: What proportion of people who are managed by a primary-contact physiotherapy service in Diagnostic imaging an emergency department experience adverse events? For people presenting to the emergency Extended scope department with minor trauma, does the length of stay differ between those managed by the Emergency department physiotherapy service and those managed by medical staff? For people presenting to the emergency Musculoskeletal department with minor trauma, is diagnostic imaging ordered as often by the physiotherapy service as it is by medical staff? Design: Prospective, observational, cohort study. Participants: A consecutive sample of 1320 people presenting to an emergency department and managed by the physiotherapy service was analysed. Where possible, these patients were matched by diagnostic codes – typically for minor trauma including closed fractures of the periphery – to patients who were managed by medical staff in order to generate two matched cohorts for comparison. Outcome measures: The outcome measures were adverse events among the patients managed by the physiotherapy service, the average length of stay of each cohort in the emergency department, and the proportion of patients in each cohort who underwent diagnostic imaging studies, including plain radiographs, computerised tomographic scans, and ultrasound imaging studies. Results: No misdiagnoses or adverse events were identified for any patient managed by the physiotherapy service. The patients managed by the physiotherapy service had a significantly reduced length of stay (mean difference 83 minutes, 95% CI 75 to 91) and significantly fewer requests for each type of imaging than the matched patients managed by medical staff. Conclusion: Primary-contact physiotherapists can manage a minor trauma caseload in the emergency department without adverse events. A physiotherapy service in the emergency department may result in a reduced length of stay and fewer requests for imaging. However, potential confounding of the results for length of stay and imaging must be recognised because matching diagnostic codes may not ensure completely equivalent cohorts. [Sutton M, Govier A, Prince S, Morphett M (2015) Primary-contact physiothera- pists manage a minor trauma caseload in the emergency department without misdiagnoses or adverse events: an observational study. Journal of Physiotherapy 61: 77–80] Crown Copyright ß 2015 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). Introduction Imaging investigations are valuable and, at times, necessary tools to assist healthcare professionals in the diagnosis of many Physiotherapists are highly skilled clinicians with the ability to musculoskeletal and trauma-related conditions. However, imaging diagnose and treat a wide range of physical disorders, including modalities such as plain radiography and computerised tomogra- musculoskeletal conditions and minor trauma. The expertise of phy (CT) do expose patients to substantial amounts of ionising physiotherapists in assessing and managing these conditions and radiation, so the rate and appropriateness of referral for these the functional deficits associated with them may improve patient examinations are important safety issues. Any reduction in outcomes in the emergency department.1 Also, in the context of an imaging rates would provide potential safety benefits for increasing drive to improve patient flow through emergency emergency department patients, as well as reducing associated departments in Australia, it has been proposed that primary- healthcare costs. Reduced imaging rates may also improve contact physiotherapists with extended roles may reduce length of productivity in the emergency department due to the large stay in the emergency department setting.1–3 However, limited number of processes and staff requirements for imaging studies. evidence exists to support these claims. While there is strong Analyses have shown that imaging is an independent predictor of consumer satisfaction associated with these roles, no evidence increased length of stay in the emergency department.5,6 Thus, any currently supports the role of primary-contact physiotherapists in reduction in the rates of imaging will potentially improve emergency departments at either a systemic or provider level.4 productivity, healthcare costs and patient safety. http://dx.doi.org/10.1016/j.jphys.2015.02.012 1836-9553/Crown Copyright ß 2015 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
78 Sutton et al: Emergency department physiotherapists for minor trauma The main aim of this study was to evaluate the safety of a Conditions managed by the service included closed limb primary-contact physiotherapy service through the identification fractures, non-traumatic spinal pain, and soft tissue conditions of any adverse events and misdiagnoses in the emergency such as strains and sprains. Patients that were eligible to be seen department of a major metropolitan tertiary hospital in Australia. by the physiotherapy service were identified by the physiothera- Secondary aims were to compare the length of stay and use of pists themselves, based on the information provided by the diagnostic imaging between two matched cohorts of patients with patient at time of triage nursing assessment. minor trauma: those managed by the physiotherapy service and those managed by the usual emergency department medical Outcome measures officers. Therefore, the research questions for this study were: The primary outcome was the number of adverse events among 1. What proportion of people who are managed by a primary- all of the patients managed by the physiotherapy service. Adverse contact physiotherapy service in an emergency department events were identified by a review of re-presentations to the experience adverse events? emergency department within 28 days, a review of consumer complaints, and incidents reported on the local safety reporting 2. For people presenting to the emergency department with minor systems over the study period. Re-presentations within 7 days are trauma, does the length of stay differ between those managed by routinely reviewed by an emergency medicine consultant; this the physiotherapy service and those managed by medical staff? was performed by reviewing both the electronic capturing systems and the case notes, if necessary. Re-presentations between 7 and 3. For people presenting to the emergency department with minor 28 days were reviewed by the lead author. trauma, is diagnostic imaging ordered as often by the physiotherapy service as it is by medical staff? One secondary outcome was the length of stay in the emergency department in each matched cohort, which was Method defined as the duration of time from initial presentation at triage to discharge from the emergency department. The other second- Design ary outcomes were the proportion of patients in each matched cohort who were referred for radiographic, CT and ultrasound This study was undertaken as part of an evaluation of a imaging in each cohort. primary-contact physiotherapy service commencing in October 2012, and part of a national program to evaluate the impact of Data analysis extended scope of practice roles for non-medical practitioners. All people presenting to the emergency department over a 12-month The number of patients managed by the physiotherapy service period were considered for inclusion in the study. All patients who experienced an adverse event was estimated as a population managed by the primary-contact physiotherapy service were proportion, reported with a 95% CI. Length of stay was reported as a analysed in order to identify the number of adverse events and mean (SD) for each of the two matched cohorts and the difference misdiagnoses that occurred, using data collected by electronic between the cohorts was analysed using an independent-samples capturing systems used as part of routine care. t-test. The number of patients referred for each type of imaging was reported as a percentage for each matched cohort and the All people presenting to the emergency department are difference between the cohorts was analysed as the absolute assigned a diagnostic code as part of routine care by the treating difference in these percentages, again reported with a 95% CI. The physiotherapist, medical officer or nurse. This code is based on the ‘number needed to treat’ statistic was also calculated to indicate International Classification of Disease (ICD) coding system the number of patients that would need to be managed by the developed by the World Health Organization, which contains physiotherapy service instead of the medical staff to prevent one over 13 000 separate diagnostic codes. Prior to study commence- request for imaging, and reported with a 95% CI. Data are presented ment, a list of all codes that were appropriate for the physiotherapy with 95% CIs to indicate the precision of the estimate and, for service, such as soft tissue injuries and simple closed peripheral between-cohort comparisons, whether the difference is statisti- fractures, was developed by the lead author and validated by a cally significant. specialist in Emergency Medicine (MM). The final list included 444 diagnostic codes (Appendix 1). Any patient assigned one of Results these codes had additional data (length of stay, requests for medical imaging) collected by electronic capturing systems used as Flow of patients and therapists through the study part of routine care for possible analysis in the study. These patients were then split into those managed by the physiotherapy A total of 71 880 patients presented to the emergency service and those managed by usual medical staff. For each patient department during the study period. Of these, 1320 were managed managed by the physiotherapy service, a patient with the same ICD by the physiotherapy service and were analysed for adverse events. code was sought amongst the medically-managed patients. Where Of the 71 880 patients, 9037 (12.6%) were diagnosed with ICD9 more than one patient with the same code was available among the codes that had been nominated as appropriate for the physiother- medically-managed patients, the match was selected randomly. apy service. Of these 9037 patients, 1249 (14%) were managed by These two matched cohorts were then compared for length of stay the physiotherapy service and 7788 (86%) were managed by the and for the proportions of patients for whom radiograph, CT and medical team. The diagnostic codes of the other 71 patients who ultrasound diagnostic imaging were requested. were managed by the physiotherapy service were ineligible because they were too broad to warrant inclusion in the final Patients, therapists, centre list of codes, such as ‘injury unspecified’ and ‘unspecified follow up’. These 71 patients were therefore excluded from the cohort The study was conducted within an emergency department at matching process (Figure 1). a tertiary metropolitan hospital in Australia. The physiotherapy service consisted of three physiotherapists, all with postgraduate What proportion of patients managed by the physiotherapy masters qualifications in musculoskeletal and/or sports physio- service experienced adverse events? therapy. All physiotherapists had at least 10 years of experience in the field of musculoskeletal physiotherapy. The physiotherapy Analysis of re-presentation data, consumer complaints and service was provided 7 days a week during daytime working safety reporting systems showed no adverse events associated hours and it managed both adult and paediatric presentations.
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