Appraisal Index 2013 Appraisal Index To assist clinicians looking for authoritative assistance with clinical problems, the journal publishes an annual index of content from the most recent two years of Appraisal pages. This index includes content from Volumes 58 and 59 of Journal of Physiotherapy. Content is indexed under the PEDro codes: subdiscipline, intervention, problem, and body part. It is identified by Appraisal section and Volume and page number. Some content is indexed under more than one code. SUBDISCIPLINE Active Straight Leg Raise Vol 58 No 2, p 132 Ergonomics & Occupational Health Cardiothoracics Clinimetrics CAPs The Work Limitations Questionnaire Vol 58 No 4, p 277 (WLQ-25) Action plans and case manager support Vol 58 No 1, p 60 may hasten recovery of symptoms following an acute exacerbation in Clinical Practice Guidelines patients with chronic obstructive pulmonary disease (COPD) The Work Instability Scale Vol 59 No 3, p 212 Combined resistance and aerobic Vol 58 No 2, p 129 Gerontology training is more effective than aerobic training alone in people with coronary CAPs artery disease Group task-specific circuit training for Vol 58 No4, p 269 Exercise training improves Vol 58 No 2, p 130 patients discharged home after stroke cardiovascular fitness in people may be as effective as individualised receiving haemodialysis for chronic physiotherapy in improving mobility renal disease Tai Chi training is effective in reducing Vol 59 No 1, p 55 balance impairments and falls in Interval training confers greater gains Vol 58 No 3, p 199 patients with Parkinson’s disease than continuous training in people with heart failure Body-weight supported treadmill training Vol 59 No 4, p 275 improves cardiovascular fitness and Neuromuscular electrical stimulation Vol 58 No 4, p 270 walking endurance early after stroke appears to be useful in people with severe chronic obstructive pulmonary Clinical Practice Guidelines disease Palliation in aged care Vol 58 No 1, p 63 Aerobic treadmill training effectively Vol 58 No 4, p 271 Daily use of a cane for two months Vol 58 No 2, p 128 enhances cardiovascular fitness and reduced pain and improved function gait function for older persons with in patients with knee osteoarthritis chronic stroke Long-term aerobic exercise maintains Vol 59 No 1, p 56 Osteoarthritis Vol 58 No 2, p 133 peak VO, improves quality of life, and reduces hospitalisations and mortality Hip fracture Vol 58 No 4, p 275 in patients with heart failure Osteoporosis Vol 58 No 4, p 275 Exercise training following lung Vol 59 No 1, p 58 Falls in older people Vol 59 No 3, p 213 transplant is now evidence-based practice Physical activity for older people Vol 59 No 3, p 213 Telehealth reduces hospital admission Vol 59 No 2, p 129 Musculoskeletal rates in patients with COPD CAPs Sun-style T’ai Chi improves walking Vol 59 No 4, p 274 Targeted physiotherapy treatment for Vol 58 No 1, p 57 endurance and health-related quality low back pain based on clinical risk can improve clinical and economic of life in people with COPD outcomes when compared with current best practice Clinical Practice Guidelines Paediatric neuromuscular weakness Vol 59 No 2, p 133 Cardiovascular disease risk Vol 59 No 2, p 133 A specific exercise program for patients Vol 58 No2, p 127 with subacromial impingement Chronic obstructive lung disease Vol 59 No 4, p zzz syndrome can improve function and reduce the need for surgery Continence & Women’s Health Daily use of a cane for two months Vol 58 No 2, p 128 CAPs reduced pain and improved function in A 12-week exercise program performed Vol 58 No 3, p 198 patients with knee osteoarthritis during the second trimester does not prevent gestational diabetes in healthy Abdominal muscle feedforward Vol 58 No 3, p 200 pregnant women activation in patients with chronic low back pain is largely unaffected by 8 Clinimetrics weeks of core stability training 282 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013
Appraisal Index Multi-modal realignment treatment Vol 58 No 4, p 272 Repetitive facilitative exercise improves Vol 59 No 3, p 208 upper limb function in patients with decreased pain in people with medial subacute stroke tibiofemoral osteoarthritis Exercise programs for patients with Vol 59 No 1, p 57 Body-weight supported treadmill training Vol 59 No 4, p 275 cancer improve physical functioning improves cardiovascular fitness and and quality of life walking endurance early after stroke Acute low back pain usually resolves Vol 59 No 2, p 127 Clinimetrics quickly but persistent low back pain often persists The Dix-Hallpike Test Vol 58 No 2, p 131 A physiotherapy telephone assessment Vol 59 No 2, p 130 Clinical Practice Guidelines and advice service for patients with musculoskeletal problems can Cervical radiculopathy Vol 58 No 3, p 203 improve the process of care while maintaining clinical effectiveness Amyotrophic lateral sclerosis (ALS) Vol 59 No 1, p 61 Paediatric neuromuscular weakness Vol 59 No 2, p 133 Reconstruction surgery is not always Vol 58 No 3, p 209 necessary for active young people who rupture their anterior cruciate Orthopaedics ligament CAPs No difference in functional outcomes Vol 59 No 3, p 210 A specific exercise program for patients Vol 58 No2, p 127 between surgery and physiotherapy with subacromial impingement for symptomatic patients with a syndrome can improve function meniscal tear and knee osteoarthritis and reduce the need for surgery Clinimetrics Daily use of a cane for two months Vol 58 No 2, p 128 reduced pain and improved function Western Ontario Rotator Cuff Index Vol 58 No 3, p 201 in patients with knee osteoarthritis The patient-rated elbow evaluation Vol 58 No 4, p 274 Multi-modal realignment treatment Vol 58 No 4, p 272 (PREE) decreased pain in people with medial Pain Free Grip Strength Test Vol 59 No 1, p 59 tibiofemoral osteoarthritis STarT Back Screening Tool Vol 59 No 2, p 131 Acute low back pain usually resolves Vol 59 No 2, p 127 quickly but persistent low back pain The Ten Test for Sensation Vol 59 No 2, p 132 often persists painDETECT Questionnaire Vol 59 No 3, p 211 Repetitive facilitative exercise improves Vol 59 No 3, p 208 upper limb function in patients with The Work Instability Scale Vol 59 No 3, p 212 subacute stroke Clinical Practice Guidelines Reconstruction surgery is not always Vol 58 No 3, p 209 necessary for active young people Osteoarthritis Vol 58 No 2, p 133 who rupture their anterior cruciate ligament Hand, hip, and knee osteoarthritis Vol 58 No 3, p 203 Cervical radiculopathy Vol 58 No 3, p 203 Clinimetrics Hip fracture Vol 58 No 4, p 275 The patient-rated elbow evaluation Vol 58 No 4, p 274 (PREE) Osteoporosis Vol 58 No 4, p 275 Frozen shoulder Vol 59 No 1, p 61 Pain Free Grip Strength Test Vol 59 No 1, p 59 /FVSPMPHZ The Ten Test for Sensation Vol 59 No 2, p 132 CAPs Clinical Practice Guidelines Bimanual therapy and constraint- Vol 58 No 1, p 59 Osteoarthritis Vol 58 No 2, p 133 induced movement therapy are equally effective in improving hand Hand, hip, and knee osteoarthritis Vol 58 No 3, p 203 function in children with congenital hemiplegia Hip fracture Vol 58 No 4, p 275 Osteoporosis Vol 58 No 4, p 275 Group task-specific circuit training for Vol 58 No 4, p 269 Frozen shoulder Vol 59 No 1, p 61 patients discharged home after stroke may be as effective as individualised Paediatrics physiotherapy in improving mobility CAPs Tai Chi training is effective in reducing Vol 59 No 1, p 55 balance impairments and falls in patients with Parkinson’s disease Bimanual therapy and constraint- Vol 58 No 1, p 59 induced movement therapy are Repetitive transcranial magnetic Vol 59 No 2, p 128 equally effective in improving hand stimulations combined with function in children with congenital treadmill training can modulate hemiplegia corticomotor inhibition and improve walking performance in people with Functional progressive resistance Vol 58 No 3, p 197 Parkinson’s disease training improves muscle strength but not walking ability in children with cerebral palsy Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013 283
Appraisal Index Reconstruction surgery is not always Vol 58 No 3, p 209 Combined resistance and aerobic Vol 58 No 2, p 129 necessary for active young people Vol 59 No 4, p 273 training is more effective than aerobic who rupture their anterior cruciate training alone in people with coronary ligament artery disease Wearing pedometers in conjunction Functional progressive resistance Vol 58 No 3, p 197 with daily step goals and incentives training improves muscle strength can increase physical activity among but not walking ability in children with children cerebral palsy Clinical Practice Guidelines Vol 58 No 2, p 133 A 12-week exercise program performed Vol 58 No 3, p 198 Vol 59 No 2, p 133 during the second trimester does not Developmental co-ordination disorder prevent gestational diabetes in healthy Paediatric neuromuscular weakness pregnant women Sports Interval training confers greater gains Vol 58 No 3, p 199 than continuous training in people CAPs with heart failure Eccentric hamstring muscle training can Vol 58 No 1, p 58 Abdominal muscle feedforward Vol 58 No 3, p 200 prevent hamstring injuries in soccer activation in patients with chronic low players back pain is largely unaffected by 8 weeks of core stability training Reconstruction surgery is not always Vol 58 No 3, p 209 Group task-specific circuit training for Vol 58 No4, p 269 necessary for active young people patients discharged home after stroke who rupture their anterior cruciate may be as effective as individualised ligament physiotherapy in improving mobility Clinimetrics Aerobic treadmill training effectively Vol 58 No 4, p 271 enhances cardiovascular fitness and Pain Free Grip Strength Test Vol 59 No 1, p 59 gait function for older persons with chronic stroke Other CAPs Multi-modal realignment treatment Vol 58 No 4, p 272 decreased pain in people with medial Positive expiratory pressure prevents Vol 59 No 4, p 276 tibiofemoral osteoarthritis more exacerbations than high frequency chest wall oscillation via Long-term aerobic exercise maintains Vol 59 No 1, p 56 a vest in people with cystic fibrosis peak VO, improves quality of life, and reduces hospitalisations and mortality Clinimetrics in patients with heart failure Pain Intensity Ratings Vol 58 No 1, p 61 Exercise training following lung Vol 59 No 1, p 58 transplant is now evidence-based The Dix-Hallpike Test Vol 58 No 2, p 131 practice Brief Illness Perception Questionnaire Vol 58 No 3, p 202 Reconstruction surgery is not always Vol 58 No 3, p 209 (Brief IPQ) necessary for active young people who rupture their anterior cruciate SPHERE 12 Screening Questionnaire Vol 58 No 4, p 273 ligament Ice-water (cold stress) immersion testing Vol 59 No 4, p 278 Sun-style T’ai Chi improves walking Vol 59 No 4, p 274 endurance and health-related quality INTERVENTION of life in people with COPD Behaviour Modification Body-weight supported treadmill training Vol 59 No 4, p 275 improves cardiovascular fitness and walking endurance early after stroke CAPs Clinical Practice Guidelines A telephone-delivered behavioural Vol 59 No 2, p 133 Physical activity for older people Vol 59 No 3, p 213 intervention confers a small reduction in body weight in people with Type 2 3FTQJSBUPSZ5IFSBQZ diabetes Education CAPs CAPs Action plans and case manager support Vol 58 No 1, p 60 may hasten recovery of symptoms Wearing pedometers in conjunction Vol 59 No 4, p zz following an acute exacerbation in with daily step goals and incentives patients with chronic obstructive can increase physical activity among pulmonary disease (COPD) children Neuromuscular electrical stimulation Vol 58 No 4, p 270 'JUOFTT5SBJOJOH appears to be useful in people with severe chronic obstructive pulmonary CAPs disease Exercise training following lung Vol 59 No 1, p 58 transplant is now evidence-based practice 284 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013
Appraisal Index Telehealth reduces hospital admission Vol 59 No 2, p 129 Clinical Practice Guidelines Vol 59 No 4, p 279 rates in patients with COPD Vol 59 No 4, p 274 Vol 59 No 4, p 276 Chronic obstructive lung disease Sun-style T’ai Chi improves walking endurance and health-related quality Vol 59 No 4, p 279 Impaired Ventilation of life in people with COPD CAPs Positive expiratory pressure prevents more exacerbations than high Action plans and case manager support Vol 58 No 1, p 60 frequency chest wall oscillation via a may hasten recovery of symptoms vest in people with cystic fibrosis following an acute exacerbation in patients with chronic obstructive Clinical Practice Guidelines pulmonary disease (COPD) Chronic obstructive lung disease Neuromuscular electrical stimulation Vol 58 No 4, p 270 appears to be useful in people with 4USFOHUI5SBJOJOH severe chronic obstructive pulmonary disease CAPs Eccentric hamstring muscle training can Vol 58 No 1, p 58 Telehealth reduces hospital admission Vol 59 No 2, p 129 prevent hamstring injuries in soccer rates in patients with COPD players Sun-style T’ai Chi improves walking Vol 59 No 4, p 274 Combined resistance and aerobic Vol 58 No 2, p 129 endurance and health-related quality training is more effective than aerobic training alone in people with coronary of life in people with COPD artery disease Positive expiratory pressure prevents Vol 59 No 4, p 276 more exacerbations than high Functional progressive resistance Vol 58 No 3, p 197 frequency chest wall oscillation via a training improves muscle strength vest in people with cystic fibrosis but not walking ability in children with cerebral palsy Clinical Practice Guidelines Abdominal muscle feedforward Vol 58 No 3, p 200 Chronic obstructive lung disease Vol 59 No 4, p 279 activation in patients with chronic low back pain is largely unaffected by 8 Muscle Weakness weeks of core stability training CAPs Repetitive facilitative exercise improves Vol 59 No 3, p 208 Bimanual therapy and constraint- Vol 58 No 1, p 59 upper limb function in patients with induced movement therapy are subacute stroke equally effective in improving hand function in children with congenital Body-weight supported treadmill training Vol 59 No 4, p 275 hemiplegia improves cardiovascular fitness and walking endurance early after stroke Functional progressive resistance Vol 58 No 3, p 197 training improves muscle strength Clinical Practice Guidelines but not walking ability in children with cerebral palsy Falls in older people Vol 59 No 3, p 213 Stretching, Mobilisation, Abdominal muscle feedforward Vol 58 No 3, p 200 Manipulation, Massage activation in patients with chronic low back pain is largely unaffected by 8 CAPs weeks of core stability training Group task-specific circuit training for Vol 58 No 4, p 269 Group task-specific circuit training for Vol 58 No4, p 269 patients discharged home after stroke patients discharged home after stroke may be as effective as individualised may be as effective as individualised physiotherapy in improving mobility physiotherapy in improving mobility Aerobic treadmill training effectively Vol 58 No 4, p 271 enhances cardiovascular fitness and Aerobic treadmill training effectively Vol 58 No 4, p 271 gait function for older persons with enhances cardiovascular fitness and chronic stroke gait function for older persons with chronic stroke Multi-modal realignment treatment Vol 58 No 4, p 272 Multi-modal realignment treatment Vol 58 No 4, p 272 decreased pain in people with medial decreased pain in people with medial tibiofemoral osteoarthritis tibiofemoral osteoarthritis Tai Chi training is effective in reducing Vol 59 No 1, p 55 balance impairments and falls in PROBLEM patients with Parkinson’s disease Exercise programs for patients with Vol 59 No 1, p 57 cancer improve physical functioning Difficulty with Sputum Clearance and quality of life CAPs Positive expiratory pressure prevents Vol 59 No 4, p 276 more exacerbations than high frequency chest wall oscillation via a vest in people with cystic fibrosis Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013 285
Appraisal Index Repetitive transcranial magnetic Vol 59 No 2, p 128 Aerobic treadmill training effectively Vol 58 No 4, p 271 stimulations combined with enhances cardiovascular fitness and treadmill training can modulate gait function for older persons with corticomotor inhibition and improve chronic stroke walking performance in people with Parkinson’s disease Long-term aerobic exercise maintains Vol 59 No 1, p 56 Repetitive facilitative exercise improves Vol 59 No 3, p 208 peak VO, improves quality of life, and upper limb function in patients with reduces hospitalisations and mortality subacute stroke in patients with heart failure Exercise programs for patients with Vol 59 No 1, p 57 cancer improve physical functioning Body-weight supported treadmill training Vol 59 No 4, p 275 and quality of life improves cardiovascular fitness and walking endurance early after stroke Exercise training following lung Vol 59 No 1, p 58 transplant is now evidence-based Clinimetrics practice Western Ontario Rotator Cuff Index Vol 58 No 3, p 201 Wearing pedometers in conjunction Vol 59 No 4, p 273 with daily step goals and incentives Pain Free Grip Strength Test Vol 59 No 1, p59 can increase physical activity among children Clinical Practice Guidelines Frozen shoulder Vol 59 No 1, p 61 Sun-style T’ai Chi improves walking Vol 59 No 4, p 274 Amyotrophic lateral sclerosis (ALS) Vol 59 No 1, p 61 endurance and health-related quality Paediatric neuromuscular weakness Vol 59 No 2, p 133 of life in people with COPD Pain Clinimetrics Rating of Perceived Exertion (RPE) Vol 58 No 1, p 62 CAPs Clinical Practice Guidelines Multi-modal realignment treatment Vol 58 No 4, p 272 Physical activity for older people Vol 59 No 3, p 213 decreased pain in people with medial tibiofemoral osteoarthritis Other Acute low back pain usually resolves Vol 59 No 2, p 127 CAPs quickly but persistent low back pain often persists Targeted physiotherapy treatment for Vol 58 No 1, p 57 low back pain based on clinical risk Clinimetrics can improve clinical and economic outcomes when compared with Pain Intensity Ratings Vol 58 No 1, p 61 current best practice Active Straight Leg Raise Vol 58 No 2, p 132 Western Ontario Rotator Cuff Index Vol 58 No 3, p 201 Daily use of a cane for two months Vol 58 No 2, p 128 The patient-rated elbow evaluation Vol 58 No 4, p 274 reduced pain and improved function in (PREE) patients with knee osteoarthritis Pain Free Grip Strength Test Vol 59 No 1, p 59 Combined resistance and aerobic Vol 58 No 2, p 129 training is more effective than aerobic Chronic Pain Grade Questionnaire Vol 59 No 1, p 60 training alone in people with coronary artery disease STarT Back Screening Tool Vol 59 No 2, p 131 Exercise training improves Vol 58 No 2, p 130 painDETECT Questionnaire Vol 59 No 3, p 211 cardiovascular fitness in people receiving haemodialysis for chronic The Work Instability Scale Vol 59 No 3, p 212 renal disease Clinical Practice Guidelines Exercise programs for patients with Vol 59 No 1, p 57 cancer improve physical functioning Osteoarthritis Vol 58 No 2, p 133 and quality of life Hand, hip, and knee osteoarthritis Vol 58 No 3, p 203 Cervical radiculopathy Vol 58 No 3, p 203 Repetitive transcranial magnetic Vol 59 No 2, p 128 stimulations combined with Frozen shoulder Vol 59 No 1, p 61 treadmill training can modulate corticomotor inhibition and improve 3FEVDFE&YFSDJTF5PMFSBODF walking performance in people with Parkinson’s disease CAPs A physiotherapy telephone assessment Vol 59 No 2, p 130 and advice service for patients Interval training confers greater gains Vol 58 No 3, p 199 with musculoskeletal problems can than continuous training in people improve the process of care while with heart failure maintaining clinical effectiveness Group task-specific circuit training for Vol 58 No4, p 269 A telephone-delivered behavioural Vol 59 No 2, p 133 patients discharged home after stroke intervention confers a small reduction may be as effective as individualised in body weight in people with Type 2 physiotherapy in improving mobility diabetes 286 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013
Appraisal Index Repetitive facilitative exercise improves Vol 59 No 3, p 208 Western Ontario Rotator Cuff Index Vol 58 No 3, p 201 upper limb function in patients with subacute stroke The patient-rated elbow evaluation Vol 58 No 4, p 274 (PREE) Reconstruction surgery is not always Vol 58 No 3, p 209 Clinical Practice Guidelines necessary for active young people who rupture their anterior cruciate A specific exercise program for patients Vol 58 No2, p 127 ligament with subacromial impingement syndrome can improve function and No difference in functional outcomes Vol 59 No 3, p 210 reduce the need for surgery between surgery and physiotherapy for symptomatic patients with a Frozen shoulder Vol 59 No 1, p 61 meniscal tear and knee osteoarthritis Wearing pedometers in conjunction Vol 59 No 4, p 273 Hand or Wrist with daily step goals and incentives can increase physical activity among CAPs Vol 58 No 1, p 59 children Vol 58 No 3, p 203 Bimanual therapy and constraint- Body-weight supported treadmill training Vol 59 No 4, p 275 induced movement therapy are improves cardiovascular fitness and equally effective in improving hand walking endurance early after stroke function in children with congenital hemiplegia Clinimetrics Clinical Practice Guidelines Rating of Perceived Exertion (RPE) Vol 58 No 1, p 62 Hand, hip, and knee osteoarthritis The Dix-Hallpike Test Vol 58 No 2, p 131 Brief Illness Perception Questionnaire Vol 58 No 3, p 202 Chest (Brief IPQ) CAPs SPHERE 12 Screening Questionnaire Vol 58 No 4, p 273 Action plans and case manager support Vol 58 No 1, p 60 Pain Free Grip Strength Test Vol 59 No 1, p 59 may hasten recovery of symptoms following an acute exacerbation in Chronic Pain Grade Questionnaire Vol 59 No 1, p 60 patients with chronic obstructive pulmonary disease (COPD) The Ten Test for Sensation Vol 59 No 2, p 132 The Work Limitations Questionnaire Vol 58 No 4, p 277 Combined resistance and aerobic Vol 58 No 2, p 129 (WLQ-25) training is more effective than aerobic Ice-water (cold stress) immersion testing Vol 59 No 4, p 278 training alone in people with coronary artery disease Clinical Practice Guidelines Neuromuscular electrical stimulation Vol 58 No 4, p 270 appears to be useful in people with Palliation in aged care Vol 58 No 1, p 63 severe chronic obstructive pulmonary disease Osteoporosis Vol 58 No 4, p 275 Cardiovascular disease risk Vol 59 No 2, p 133 Long-term aerobic exercise maintains Vol 59 No 1, p 56 Falls in older people Vol 59 No 3, p 213 peak VO, improves quality of life, and reduces hospitalisations and mortality Physical activity for older people Vol 59 No 3, p 213 in patients with heart failure BODY PART Telehealth reduces hospital admission Vol 59 No 2, p 129 rates in patients with COPD Sun-style T’ai Chi improves walking Vol 59 No 4, p 274 )FBE/FDL endurance and health-related quality CAPs of life in people with COPD Repetitive transcranial magnetic Vol 59 No 2, p 128 Clinical Practice Guidelines stimulations combined with Vol 58 No 2, p 131 treadmill training can modulate Paediatric neuromuscular weakness Vol 59 No 2, p 133 corticomotor inhibition and improve walking performance in people with Chronic obstructive lung disease Vol 59 No 4, p 279 Parkinson’s disease 5IPSBDJD4QJOF Vol 58 No 3, p 203 Clinimetrics Clinical Practice Guidelines The Dix-Hallpike Test Cervical radiculopathy Upper Arm, Shoulder or Shoulder Girdle Lumbar Spine, SIJ or Pelvis CAPs CAPs Repetitive facilitative exercise improves Vol 59 No 3, p 208 Targeted physiotherapy treatment for Vol 58 No 1, p 57 upper limb function in patients with low back pain based on clinical risk subacute stroke can improve clinical and economic outcomes when compared with Clinimetrics current best practice Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013 287
Appraisal Index Abdominal muscle feedforward Vol 58 No 3, p 200 Interval training confers greater gains Vol 58 No 3, p 199 activation in patients with chronic low than continuous training in people back pain is largely unaffected by 8 with heart failure weeks of core stability training Aerobic treadmill training effectively Vol 58 No 4, p 271 enhances cardiovascular fitness and Acute low back pain usually resolves Vol 59 No 2, p 127 gait function for older persons with quickly but persistent low back pain chronic stroke often persists Clinimetrics Tai Chi training is effective in reducing Vol 59 No 1, p 55 balance impairments and falls in Active Straight Leg Raise Vol 58 No 2, p 132 patients with Parkinson’s disease STarT Back Screening Tool Vol 59 No 2, p 131 Exercise programs for patients with Vol 59 No 1, p 57 cancer improve physical functioning painDETECT Questionnaire Vol 59 No 3, p 211 and quality of life Perineum or Genito-Urinary System Exercise training following lung Vol 59 No 1, p 58 transplant is now evidence-based Clinimetrics practice Exercise training improves Vol 58 No 2, p 130 A physiotherapy telephone assessment Vol 59 No 2, p 130 cardiovascular fitness in people and advice service for patients receiving haemodialysis for chronic with musculoskeletal problems can renal disease improve the process of care while maintaining clinical effectiveness 5IJHIPS)JQ A telephone-delivered behavioural Vol 59 No 2, p 133 intervention confers a small reduction CAPs in body weight in people with Type 2 diabetes Eccentric hamstring muscle training can Vol 58 No 1, p 58 prevent hamstring injuries in soccer Repetitive facilitative exercise improves Vol 59 No 3, p 208 players upper limb function in patients with subacute stroke Multi-modal realignment treatment Vol 58 No 4, p 272 decreased pain in people with medial Wearing pedometers in conjunction Vol 59 No 4, p 273 with daily step goals and incentives tibiofemoral osteoarthritis can increase physical activity among children Clinical Practice Guidelines Hand, hip, and knee osteoarthritis Vol 58 No 3, p 203 Hip fracture Vol 58 No 4, p 275 Sun-style T’ai Chi improves walking Vol 59 No 4, p 274 endurance and health-related quality of Lower Leg or Knee life in people with COPD CAPs Vol 58 No 2, p 128 Body-weight supported treadmill training Vol 59 No 4, p 275 Vol 58 No 3, p 209 improves cardiovascular fitness and Daily use of a cane for two months walking endurance early after stroke reduced pain and improved function Vol 59 No 3, p 210 in patients with knee osteoarthritis Positive expiratory pressure prevents Vol 59 No 4, p 276 Vol 58 No 2, p 133 more exacerbations than high Reconstruction surgery is not always Vol 58 No 3, p 203 frequency chest wall oscillation via a necessary for active young people Vol 58 No 4, p 275 vest in people with cystic fibrosis who rupture their anterior cruciate ligament Clinimetrics No difference in functional outcomes Brief Illness Perception Questionnaire Vol 58 No 3, p 202 between surgery and physiotherapy (Brief IPQ) for symptomatic patients with a meniscal tear and knee osteoarthritis SPHERE 12 Screening Questionnaire Vol 58 No 4, p 273 Clinical Practice Guidelines Pain Free Grip Strength Test Vol 59 No 1, p 59 Osteoarthritis Chronic Pain Grade Questionnaire Vol 59 No 1, p 60 Hand, hip, and knee osteoarthritis The Ten Test for Sensation Vol 59 No 2, p 132 Hip fracture The Work Limitations Questionnaire Vol 58 No 4, p 277 (WLQ-25) Whole Body/Other Clinical Practice Guidelines Palliation in aged care Vol 58 No 1, p 63 CAPs Type 2 diabetes Vol 58 No 1, p 63 Functional progressive resistance Vol 58 No 3, p 197 Developmental co-ordination disorder Vol 58 No 2, p 133 training improves muscle strength but not walking ability in children with Osteoporosis Vol 58 No 4, p 275 cerebral palsy Amyotrophic lateral sclerosis (ALS) Vol 59 No 1, p 61 A 12-week exercise program performed Vol 58 No 3, p 198 Cardiovascular disease risk Vol 59 No 2, p 133 during the second trimester does not prevent gestational diabetes in healthy Falls in older people Vol 59 No 3, p 213 pregnant women Physical activity for older people Vol 59 No 3, p 213 288 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013
Appraisal Correspondence An effective stretching regimen to prevent nocturnal leg cramps Last year we published a randomised trial demonstrating category of the International Classification of Sleep that stretching before sleep reduces the frequency and Disorders (ICSD-2). In this classification system, nocturnal severity of nocturnal leg cramps in older adults (Hallegraeff leg cramps are termed ‘sleep-related leg cramps’ and are et al 2012). The results of that study align perfectly with consistent with the International Classification of Diseases the uncontrolled study of Daniell (1979). In a recent letter (ICD-9) code 327.52, which has the following definition: to this journal, Daniell and Pentrack (2013) proposed an A painful sensation in the leg or foot is associated with alternative stretching procedure for preventing nocturnal sudden muscle hardness or tightness indicating a strong leg cramps. Some major differences can be identified muscle contraction and the painful muscle contractions between their new stretching procedure and the procedure in the legs or feet occur during the sleep period, although used in our study. they may arise from either wakefulness or sleep. Forceful stretching relieves the pain of the affected muscles and leg First, although they are not a commonly affected muscle cramps are not explained by another current (medical) group, the hamstrings can be the site of nocturnal leg cramps sleep disorder or medication use. All of these criteria (Allen and Kirby 2012, Monderer et al 2010). Because should be present for a proper diagnosis. These criteria are of this, the stretching procedures in our study included essential to distinguish nocturnal leg cramps from restless stretches of the hamstrings, in contrast to the alternative legs syndrome (ICD-9 333.93), which is an urge to move the stretching procedure of Daniell and Pentrack. legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs, which begin or worsen at Second, we have concerns that the alternative stretching rest. The urge to move whereby unpleasant sensations are procedure proposed by Daniell and Pentrack may oppose partially or totally relieved by movement may be worse in correct execution of a full passive stretch to end of range the evening or night than during the day. and may lead to a higher risk of injuries. In their procedure, patients lower their heels independently from the edge of Joannes M Hallegraeff1, Mathieu H de Greef1,2 and a low step or platform while holding a handrail. In our Cees P van der Schans1,2 experience with this stretch, we have observed a tendency for some patients to tense the calf muscles due to proprioceptive 1Hanze University of Applied Sciences stimulation, thus opposing the execution of a full passive 2University Medical Center stretch to end of range. If the end of range position is not achieved, the intensity of the stretching intervention is not Groningen, The Netherlands controlled. There may be increased potential for injury References if patients stretch while the muscle is contracting, or if patients were to fall from the edge of the low platform. In Allen RE, Kirby KA (2012) Am Fam Physician 86: 350–355. our regimen, the calf stretch in standing involves ‘flexing Daniell HW (1979) New Engl J Med 301: 216. the front knee so that the trunk moves forward, keeping Daniell HW, Pentrack J (2013) J Physiother 59: 138. the trunk straight and the heels in contact with the floor’, Hallegraeff JM et al (2012) J Physiother 58: 17–22. as shown in Figure 1. In this stretch, patients can control Merlino G, Gigli GL (2011) Neurol Sci 33: 491–513. their performance because the heels stay in ground contact Monderer RS et al (2010) Curr Neurol Neurosci 10: 53–59. through to the final stretch position, ensuring correct execution of a full passive stretch to end of range. Correct Figure 1. Calf stretch in standing, which was one of three application of a full passive stretch may also be relevant in stretches in the regimen used in the trial by Hallegraeff et community dwelling elderly because insufficient stretching al (2012). may promote tendon shortening, which may itself increase nocturnal leg cramps (Monderer et al 2010). Finally, we note that the stretching regimens also differ in the duration of stretch and the time of the day that the stretches are applied. All these issues highlight that, while theoretical arguments can be raised to suggest modification of an intervention with proven effects, arguments against the modification can also be raised. Ultimately, physiotherapists should seek randomised comparisons of the procedures to decide whether to accept the modified version. /PUFPGDBVUJPOGPSEJBHOPTJOHOPDUVSOBMMFH cramps When considering a diagnosis of nocturnal leg cramps, physiotherapists should be careful to distinguish the symptoms from restless legs syndrome. Both disorders are reviewed in detail by Merlino and Gigli (2011), among a series of conditions in the ‘sleep-related movement disorders’ Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013 279
Appraisal Media A useful site for consumers, families and busy clinicians 4USPLF&OHJOFXFCTJUFXXXTUSPLFOHJOFDB class therapy, family support, sexuality, and virtual reality. Interestingly, there is not a topic devoted specifically to This website aims to provide information about stroke walking training, although this is covered in several topics rehabilitation to stroke survivors and their families as well such as ‘body-weight supported treadmill training’, and as to clinicians. While the website has an inter-professional ‘task-oriented training – lower extremity and mobility’. healthcare approach, it is particularly useful for allied Clicking on the intervention of interest brings up a health clinicians – predominantly physiotherapists and summary page with tabs across the top for ‘clinician quick occupational therapists. The site has three main sections: review’, ‘clinician in-depth review’, and ‘best practice’. For patients and families, For clinicians – assessments, and The clinician quick review summarises the evidence for For clinicians – interventions. an intervention in simple tables separated into relevant outcomes and supported by evidence ratings. The clinician For patients and families in-depth review provides an overview of the evidence in a readable format. References are hyperlinked, taking the This section includes information about effective therapies user to a table summarising the study design, outcomes, for post-stroke impairments and activity limitations. and a PEDro score of quality. The best practice section The language is appropriate and the site makes good contains relevant quotes from the Canadian Best Practice use of hyperlinks to glossary terms with easy-to-follow Recommendations for Stroke Care (Lindsay et al 2010). explanations. Problems and therapies are listed in a panel Not all the interventions have the in-depth review or best to the left of the page. Each consumer page is downloadable practice sections, but this website is a work in progress. as a PDF document. There are two case studies that serve to introduce the main topics, but these appear to be based on Although the site contains numerous references, these are theory rather than real stories. The addition of stories from not up to date in all areas. For example, the Biofeedback stroke survivors would add value and impact. – lower extremity section provides references up to 2005, whereas a more recent systematic review on this topic 'PSDMJOJDJBOToBTTFTTNFOUT (Stanton et al 2011) found three additional good quality trials published after 2005. Neither the trials nor the review This section presents information on many of the are referenced. assessment tools available for use in stroke rehabilitation – at the time of this review 90 assessment tools were listed. There are a few oddities in the way information is They are listed alphabetically as well as under ‘domains’ organised and presented, eg, ‘positioning’ is listed as an (eg, activities of daily living, participation, mobility, upper effective treatment for balance in the consumer section limb function). There is also meant to be a search function, – with links to information about upper limb positioning but this was not functional at the time of the review. The and gait aid provision. In the intervention section, there is glossary tab in this section provides easy-to-understand a comprehensive section on the effectiveness of treadmill definitions of the various terms relating to psychometric training with body weight support, but not for treadmill properties of measurement tools. Each assessment tool training without body weight support. Despite this, the has its own page that includes an in-depth review of the ‘best practice’ section recommends use of treadmill without measure, a description of its psychometric properties, a body weight support. summary table, and links to either download the tool or to the relevant website from which the tool can be obtained. This is a comprehensive and useful website that attempts to cover the breadth of evidence for effective interventions Clinicians can quickly find either a quick summary or a after stroke in a way that is easily digestible for families more in-depth review of many assessment tools available and busy clinicians. It is supported by the Canadian Stroke for use with stroke survivors. However, while there is an Network and has been recognised for its scientific rigour extensive list of tools to assess upper limb function and by the Canadian Cochrane Centre. Users can sign up for cognitive ability, the list of balance and mobility-related RSS feeds of new additions and/or follow the website on assessments is less comprehensive – the Berg Balance Scale Facebook. The challenge for the developers is to ensure that is the only balance measure included, and walking speed information stays as up to date as possible. is not mentioned at all. While the most commonly used measure of walking ability after stroke – the 6MWT – is Coralie English included, it is presented primarily as a measure of exercise University of South Australia tolerance. However, the 6MWT has been shown to be a poor measure of cardiorespiratory fitness (Pang et al 2005) References or perceived exertion (Eng et al 2002) in stroke survivors. It is, however, a valid measure of walking capacity, and is Eng JJ et al (2002) Stroke 33: 756–761. strongly correlated to stroke-related impairments such as lower limb strength, spasticity, and in particular postural LindsayMetal(2010)CanadianBestPracticeRecommendations control in standing (Pang et al 2005, Eng et al 2002, Pohl for Stroke Care (Update 2010). Canadian Stroke Network. et al 2002). IUUQTUSPLFCFTUQSBDUJDFTDBXQDPOUFOUVQMPBET SBP2013_Stroke-Rehabilitation-Update_July-10_FINAL.pdf 'PSDMJOJDJBOToJOUFSWFOUJPOT Pang MY et al (2005) Chest 127: 495–501. The home page of this section includes tabs leading to information about the evidence for each intervention and a Pradon D et al (2013) J Rehabil Med 45: 105–108. glossary of terms. A comprehensive range of interventions is included with topics ranging from acupuncture, use of Pohl PS et al (2002) J Rehabil Res Dev 39: 439–444. assistive devices, aphasia therapy, biofeedback, circuit Stanton R et al (2011) J Physiother 57: 145–155. 280 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013
Appraisal Critically Appraised Papers Body-weight supported treadmill training improves cardiovascular fitness and walking endurance early after stroke Synopsis group was instructed to walk overground at comfortable, self-selected speeds for the same duration. The two groups Summary of: MacKay-Lyons M, et al (2013) Dual effects of were given home programs (3 days per week) after the body-weight supported treadmill training on cardiovascular 12-week supervised training. Outcome measures: The fitness and walking ability early after stroke: a randomized primary outcomes were peak VO2, 6MWT, and overground controlled trial. Neurorehabil Neural Repair. DOI: walking speed. The secondary outcomes were Berg 10.1177/1545968313484809. [Prepared by Marco YC Pang, Balance Scale, and Chedoke-McMaster Stages of Recovery CAP Editor.] (CMSR) score. Outcomes were measured at baseline, post- training, and at 6- and 12-month follow-up. Results: 37 Question: Does body-weight supported treadmill training participants completed the study. The experimental group improve cardiovascular fitness and walking function in improved more than the control group for measures of people with subacute stroke compared with overground peak VO2, 6MWT, and CMSR foot score. At the end of the gait training? Design: Randomised, controlled trial with 12-week intervention period, the experimental group had concealed allocation and blinded outcome assessment. significant improvement in peak VO2 (by 4.2 ml/kg/min, Setting: Stroke rehabilitation unit in Canada. Participants: 95% CI 2.5 to 5.9) and CMSR foot score (by 1.0 point, 95% Adults within 1 month of a first ischaemic stroke, and CI 0.3 to 1.7) whereas the control group had no significant ability to walk 5 m with or without walking aids or standby improvement in these variables. The experimental group assistance were key inclusion criteria. A key exclusion also had significantly more improvement in the 6MWT criterion was contraindication to maximal exercise stress (by 89.7 m, 95% CI 54.4 to 125.0) than the control group testing. Randomisation of 50 participants allocated 24 (by 36.8 m, 95 %CI 4.2 to 69.4). These effects were largely to the experimental group and 26 to the control group. preserved at 12-month follow-up. There were no between- Interventions: Both groups were trained 5 days per week group differences for other outcomes. Conclusion: A body- for 6 weeks and then 3 days per week for a further 6 weeks. weight supported treadmill training program is effective in The experimental group underwent body-weight supported improving cardiovascular fitness and walking endurance in treadmill training. The target exercise intensity and duration people after stroke. was set at 60–75% of the peak oxygen consumption rate (peak VO2) for a minimum of 20 minutes. The control Given the presence of post-stroke neuromotor impairment and cardiovascular deconditioning, and the interaction Commentary between these factors on functional mobility, it is important to develop interventions that effectively and concurrently Regaining the ability to walk is a common goal priority address these issues and capitalise on the early time after stroke such that gait-related activities receive the most window of opportunity to maximise benefit. The results attention during stroke rehabilitation (Latham et al 2005). of this trial offer promising evidence supporting the use of Body-weight supported treadmill training (BWSTT) has individualised and progressive BWSTT among people in received much attention as a modality to improve walking the early stages of stroke recovery. outcomes, but its superiority over other means of gait training has not been consistently demonstrated (Duncan et Ada Tang al 2011, Moseley et al 2005). School of Rehabilitation Science, McMaster University, Low fitness levels may compound mobility limitations Canada after stroke. There is an important interaction between neuromotor impairments and cardiovascular fitness as the References capacity to meet the high metabolic demands of walking is reduced (Tang et al 2007). Historically, therapy during Duncan PW et al (2011) N Engl J Med 364: 2026–2036. stroke rehabilitation provided minimal aerobic challenge (MacKay-Lyons et al 2002), but now it is known that early Latham NK et al (2005) Arch Phys Med Rehabil 86 (Suppl 2): exercise interventions can improve fitness and walking S41–S50. ability (Stoller et al 2012), MacKay-Lyons MJ et al (2002) Arch Phys Med Rehabil 83: The randomised trial conducted by MacKay-Lyons and 1378–1383. colleagues contributes novel and important evidence in a number of ways. First, they demonstrated that BWSTT was Moseley AM et al (2005) Cochrane Database Syst Rev 4: effective in concurrently addressing cardiovascular fitness CD002840. and walking ability in individuals with limited ambulatory capacity. It was also conducted within the first month Stoller O et al (2012) BMC Neurol 12: 45. post-stroke, capitalising on the window of opportunity for neurological recovery. Finally, it demonstrated that gains Tang A et al (2009) Neurorehabil Neural Repair 23: 398–406. were retained long after completion of training. 274 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013
Appraisal Clinical Practice Guidelines Chronic obstructive lung disease Chronic obstructive lung disease Description: This extensive 99-page guideline includes over 500 references providing evidence for the diagnosis, Latest update: February 2013. Next update: Not stated. assessment, management, and prevention of COPD. Key Patient group: Adults with chronic obstructive lung disease points are provided at the start of every section and a (COPD). Intended audience: Health care professionals summary of changes from the 2011 report is provided at and public health officials involved in the prevention and the start of the document. Data on the burden of COPD, management of people with COPD. Additional versions: evidence for factors that influence disease development The current guideline is an update of a 2011 report: Global and progression, and information on the pathology, Strategy for the Diagnosis, Management and Prevention pathogenesis, and pathophysiology of COPD are presented of COPD. Two companion documents, a pocket guide to first. Indicators for a diagnosis of COPD including the COPD diagnosis, management and prevention, and a COPD sensitivity of approaches for assessment of symptoms (eg, diagnosis and management at-a-glance desk reference spirometry, questionnaires), is provided. Evidence for document are also available. Expert working group: spirometry, cut points of severity levels, and the assessment A 14-member committee of medical professionals from of exacerbation risk is presented along with indicators to Europe, North America and Asia comprised the expert assist with a differential diagnosis. Evidence for therapeutic working group. Funded by: Not stated. Consultation with: options for the management of COPD are presented in detail The guidelines were reviewed by 27 experts from Europe, and include smoking cessation, pharmacologic therapy, North and South America, Asia, and Africa including vaccination, oxygen therapy, surgical treatments, and Australia. Approved by: the Global Initiative for Chronic pulmonary rehabilitation, including a review on the relative Obstructive Lung Disease (GOLD). This is an international benefit of various components of pulmonary rehabilitation consortium of leading scientific and clinical experts in (eg, exercise, education, nutrition, smoking cessation). COPD, supported by the National Heart, Lung and Blood Comprehensive sections are presented on the evidence Institute USA, National Institutes of Health USA, and the underpinning these management approaches both for stable World Health Organization. Location: The guidelines COPD and the assessment and treatment of exacerbations. and companion documents are available at: http://www. Finally, evidence for links between COPD and other co- goldcopd.org morbidities are presented. Sandra Brauer The University of Queensland Brain injury rehabilitation Brain injury rehabilitation in adults Latest update: March 2013. Next update: In three years. Description: This 75-page guideline provides evidence Patient group: Adults with brain injury. Intended audience: for the post-acute assessment of adults with brain injury, People who have a responsibility for the management of and interventions for physical, cognitive, communicative, adults with brain injuries in primary, secondary, tertiary, emotional, and behavioural rehabilitation. Evidence guiding or independent health care, or the voluntary sector service delivery models such as settings of care, discharge including medical, nursing, and allied health professionals. planning and telemedicine is also presented. It begins with Additional versions: This is a companion document a specific section dedicated to the assessment and treatment to SIGN 110, a guideline focused on early management of mild traumatic brain injury, providing information of patients with head injury. Expert working group: on a range of predominantly cognitive symptoms and A 21-member group including medical specialists, prognostic factors, and evidence for treatment options neuropsychologists, physiotherapists, speech pathologists, such as education, pharmacological and psychological nurses, and a carer from Scotland comprised the expert interventions. The rest of the guidelines are not directed working group. Funded by: Not stated. Consultation with: at any specific level of severity. Evidence underpinning A draft guideline was presented at a Scottish national open physical rehabilitation and management is presented, meeting, made available for public comment, and circulated covering gait, balance, and mobility (eg, treadmill training, to over 40 independent expert reviewers from a variety orthoses/aids, task-specific repetitive task training, physical of professional backgrounds in the UK. The guidelines fitness training, and virtual reality), spasticity and tone (eg, were produced by the Scottish Intercollegiate Guidelines splints, stretches, botulinum neurotoxin therapy, oral anti- Network. Approved by: National Health Service Scotland. spasticity medication, electrical stimulation), and upper Location: The guidelines are available at: http://www.sign. limb function. Evidence for intervention to address cognitive ac.uk/pdf/sign130.pdf dysfunctions, communication and swallowing impairments is outlined, with vocational rehabilitation interventions discussed. The guidelines also present recommendations for the management of the patient in a minimally conscious or vegetative state. Sandra Brauer The University of Queensland 278 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013
Appraisal Clinical Practice Guidelines Chronic obstructive lung disease Chronic obstructive lung disease Description: This extensive 99-page guideline includes over 500 references providing evidence for the diagnosis, Latest update: February 2013. Next update: Not stated. assessment, management, and prevention of COPD. Key Patient group: Adults with chronic obstructive lung disease points are provided at the start of every section and a (COPD). Intended audience: Health care professionals summary of changes from the 2011 report is provided at and public health officials involved in the prevention and the start of the document. Data on the burden of COPD, management of people with COPD. Additional versions: evidence for factors that influence disease development The current guideline is an update of a 2011 report: Global and progression, and information on the pathology, Strategy for the Diagnosis, Management and Prevention pathogenesis, and pathophysiology of COPD are presented of COPD. Two companion documents, a pocket guide to first. Indicators for a diagnosis of COPD including the COPD diagnosis, management and prevention, and a COPD sensitivity of approaches for assessment of symptoms (eg, diagnosis and management at-a-glance desk reference spirometry, questionnaires), is provided. Evidence for document are also available. Expert working group: spirometry, cut points of severity levels, and the assessment A 14-member committee of medical professionals from of exacerbation risk is presented along with indicators to Europe, North America and Asia comprised the expert assist with a differential diagnosis. Evidence for therapeutic working group. Funded by: Not stated. Consultation with: options for the management of COPD are presented in detail The guidelines were reviewed by 27 experts from Europe, and include smoking cessation, pharmacologic therapy, North and South America, Asia, and Africa including vaccination, oxygen therapy, surgical treatments, and Australia. Approved by: the Global Initiative for Chronic pulmonary rehabilitation, including a review on the relative Obstructive Lung Disease (GOLD). This is an international benefit of various components of pulmonary rehabilitation consortium of leading scientific and clinical experts in (eg, exercise, education, nutrition, smoking cessation). COPD, supported by the National Heart, Lung and Blood Comprehensive sections are presented on the evidence Institute USA, National Institutes of Health USA, and the underpinning these management approaches both for stable World Health Organization. Location: The guidelines COPD and the assessment and treatment of exacerbations. and companion documents are available at: http://www. Finally, evidence for links between COPD and other co- goldcopd.org morbidities are presented. Sandra Brauer The University of Queensland Brain injury rehabilitation Brain injury rehabilitation in adults Latest update: March 2013. Next update: In three years. Description: This 75-page guideline provides evidence Patient group: Adults with brain injury. Intended audience: for the post-acute assessment of adults with brain injury, People who have a responsibility for the management of and interventions for physical, cognitive, communicative, adults with brain injuries in primary, secondary, tertiary, emotional, and behavioural rehabilitation. Evidence guiding or independent health care, or the voluntary sector service delivery models such as settings of care, discharge including medical, nursing, and allied health professionals. planning and telemedicine is also presented. It begins with Additional versions: This is a companion document a specific section dedicated to the assessment and treatment to SIGN 110, a guideline focused on early management of mild traumatic brain injury, providing information of patients with head injury. Expert working group: on a range of predominantly cognitive symptoms and A 21-member group including medical specialists, prognostic factors, and evidence for treatment options neuropsychologists, physiotherapists, speech pathologists, such as education, pharmacological and psychological nurses, and a carer from Scotland comprised the expert interventions. The rest of the guidelines are not directed working group. Funded by: Not stated. Consultation with: at any specific level of severity. Evidence underpinning A draft guideline was presented at a Scottish national open physical rehabilitation and management is presented, meeting, made available for public comment, and circulated covering gait, balance, and mobility (eg, treadmill training, to over 40 independent expert reviewers from a variety orthoses/aids, task-specific repetitive task training, physical of professional backgrounds in the UK. The guidelines fitness training, and virtual reality), spasticity and tone (eg, were produced by the Scottish Intercollegiate Guidelines splints, stretches, botulinum neurotoxin therapy, oral anti- Network. Approved by: National Health Service Scotland. spasticity medication, electrical stimulation), and upper Location: The guidelines are available at: http://www.sign. limb function. Evidence for intervention to address cognitive ac.uk/pdf/sign130.pdf dysfunctions, communication and swallowing impairments is outlined, with vocational rehabilitation interventions discussed. The guidelines also present recommendations for the management of the patient in a minimally conscious or vegetative state. Sandra Brauer The University of Queensland 278 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013
de Jong et al: Combined arm positioning and NMES poststroke Combined arm stretch positioning and neuromuscular electrical stimulation during rehabilitation does not improve range of motion, shoulder pain or function in patients after stroke: a randomised trial Lex D de Jong1,2, Pieter U Dijkstra2,3, Johan Gerritsen4, Alexander CH Geurts5 and Klaas Postema2 1School of Physiotherapy, Hanze University of Applied Sciences, Groningen, 2Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, 3Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, 4ViaReva, Center for Rehabilitation, Apeldoorn, 5Department of Rehabilitation, Radboud University Nijmegen Medical Center, Nijmegen The Netherlands Question: Does static stretch positioning combined with simultaneous neuromuscular electrical stimulation (NMES) in the subacute phase after stroke have beneficial effects on basic arm body functions and activities? Design: Multicentre randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis. Participants: Forty-six people in the subacute phase after stroke with severe arm motor deficits (initial Fugl-Meyer Assessment arm score ) 18). Intervention: In addition to conventional stroke rehabilitation, participants in the experimental group received arm stretch positioning combined with motor amplitude NMES for two 45-minute sessions a day, five days a week, for eight weeks. Control participants received sham arm positioning (ie, no stretch) and sham NMES (ie, transcutaneous electrical nerve stimulation with no motor effect) to the forearm only, at a similar frequency and duration. Outcome measures: The primary outcome measures were passive range of arm motion and the presence of pain in the hemiplegic shoulder. Secondary outcome measures were severity of shoulder pain, restrictions in performance of activities of daily living, hypertonia, spasticity, motor control and shoulder subluxation. Outcomes were assessed at baseline, mid-treatment, at the end of the treatment period (8 weeks) and at follow-up (20 weeks). Results: Multilevel regression analysis showed no significant group effects nor significant time × group interactions on any of the passive range of arm motions. The relative risk of shoulder pain in the experimental group was non-significant at 1.44 (95% CI 0.80 to 2.62). Conclusion: In people with poor arm motor control in the subacute phase after stroke, static stretch positioning combined with simultaneous NMES has no statistically significant effects on range of motion, shoulder pain, basic arm function, or activities of daily living. 5SJBMSFHJTUSBUJPO: NTR1748. <EF+POH-% %JKLTUSB16 (FSSJUTFO+ (FVSUT\"$) 1PTUFNB, $PNCJOFEBSN stretch positioning and neuromuscular electrical stimulation during rehabilitation does not improve range of motion, TIPVMEFSQBJOPSGVODUJPOJOQBUJFOUTBGUFSTUSPLFBSBOEPNJTFEUSJBMJournal of Physiotherapyo> Keywords: Stroke, Upper extremity, Muscle stretching exercises, Electrical stimulation, Activities of daily living, Randomized controlled trial Introduction (Coupar et al 2010) or constraint-induced movement therapy (Sirtori et al 2009). However, these interventions are not Annually, 15 million people worldwide suffer a stroke suitable for people with severe motor deficits because they (Mackay and Mensah 2004). About 77–81% of stroke require ‘active’ residual arm motor capacity. For these survivors show a motor deficit of the extremities (Barker people ‘passive’ interventions may be needed to prevent and Mullooly 1997). In almost 66% of patients with an secondary impairments and optimise long-term handling initial paralysis, the affected arm remains inactive and immobilised due to a lack of return of motor function after What is already known on this topic: Contracture of six months (Sunderland et al 1989, Wade et al 1983). Over muscles in the arm after stroke is common. Stretch time, the central nervous system as well as muscle tissue alone does not typically produce clinically important of the arm adapt to this state of inactivity, often resulting reductions in contracture in people with neurological in residual impairments such as hypertonia (de Jong et al conditions. Hypertonia may limit the application of 2011, van Kuijk et al 2007), spasticity (O’Dwyer et al 1996) stretch and therefore its potential benefits. or contractures (Kwah et al 2012, O’Dwyer et al 1996, Pandyan et al 2003). In turn, these secondary impairments What this study adds: In people with poor arm are associated with hemiplegic shoulder pain (Aras et al motor control after stroke, static arm positioning to 2004, Roosink et al 2011) and restrictions in performance stretch muscles prone to contracture combined with of activities of daily living (Lindgren et al 2007, Lundström neuromuscular stimulation of the antagonist muscles et al 2008). did not have significant benefits with respect to range of motion, shoulder pain, performance of activities of Several interventions improve arm function after stroke and daily living, hypertonia, spasticity, motor control or prevent secondary impairments, eg, bilateral arm training shoulder subluxation. Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 245
Research and assistive use of the affected arm. It is also important Method to elicit muscle activity if at all possible, and to improve arm function. To prevent the loss of passive range of joint Design motion as a result of contracture of at-risk muscles in the shoulder (eg, internal rotators, adductors) and forearm A multicentre, assessor-blinded, randomised controlled (eg, pronators, wrist and finger flexors) in particular, the trial was conducted. After inclusion, participants were application of arm stretch positioning alongside regular randomised in blocks of four (2:2 allocation ratio) in two physiotherapy was deemed important (Ada and Canning strata (Fugl-Meyer Assessment arm score 0–11 points 1990), especially because contractures are associated with and 12–18 points) at each treatment centre. Opaque, shoulder pain (Aras et al 2004, de Jong et al 2007, Wanklyn sealed envelopes containing details of group allocation et al 1996). However, in general, passive stretch does not were prepared by the main co-ordinator (LDdJ) before produce clinically important changes in joint range of trial commencement. After a local trial co-ordinator had motion, pain, spasticity, or activity limitations (Katalinic et determined eligibility and obtained a patient’s consent, the al 2011). One explanation for the lack of effect of passive main co-ordinator was contacted by phone. He instructed an stretch of the shoulder muscles could be the inadequate independent person to draw an envelope blindfolded and to duration of stretch, with clinical trials using a dose of 20 or communicate the result back to the local trial co-ordinator. 30 minutes only (Borisova and Bohannon 2009). However, The local trial co-ordinator then made arrangements it is questionable whether stretch of the shoulder muscles for the baseline measurement after which the allocated for much more than 60 minutes per day during intensive intervention was initiated. Mid-treatment, end-treatment, rehabilitation programs is feasible (Turton and Britton and follow-up measurements took place at 4, 8, and 20 2005). weeks after baseline measurement by two independent assessors (physiotherapists), who were unaware of group People with severe motor deficits after stroke have a allocation and not involved in the treatment of participants. higher risk of developing increased resistance to passive To keep the assessors blinded, participants were reminded muscle stretch (hypertonia) and spasticity of the muscles before each measurement not to reveal the nature of their responsible for an antigravity posture (de Jong et al 2011, treatment. Participants were considered to be unaware of Kwah et al 2012, Urban et al 2010). These muscles are also group allocation because they were informed about the at risk of developing contracture. As a result, the passive existence of two intervention groups but not about the range of the hemiplegic shoulder (exteral rotation, flexion study hypothesis. The participants’ and assessors’ beliefs and abduction), elbow (extension), forearm (supination) and regarding allocation were checked at the eight-week (ie, end wrist (extension) can become restricted. of treatment) assessment using a three-point nominal scale (I suspect allocation to experimental/control group, I have Stretching hypertonic muscles is difficult when they are no clue of group allocation). All investigators, staff, and not sufficiently relaxed. Cyclic neuromuscular electrical participants were kept blinded with regard to the outcome stimulation (NMES) (Chae et al 2008), another example of measurements. a ‘passive’ intervention, can not only be used to improve pain-free range of passive humeral lateral rotation (Price Participants and Pandyan 2000), but also to reduce muscle resistance (King 1996) and glenohumeral subluxation (Pomeroy et Between August 2008 and September 2010, consecutive al 2006, Price and Pandyan 2000). From these results we newly admitted patients on the neurological units of three hypothesised that NMES of selected arm muscles opposite rehabilitation centres in the Netherlands (Beetsterzwaag, to muscles that are prone to the development of spasticity Doorn, and Zwolle) were approached for participation. and contracture might facilitate static arm stretching both Willing patients were initially screened by a physician for through reciprocal inhibition (‘relaxation’) of antagonist the following inclusion criteria: first-ever or recurrent stroke muscles (Alfieri 1982, Dewald et al 1996, Fujiwara et al (except subarachnoid haemorrhages) between two and eight 2009) and the imposed (cyclic) stretch caused by motor weeks poststroke; age > 18 years; paralysis or severe paresis amplitude NMES. Consequently, static arm stretch of the affected arm scoring 1–3 on the recovery stages positioning combined with NMES could potentially result of Brunnstrom (1970); and no planned date of discharge in larger improvements of arm passive range of motion and within four weeks. Subsequently, a local trial co-ordinator less (severe) shoulder pain compared to NMES or static excluded patients with: contraindications for electrical stretching alone. From these hypotheses we developed the stimulation (eg, metal implants, cardiac pacemaker); pre- following research questions: existing impairments of the affected arm (pre-existing contracture was not an exclusion criterion); severe cognitive 1. Does eight weeks of combined static arm stretch deficits and/or severe language comprehension difficulties, positioning with simultaneous NMES prevent the loss defined as < 3/4 correct verbal responses and/or < 3 correct of shoulder passive range of motion and the occurrence visual graphic rating scale scores on the AbilityQ (Turner- of shoulder pain more than sham stretch positioning Stokes and Rusconi 2003); and moderate to good arm with simultaneous sham NMES (ie, transcutaneous motor control (> 18 points on the Fugl-Meyer Assessment electrical stimulation, TENS) in the subacute phase arm score). of stroke? Interventions 2. Does the experimental intervention have any additional effects on timing and severity of shoulder pain, All participants received multidisciplinary stroke restrictions in daily basic arm activities, resistance to rehabilitation, ie, daily training in activities of daily passive stretch (hypertonia) and spasticity, arm motor living by rehabilitation nurses, occupational therapists, control, and the degree of shoulder subluxation? physiotherapists, and speech therapists. These interventions were not standardised, but generally administered in a way that was consistent with the recommendations of 246 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
de Jong et al: Combined arm positioning and NMES poststroke ABC Figure 1. Experimental and control arm muscle stretch positions and electrode placements. (a) The intervention used by experimental group participants with sufficient shoulder external rotation to achieve the position. (b) The intervention used by experimental group participants with insufficient shoulder external rotation. (c) The control (ie, sham) intervention. the Dutch stroke guidelines (Van Peppen et al 2004). the same two trained assessors. Every effort was made to Participants were requested to undergo the additional motivate participants to undergo all planned measurements allocated treatment twice daily for 45 minutes on weekdays even after withdrawal from the study. for 8 weeks. Participants from the experimental group received arm stretch positioning (presented in Figures 1a Passive range of shoulder external rotation, flexion and and 1b) with simultaneous four-channel motor amplitude abduction, elbow extension, forearm supination, wrist NMES. Participants from the control group received a extension with extended and flexed fingers were assessed sham stretch positioning procedure (presented in Figure because these movements often develop restrictions in range 1c) with simultaneous sham conventional TENS with as a result of imposed immobility, with muscle contractures minimal sensory sensation by using a similar treatment causing a typical flexion posture of the hemiplegic arm. The protocol, electrical stimulator and electrode placement (entire) ShoulderQ was administered in participants who (but on the forearm only) as the experimental group. A indicated that they had shoulder pain. This questionnaire detailed description of the experimental and control group assesses timing and severity of pain by means of eight procedures can be found in Appendix 1 (see the eAddenda verbal questions and three vertical visual graphic rating for Appendix 1). scales. We were primarily interested in the answer to the (verbal) question How severe is your shoulder pain overall? Treatment was planned to result in 60 hours of positioning (1= mild, 2 = moderate, 3 = severe, 4 = extremely severe) and 51 hours of NMES/TENS. All procedures were and pain severity measured at rest, on movement, and at performed by the local trial coordinator or instructed night using the 10-cm vertical visual graphic rating scales. nursing staff. Nursing staff monitored compliance to the The ShoulderQ is sensitive (Turner-Stokes and Jackson intervention by logging each session on a record sheet, 2006) and responsive to change in pain experience (Turner- which was always kept in the vicinity of the participant’s Stokes and Rusconi 2003). Performance of basic functional bed. During the first 8 weeks of the trial, prescription of activities of daily life involving the passive arm was pain and spasticity medication as well as content of physical assessed using the Leeds Adult/Arm Spasticity Impact Scale and occupational therapy sessions for the arm were also (Ashford et al 2008). Using this semi-structured interview, monitored. participants were asked to indicate whether they or their carer(s) experienced difficulty performing 12 different Outcome measures tasks involving the hemiplegic arm (cleaning the palm/ elbow/armpits, cutting fingernails, putting the arm through The primary outcome measures were passive range of arm a sleeve/in a glove, rolling over in bed, doing exercises, motion and pain in the hemiplegic shoulder. All goniometric balancing while standing/walking, and holding objects). assessments were performed by two observers using a The scores on the separate items (1 point = no difficulty, fluid-filled goniometera. Inter-observer reliability of this 0 = difficulty or activity not yet performed) were summed, technique was high (de Jong et al 2012). The presence of divided by the total number of items performed and shoulder pain was checked using the first (yes/no) question multiplied by 100, resulting in a summary score (0 = severe of the ShoulderQ (Turner-Stokes and Jackson 2006). The disability, 100 = no disability). Hypertonia and spasticity of secondary outcome measures were timing and severity of the shoulder internal rotators, elbow flexors, and long finger poststroke shoulder pain, performance of real-life passive flexors were assessed using a detailed version (Morris and basic daily active arm activities, hypertonia and 2002) of the Tardieu Scale (Held and Pierrot-Deseilligny spasticity, arm motor control and shoulder subluxation. All 1969). The Tardieu Scale can differentiate spasticity from measurements were carried out in the same fixed order by Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 247
Research Screened for eligibility (n = 260) Excluded after initial screening (n = 180)a Excluded after inclusion testing (n = 32) t OPJTDIBFNJDIBFNPSSIBHJDTUSPLF O t unable to fill out, read or understand the AbilityQ (n = 9) t > 8 weeks post stroke (n = 28) t Fugl-Meyer Assessment Arm score > 18 points (n = 14) t Brunnstrom’s recovery stage * 4 (n = 169) t contraindications to electrical stimulation (n = 1) t pre-existing arm impairments (n = 24) t other reasons (n = 8) t planned date of discharge too soon (n = 64) t SFGVTFEVOBCMFUPQBSUJDJQBUF O t other (n = 8)b t VOLOPXONJTTJOHEBUB O Measured passive range of motion, shoulder pain, restrictions in performance of activities Week 0 PGEBJMZMJGF IZQFSUPOJBTQBTUJDJUZ NPUPSDPOUSPMBOETIPVMEFSTVCMVYBUJPO (n = 24) Randomised (n = 24) (n = 23) Analysedc (n = 23) Discontinued Experimental group Control group Lost to follow-up intervention t multidisciplinary stroke t multidisciplinary stroke treadmission to t shoulder rehabilitation rehabilitation hospitald (n = 1) pain (n = 2) t static arm positioning t sham arm positioning Discontinued and NMES 90 min per and TENS 90 min per intervention day, 5 days per week day, 5 days per week tdischarge (n = 1) Measured passive range of motion, shoulder pain, restrictions in performance of activities Week 4 PGEBJMZMJGF IZQFSUPOJBTQBTUJDJUZ NPUPSDPOUSPMBOETIPVMEFSTVCMVYBUJPO (n = 21) Received prescribed intervention (n = 21) (n = 23) Analysed (n = 21)e Lost to follow-up Experimental group Control group Discontinued intervention tdeath (n = 1) t multidisciplinary stroke t multidisciplinary stroke t increased rehabilitation rehabilitation tforearm pain (n = 1) trecurrent stroke shoulder pain t static arm positioning t sham arm positioning (n = 1) and NMES 90 min per and TENS 90 min per (n = 2) Discontinued day, 5 days per week day, 5 days per week intervention tdischarge (n = 1) tdischarge (n = 1) Measured passive range of motion, shoulder pain, restrictions in performance of activities Week 8 PGEBJMZMJGF IZQFSUPOJBTQBTUJDJUZ NPUPSDPOUSPMBOETIPVMEFSTVCMVYBUJPO (n = 18) Received prescribed intervention (n = 17) (n = 21) Analysed (n = 21)f Lost to follow-up Experimental group Control group t no intervention t no intervention tsevere shoulder subluxation (n = 1) tdid not attend (n = 3) Measured passive range of motion, shoulder pain, restrictions in performance of activities of Week 20 EBJMZMJGF IZQFSUPOJBTQBTUJDJUZ NPUPSDPOUSPMBOETIPVMEFSTVCMVYBUJPO (n = 17) Analysed (n = 22) Figure 2. Design and flow of participants through the trial. aAll reasons for exclusion are listed where patients were ineligible for multiple reasons. bIncluding multiple sclerosis, Alzheimer’s disease, locked-in syndrome, recurrent stroke, and participation in another trial. NMES = neuromuscular electrical stimulation. cOne participant from each group dropped out after randomisation but before receiving any intervention. dUnrelated to stroke. eOne participant missed the Week 4 assessment due to poor weather. fOne participant missed the Week 8 assessment due to recurrent stroke but was subsequently available for the Week 20 follow-up assessment. 248 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
de Jong et al: Combined arm positioning and NMES poststroke 5BCMF Baseline characteristics of participants and datasets, we aimed to recruit at least 20 participants per centres. group. Characteristic Exp Con All participants minus two premature dropouts were (n = 23) (n = 23) analysed as randomised (intention-to-treat). Arm passive range of motion was analysed using a multilevel regression Age (yr), mean (SD) 56.6 (14.2) 58.4 (9.6) analysis. As main factors time (baseline, 4, 8, and 20 weeks), 43.7 (13.3) 43.3 (15.5) group allocation (2 groups) and time × group interaction Time post-stroke at were explored using the –2log-likelihood criterion for baseline (days), 27 (23 to 28.25) 28 (26 to 29.5) model fit, as well as random effects of intercept and slope. mean (SD) 15 (65) 12 (52) For completeness, this analysis was repeated using the data MMSEa, median of the participants including the two premature dropouts (n (IQR) 19 (83) 18 (78) = 48) using the last observation carried forward approach. 4 (17) 5 (22) Nominal outcome measures (presence of hypertonia/ Gender, n males 12 (52) 8 (35) spasticity and subluxation) at eight weeks were analysed (%) using a Chi-square test. Ordinal outcome measures (Fugl- 5 (22) 6 (26) Meyer Assessment, Leeds Adult/Arm Spasticity Impact Stroke type, n (%) Scale, ShoulderQ) were first analysed for time effects 19 (83) 17 (74) within subjects using the Friedman test. If differences over ICVA 4 (17) 6 (26) time (from baseline to follow-up) were found, these were further explored using the Wilcoxon signed-rank test with HCVA 7 (30) 8 (35) Bonferroni-Hochberg correction (Norman and Streiner 4 (17) 4 (17) 2000). Between-group differences were analysed using Affected 12 (52) 11 (48) a Mann-Whitney U test only at 8 weeks to avoid multiple hemisphere, n right testing. (%) Results Aphasia, n (%) Flow of participants through the trial Initial FMA arm score, n (%) The flow of participants through the trial is presented in Figure 2. Forty-eight patients met all eligibility criteria. 0–11 points One participant from the experimental group (a 68-year- old female with a right-sided ischaemic stroke who 12–18 points regretted participation) and one from the control group (a 62-year old male with a left-sided ischaemic stroke who Centres, was rehospitalised due to acute liver and kidney failure) participants dropped out the day after baseline measurement and before treated, n (%) receiving any intervention. These participants were not included in the analyses because their data were missing Beetsterzwaag due to unavailability for further measurements. Doorn Of the 11 patients who were lost to follow-up or discontinued their prescribed intervention during the Zwolle 8-week treatment period, four (36%) complained of pain. Baseline characteristics of the 46 participants analysed are Exp = experimental group, Con = control group, FMA = shown in Table 1. Twenty-two participants (51%, n = 43) Fugl-Meyer Assessment arm score, HCVA = haemorrhagic had no clue as to which group they were allocated, but 17 cerebrovascular accident, ICVA = ischaemic cerebrovascular participants (40%) were correct in their belief regarding accident, MMSE = Mini Mental State Examination. aNot allocation. The three participants who were lost to follow- administered in subjects with aphasia. up before 8 weeks did not provide data about allocation beliefs. The two assessors had no clue regarding group contracture (Haugh et al 2006, Patrick and Ada 2006) and allocation in 67% and 72% of the cases. They were correct has fair to excellent test-retest reliability and inter-observer in their belief regarding allocation in 9 (21%) and 4 (9%) of reliability (Paulis et al 2011). The mean angular velocity the participants, respectively. of the Tardieu Scale’s fast movement was standardised (see the eAddenda for Appendix 2). Muscle reaction Co-interventions and compliance with trial quality scores * 2 were considered to be clinically relevant method hypertonia. Spasticity was deemed present if the angle of catch was present and occurred earlier in range than the In the experimental group more participants were prescribed maximal muscle length after slow stretching (ie, spasticity pain and spasticity medication, as presented in Table 2. angle > 0 degs). Arm motor control was assessed using the They also received slightly more conventional therapy for 66-point arm section of the Fugl-Meyer Assessment (Fugl- the arm and adhered less to the prescribed intervention Meyer et al 1975, Gladstone et al 2002). Shoulder inferior protocol. Overall, compliance in the experimental group subluxation was diagnosed by palpation (Bohannon and was 68% (stretch positioning) and 67% (NMES), compared Andrews 1990) in finger breadths (< ½, < 1, * 1, > 1½) and to 78% (sham positioning) and 75% (TENS) in the control considered present if it was one category higher than on the group. Non-compliance was mainly caused by drop-out and nonaffected side. Data analysis Sample size calculation was based on a reliably assessable change in passive shoulder external rotation range of motion of * 17 degs (de Jong et al 2012). The clinically relevant difference between the experimental and control intervention was therefore set at a minimum of 20 deg. The standard deviation was considered to be 21.5 deg (Ada et al 2005). Alpha was set at 5% (two-sided), beta at 80%. Thus, the required number of participants in each group was 18. Anticipating a 10% drop-out rate and requiring 36 complete Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 249
Research 5BCMF. Mean (SD) or number of participants (%) for co-interventions and compliance to the intervention protocol during the eight-week intervention period and mean difference (MD) or percentage risk difference (RD) between groups, with 95% confidence intervals (95% CI). Outcome Groups Difference between groups (95% CI) Prescription of pain medication, n (%) Exp Con RD 25% (–4% to 50%) Prescription of spasticity medication, n (%) (n = 23) (n = 23) RD 14% (–8% to 36%) Upper limb occupational therapy (hr), mean (SD) 16 (73)a 11 (48) Upper limb physiotherapy (hr), mean (SD) 5 (23)a MD 1 (–2 to 3) Total of positioning (hr), mean (SD) 2 (9) MD 1 (–2 to 3) Total of electrical stimulation (hr), mean (SD) 5 (4)a 4 (4)a MD –6 (–15 to 4) 2 (3)a MD –4 (–13 to 5) 3 (5) 47 (16) 41 (17)a 38 (14) 34 (16)a Exp = experimental group, Con = control group. aData missing for one participant. early weekend leaves. All mentioned differences between Discussion the groups were not statistically significant. To our knowledge this is the first study to analyse the effects Effect of intervention of a daily arm stretch positioning procedure combined with simultaneous NMES in patients with a poor prognosis for All primary and secondary outcome measures are functional recovery in the subacute phase after stroke. presented in Tables 3, 4 and 5. Individual participant data The 8-week high-intensity multimodal intervention did are presented in Table 6 (see eAddenda for Tables 4, 5 and not result in any significant differences in arm passive 6). Except for elbow extension and the control participants’ range of motion (contractures), shoulder pain, basic arm wrist extension with extended fingers, both groups showed activities, hypertonia/spasticity, arm motor control or reductions in mean passive range of motion of all joints shoulder subluxation compared to a control group receiving (Table 3). The multilevel regression analysis identified a similar amount of sham positioning combined with TENS significant time effects for the three shoulder movements in addition to conventional rehabilitation. and for forearm supination. There was no significant group effect nor a significant time × group interaction. A random Previous attempts to maintain hemiplegic arm joint range intercept model fitted the data best (–2log-likelihood of motion using static muscle stretching procedures could criterion). At end-treatment, the mean between-group not prevent considerable loss of shoulder passive range of difference for passive shoulder external rotation was 13 deg motion (Ada et al 2005, Gustafsson and McKenna 2006, de (95% CI 1 to 24). Jong et al 2006, Turton and Britton 2005). Our participants showed similar reductions in mean passive range of motion At baseline, 37% of all participants (ie, 17/46) reported across most arm joints. Overall, there were no significant shoulder pain, as presented in Table 4 (see eAddenda for differences in passive range of motion between the two Table 4). At 8 weeks, this percentage was 52% (ie, 22/42) groups. At baseline (on average, six weeks post-stroke), with a relative risk of shoulder pain in the experimental 37% of the participants reported (shoulder) pain. During group of 1.44 (95% CI 0.80 to 2.62), but no significant the intervention period, the prevalence increased to 52% difference between the groups (r2 = 1.53, p = 0.217). At and decreased to 36% three months later. These findings follow-up 36% (ie, 13/39) of all participants had shoulder are in line with reports that post-stroke shoulder pain is pain. At 8 weeks, participants with shoulder pain showed common, affecting 22–64% of cases, particularly patients no significant between-group differences in their responses with poor arm function (Aras et al 2004, Gamble et al 2002, to the verbal question as well as in the visual graphic Lindgren et al 2007). Overall, pain severity also increased, rating scale scores on movement and at night. Overall, the particularly on movement and at night. This adverse effect pain scores showed inconsistent patterns which hindered was also noted in other trials (Gustafsson and McKenna within- and between-group comparisons of those with 2006, Turton and Britton 2005). Although there were no shoulder pain only. There were no significant between- significant between-group differences regarding shoulder group differences on the Leeds Adult/Arm Spasticity pain, worrisome observations were that in the experimental Impact Scale, the Modified Tardieu Scale, the Fugl-Meyer group some participants reported that they considered Assessment arm score, and the subluxation scores at end- the intervention to be very arduous, pain and spasticity treatment, as presented in Table 5 (see eAddenda for Table medication were prescribed more frequently, and protocol 5). It is of note that all participants with clinically relevant compliance was lower. Combined with the finding that hypertonia also demonstrated a spasticity angle > 0 deg and shoulder pain was more likely to occur in participants in the that Tardieu Scale scores for the internal rotators could not experimental group than in the control group (relative risk be obtained in a large number of participants because they 1.44), these findings may indicate that for some participants had very limited (< 70 deg) total shoulder external rotation the experimental procedure was not well tolerated. range. The overall prevalence of subluxation decreased from baseline (61%) to follow-up (31%). During the eight weeks of intervention our participants showed increased Leeds Adult/Arm Spasticity Impact Scale sum scores and Fugl-Meyer Assessment arm motor scores – changes that were probably not clinically relevant 250 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 5BCMF. Mean (SD) for passive range of motion in degrees for each group, mean (SD) dif fe regression analysis identified significant time ef fects for the three shoulder movements and x time interaction. A random intercept results in the best fit for the data (–2log-likelihood crit Outcome Groups Week 0 Week 4 Week 8 Week 20 Exp Con Exp Con Exp Con Exp Co (n = 23) (n = 23) (n = 23) (n = 21) (n = 21) (n = 21) (n = 17) (n = Shoulder 29 34 20 19 18 11 20 21 ex ternal (20) (19) (28) (21) (23) (24) (29) (2 rotation Shoulder 130 122 111 104 107 100 107 10 flexion (33) (29) (37) (22) (37) (20) (36) (2 Shoulder 110 93 93 71 92 66 84 7 abduction (48) (41) (51) (32) (51) (27) (46) (27 Elbow 3 3 2 5 3 5 6 2 ex tensiona (8) (7) (9) (7) (10) (7) (12) (12 Forearm 77 78 68 68 67 69 59 6 supination (13) (11) (16) (15) (17) (12) (16) (16 Wrist 58 54 55 47 56 54b 54 5 extension I (18) (17) (20) (14) (20) (16) (20) (14 Wrist 66 60 59b 53 62 57 60 6 extension II (12) (14) (17) (13) (18) (15) (20) (15 Exp = experimental group, Con = control group, I = wrist extension with extended fingers, II = wrist e position, ie, degrees of elbow flexor contracture with negative values representing hyperextension. bD 251
erence within groups, and mean (95% CI) dif ference between groups. The multi-level d for forearm supination. There was no significant group ef fect nor a significant group terion). Difference within groups Dif ference between groups Week 4 Week 8 Week 20 Week 4 Week 8 Week 20 minus minus minus minus minus minus Week 0 Week 0 Week 0 Week 0 Week 0 Week 0 on Exp Con Exp Con Exp Con Exp minus Exp minus Exp = 22) Con Con minus –9 –14 –10 –23 –5 –13 21 (17) (14) (15) (21) 5 13 Con 5) (23) (21) (– 5 to 14) (1 to 24) 8 (–7 to 22) 03 –18 –15 –22 –22 –16 –18 –3 0 2 0) (24) (18) (26) (30) (31) (27) (–16 to 10) (–17 to 18) (–17 to 21) 2 –17 –17 –18 –27 –18 –20 0 9 2 7) (41) (21) (48) (34) (49) (33) (–20 to 20) (–17 to 35) (–24 to 29) 2 –1 1 0 2 2 –1 –2 –2 3 12) (6) (5) (8) (7) (8) (11) (– 5 to 2) (–7 to 3) (– 4 to 9) 7 –8 –9 –10 –9 –15 –12 1 –1 –3 de Jong et al: Combined arm positioning and NMES poststroke 6) (12) (17) (12) (12) (18) (14) (– 8 to 10) (– 8 to 7) (–13 to 7) 9 –3 –5 –2 0b –2 6 2 –3 –8 14) (11) (12) (15) (16) (20) (19) (– 5 to 9) (–12 to 7) (–21 to 5) 3 –6 –6 –4 –3 –4 3 0 –1 –7 15) (9) (8) (– 5 to 5) (–9 to 6) (–17 to 4) (11) (14) (16) (15) extension with flexed fingers. aElbow extension values indicate deviation from the neutral Data missing for one participant.
Research and caused by a mix of spontaneous post-stroke recovery of intervention will not have a clinically relevant impact in this function, learned capacity to use compensatory movement subgroup of patients either. strategies of the nonaffected arm and/or increased involvement of the carer. Overall, the prevalence of elbow Research to date suggests that it is not possible to control or flexor hypertonia and spasticity jointly increased up to 55% overcome (the emergence of) contractures and hypertonia at the end of the treatment period, roughly corresponding to using the current static arm muscle stretching procedures. three months post-stroke for our participants. These results Similarly, NMES of the antagonists of the muscles prone are in concordance with previous work (de Jong et al 2011, to shortening does not seem to provide additional benefits van Kuijk et al 2007, Urban et al 2010). The unexpected either. We therefore argue that these techniques should high prevalence of hypertonia and spasticity (62%) and be discontinued in the treatment of patients with a poor a decreasing prevalence of shoulder subluxation (31%) prognosis for functional recovery. In this subgroup of at follow-up in our sample may be explained by the fact patients it is becoming an increasingly difficult challenge to that patients with relatively poor arm motor control have a find effective treatments that can prevent the development higher risk of developing hypertonia (de Jong et al 2011). of the most common residual impairments such as contractures, hypertonia, and spasticity and its associated Although we performed an intention-to-treat analysis (ie, secondary problems such as shoulder pain and restrictions using any available data from all randomised subjects), we in performance of daily life activities. Further research is did not use forward imputation of missing data representing required to investigate what renders these interventions a clinical variable (eg, shoulder passive range of motion) ineffective. The efficacy of other approaches, such as that is worsening over time (de Jong et al 2007), as this transcranial magnetic stimulation, NMES of the muscles might increase the chance of a Type I error. However, for prone to shortening (Goldspink et al 1991), or other completeness, this stricter intention-to-treat analysis using combinations of techniques, could also be investigated. Q the data of all randomised subjects (n = 48) was performed. This analysis was similar in outcome to the original analysis Footnotes: aMIE Medical Research Ltd, Leeds, UK. but revealed an additional time effect of wrist extension bSTIWELL-med4, Otto Bock HealthCare, Germany. with flexed fingers. A per protocol analysis would also have resulted in similar results because no patients crossed over eAddenda: Table 4, 5, 6 (individual patient data) and to the other group. We also refrained from performing a Appendix 1 and 2. sensitivity analysis based on compliance because meaningful conclusions could not be drawn from the resulting limited Ethics: The study was approved by the Medical Ethics sample sizes. We furthermore acknowledge that the Leeds Committee of the University Medical Center Groningen. Adult/Arm Spasticity Impact Scale lacks psychometric All participants gave written informed consent prior to evaluation and our method to standardise the Tardieu participation. Scale’s stretch velocity (V3) using a metronome was not validated and tested for reliability. Therefore, our data Support: This study was financially supported by Fonds regarding basic arm activities, hypertonia, and spasticity NutsOhra [SNO-T-0702-72] and Stichting Beatrixoord should be interpreted with caution. Finally, because Noord-Nederland. overall compliance to both protocols was only about 70%, an underestimation of the treatment effect may also have Acknowledgements: We thank the assessors Ank Mollema occurred. Nevertheless, the combined administration of 43 and Marian Stegink (De Vogellanden, Zwolle), the local hours of static stretching and 36 hours of NMES was more trial co-ordinators Marijke Wiersma and Siepie Zonderland than administered during any previous trial (Borisova and (Revalidatie Friesland, Beetsterzwaag), Astrid Kokkeler Bohannon 2009). and Dorien Nijenhuis (MRC Aardenburg, Doorn), Alinda Gjaltema and Femke Dekker (De Vogellanden, Zwolle) A recent study produced inconclusive evidence about and the participants, physicians, physio- and occupational the effectiveness of a combined intervention of electrical therapists and nursing staff involved in the trial. stimulation in conjunction with prolonged muscle stretch (using a splint) to treat and prevent wrist contracture Competing interests: Otto Bock Healthcare provided (Leung et al 2012). Similarly, our results also showed electrical stimulators free of charge. None of the sponsors no added benefit of electrical stimulation during static had any involvement in study design, data collection stretching of the shoulder and arm. The results of these and analysis, decision to publish, or preparation of the multimodal approaches to the problem of post-stroke arm manuscript. contracture development are in line with the conclusion of a review (Katalinic et al 2011) that static stretch positioning Correspondence: Lex D de Jong, Hanze University of procedures have little, if any, short or long term effects Applied Sciences, School of Physiotherapy, Eyssoniusplein on muscle contracture (treatment effect ) 3 deg), pain, 18, 9714 CE Groningen, The Netherlands. Email: l.d.de. spasticity, or activity limitations. Although pooled data from [email protected] studies investigating the effects of electrical stimulation suggested some treatment effects on functional motor References ability (Pomeroy et al 2006) and pain-free range of passive humeral lateral rotation in patients with residual arm motor Ada L, Canning C (1990) Anticipating and avoiding muscle capacity (Price and Pandyan 2000), we found no such shortening. In Ada L, Canning C (Eds) Key Issues in results in our sample of patients without residual arm motor /FVSPMPHJDBM 1IZTJPUIFSBQZ 0YGPSE #VUUFSXPSUI capacity. As the combined procedure did not result in any Heinemann, pp 219–236. meaningful treatment effects, it suggests that application of muscle stretching or NMES alone as a monotherapeutic Ada L, Goddard E, McCully J, Stavrinos T, Bampton J (2005) Thirty minutes of positioning reduces the development 252 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
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Appraisal Trial Protocol Effect of patellar strap and sports tape on jumper’s knee symptoms: protocol of a randomised controlled trial Astrid J de Vries, Inge van den Akker-Scheek, Ron L Diercks, Johannes Zwerver and Henk van der Worp University of Groningen, University Medical Center Groningen, Center for Sports Medicine The Netherlands Abstract training and competition. Measurements: The amount of pain (both parts of the study) and sports participation Introduction: Patellar straps or sports tapes are commonly (second part only) will be measured. Analysis: To analyse used by athletes with patellar tendinopathy in order to reduce the effects of the orthoses a Linear Mixed Model will be pain and to continue sports participation. Currently, there used. Discussion: The knowledge gained in this study can is no scientific evidence for the effectiveness of a patellar be used by practitioners in their advice for athletes with strap or sports tape in the management of this common patellar tendinopathy about using patellar strap and sports injury. Aim: To investigate the effect of the use of a patellar tape during sports. strap and sports tape on pain and sports participation in subjects with patellar tendinopathy. Design: The study is Trial registration: Dutch Trial Register (NTR). divided into two parts: a randomised controlled crossover Registration number: NTR 3660. Prospective experiment and a randomised controlled trial (parallel group registration: Yes. Funded by: The Netherlands design). Participants and setting: 140 patients diagnosed Organisation for Health Research and Development with patellar tendinopathy recruited from sports medical (ZonMw). Approval number: 75020020. Anticipated centres and physiotherapist practices. Intervention: In completion: June 2014. Correspondence: Astrid J. de the first part of the study, participants serve as their own Vries, Center for Sports Medicine, University Medical control by performing three functional tests under four Center Groningen, Hanzeplein 1, 9700 RB Groningen, The different conditions (patellar strap, sports tape, placebo Netherlands. Email: [email protected] tape, and no orthosis). In the second part, participants keep a log for two weeks (control week and intervention week) Full protocol: Available on the eAddenda at jop. about the pain experienced during and after sports and physiotherapy.asn.au their level of sports participation. In the intervention week participants will use the orthosis assigned to them during Commentary al 2006) do not work during the competitive season (Visnes et al 2005), in-season pain relief strategies are needed. Athletes with patellar tendinopathy often wear a This study will determine whether patellar tendon straps patellar tendon brace while playing sport. The anecdotal or taping can deliver short-term pain relief for athletes who effectiveness of these braces in reducing pain and allowing continue to compete in jumping sports. If patellar tendon continued sporting participation requires evaluation via straps or taping are shown to reduce pain, future studies well-designed and adequately controlled clinical trials. could examine whether their use can optimise outcomes There is a plausible mechanism for the pain relieving effect from exercise-based rehabilitation. An interesting clinical of a patellar tendon strap with finite element modelling question for future studies is whether patient compliance of knee radiographs indicating that patellar tendon straps with exercise-based rehabilitation can be improved through can reduce tendon strain at the classic site of patellar providing a pain-relieving adjunct intervention. tendinopathy (Lavagnino et al 2011). Jamie Gaida This well designed protocol proposes investigating pain Department of Physiotherapy, Monash University, levels while performing aggravating activities under four intervention conditions (patellar tendon brace, patellar Australia tendon taping, placebo taping, control). A placebo taping condition is a key strength of the proposed study, however References as participants may accurately distinguish between active and placebo taping, evaluating allocation concealment Bahr R et al (2006 J Bone Joint Surg Am 88: 1689–1698. success at study completion would be worthwhile (for discussion see Schulz et al 1995). As exercise-based Lavagnino M et al (2011) Sports Health 3: 296–302. treatments that are effective during the off-season (Bahr et Schulz KF et al (1995) JAMA 273: 408–412. Visnes H et al (2005) Clin J Sport Med 15: 227–234. 270 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013
Appraisal Trial Protocol Effect of patellar strap and sports tape on jumper’s knee symptoms: protocol of a randomised controlled trial Astrid J de Vries, Inge van den Akker-Scheek, Ron L Diercks, Johannes Zwerver and Henk van der Worp University of Groningen, University Medical Center Groningen, Center for Sports Medicine The Netherlands Abstract training and competition. Measurements: The amount of pain (both parts of the study) and sports participation Introduction: Patellar straps or sports tapes are commonly (second part only) will be measured. Analysis: To analyse used by athletes with patellar tendinopathy in order to reduce the effects of the orthoses a Linear Mixed Model will be pain and to continue sports participation. Currently, there used. Discussion: The knowledge gained in this study can is no scientific evidence for the effectiveness of a patellar be used by practitioners in their advice for athletes with strap or sports tape in the management of this common patellar tendinopathy about using patellar strap and sports injury. Aim: To investigate the effect of the use of a patellar tape during sports. strap and sports tape on pain and sports participation in subjects with patellar tendinopathy. Design: The study is Trial registration: Dutch Trial Register (NTR). divided into two parts: a randomised controlled crossover Registration number: NTR 3660. Prospective experiment and a randomised controlled trial (parallel group registration: Yes. Funded by: The Netherlands design). Participants and setting: 140 patients diagnosed Organisation for Health Research and Development with patellar tendinopathy recruited from sports medical (ZonMw). Approval number: 75020020. Anticipated centres and physiotherapist practices. Intervention: In completion: June 2014. Correspondence: Astrid J. de the first part of the study, participants serve as their own Vries, Center for Sports Medicine, University Medical control by performing three functional tests under four Center Groningen, Hanzeplein 1, 9700 RB Groningen, The different conditions (patellar strap, sports tape, placebo Netherlands. Email: [email protected] tape, and no orthosis). In the second part, participants keep a log for two weeks (control week and intervention week) Full protocol: Available on the eAddenda at jop. about the pain experienced during and after sports and physiotherapy.asn.au their level of sports participation. In the intervention week participants will use the orthosis assigned to them during Commentary al 2006) do not work during the competitive season (Visnes et al 2005), in-season pain relief strategies are needed. Athletes with patellar tendinopathy often wear a This study will determine whether patellar tendon straps patellar tendon brace while playing sport. The anecdotal or taping can deliver short-term pain relief for athletes who effectiveness of these braces in reducing pain and allowing continue to compete in jumping sports. If patellar tendon continued sporting participation requires evaluation via straps or taping are shown to reduce pain, future studies well-designed and adequately controlled clinical trials. could examine whether their use can optimise outcomes There is a plausible mechanism for the pain relieving effect from exercise-based rehabilitation. An interesting clinical of a patellar tendon strap with finite element modelling question for future studies is whether patient compliance of knee radiographs indicating that patellar tendon straps with exercise-based rehabilitation can be improved through can reduce tendon strain at the classic site of patellar providing a pain-relieving adjunct intervention. tendinopathy (Lavagnino et al 2011). Jamie Gaida This well designed protocol proposes investigating pain Department of Physiotherapy, Monash University, levels while performing aggravating activities under four intervention conditions (patellar tendon brace, patellar Australia tendon taping, placebo taping, control). A placebo taping condition is a key strength of the proposed study, however References as participants may accurately distinguish between active and placebo taping, evaluating allocation concealment Bahr R et al (2006 J Bone Joint Surg Am 88: 1689–1698. success at study completion would be worthwhile (for discussion see Schulz et al 1995). As exercise-based Lavagnino M et al (2011) Sports Health 3: 296–302. treatments that are effective during the off-season (Bahr et Schulz KF et al (1995) JAMA 273: 408–412. Visnes H et al (2005) Clin J Sport Med 15: 227–234. 270 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013
Errata Erratum 1 An editorial error resulted in the omission of some author variable where we present the odds ratio associated with a corrections to the paper by Kwah et al in the September 10 year increase in age.’ issue. In particular, readers should note that the sentence in the last paragraph of page 192 which reads The journal apologises to the authors and to our readers for this error. ‘Odds ratios are associated with a one-unit increase in the predictor’ Reference should read Kwah LK, Harvey LA, Diong J, Herbert RD (2013) Models containing age and NIHSS predict recovery of ambulation ‘Odds ratios indicate the increase in odds associated with and upper limb function six months after stroke: an a one-unit increase in the predictor, except for the age observational study. Journal of Physiotherapy 59: 189–197. Erratum 2 A production error resulted in the failure to print the plots Reference in Figures 1 and 2 (p. 174) in the paper by Beekman et al in the September issue. The Figures are presented below with Beekman E, Mesters I, Hendriks EJM, Klaassen MPM, plots. Gosselink R, van Schayck OCP, de Bie RA (2013) Course length of 30 metres versus 10 metres has a significant The journal apologises to the authors and to readers for this influence on six-minute walk distance in patients with COPD: error. an experimental crossover study. Journal of Physiotherapy 59: 169–176. Difference in 6MWD (30 m-course and 10 m-course) (m)175,000 Difference in % 6MWD (30 m-course and 10 m-course) 25,000 pred 150,000 125,000 Mean + 2SD 20,000 Mean + 2SD 100,000 15,000 75,000 50,000 Mean 10,000 Mean 5,000 25,000 MCID 0 0 –25,000 400,000 600,000 Mean – 2SD Mean – 2SD 200,000 800,000 –5,000 Average of 6MWD (30 m-course and 10 m-course) (m) 40,000 50,000 60,000 70,000 80,000 90,000 100,000 110,000 Average of %pred 6MWD (30 m-course and 10 m-course) Figure 1. Bland-Altman plot showing systematic lower Figure 2. Bland-Altman plot showing the difference performance on the six-minute walk test over a 10 in %pred 6MWD using a 10 m versus 30 m course. m-course in patients with COPD. 6MWD = six-minute %pred 6MWD is based on the average of predicted values walk distance. MCID = minimum clinically important from the studies of Gibbons et al (2001), Hill et al (2011), difference. Jenkins et al (2009), and Troosters et al (1999). 6MWD = six-minute walk distance. 218 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Errata Erratum 1 An editorial error resulted in the omission of some author variable where we present the odds ratio associated with a corrections to the paper by Kwah et al in the September 10 year increase in age.’ issue. In particular, readers should note that the sentence in the last paragraph of page 192 which reads The journal apologises to the authors and to our readers for this error. ‘Odds ratios are associated with a one-unit increase in the predictor’ Reference should read Kwah LK, Harvey LA, Diong J, Herbert RD (2013) Models containing age and NIHSS predict recovery of ambulation ‘Odds ratios indicate the increase in odds associated with and upper limb function six months after stroke: an a one-unit increase in the predictor, except for the age observational study. Journal of Physiotherapy 59: 189–197. Erratum 2 A production error resulted in the failure to print the plots Reference in Figures 1 and 2 (p. 174) in the paper by Beekman et al in the September issue. The Figures are presented below with Beekman E, Mesters I, Hendriks EJM, Klaassen MPM, plots. Gosselink R, van Schayck OCP, de Bie RA (2013) Course length of 30 metres versus 10 metres has a significant The journal apologises to the authors and to readers for this influence on six-minute walk distance in patients with COPD: error. an experimental crossover study. Journal of Physiotherapy 59: 169–176. Difference in 6MWD (30 m-course and 10 m-course) (m)175,000 Difference in % 6MWD (30 m-course and 10 m-course) 25,000 pred 150,000 125,000 Mean + 2SD 20,000 Mean + 2SD 100,000 15,000 75,000 50,000 Mean 10,000 Mean 5,000 25,000 MCID 0 0 –25,000 400,000 600,000 Mean – 2SD Mean – 2SD 200,000 800,000 –5,000 Average of 6MWD (30 m-course and 10 m-course) (m) 40,000 50,000 60,000 70,000 80,000 90,000 100,000 110,000 Average of %pred 6MWD (30 m-course and 10 m-course) Figure 1. Bland-Altman plot showing systematic lower Figure 2. Bland-Altman plot showing the difference performance on the six-minute walk test over a 10 in %pred 6MWD using a 10 m versus 30 m course. m-course in patients with COPD. 6MWD = six-minute %pred 6MWD is based on the average of predicted values walk distance. MCID = minimum clinically important from the studies of Gibbons et al (2001), Hill et al (2011), difference. Jenkins et al (2009), and Troosters et al (1999). 6MWD = six-minute walk distance. 218 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Ralston et al: Functional electrical stimulation cycling in SCI Functional electrical stimulation cycling has no clear effect on urine output, lower limb swelling, and spasticity in people with spinal cord injury: a randomised cross-over trial Keira E Ralston1,2, Lisa A Harvey2,3, Julia Batty1, Bonsan B Lee1,4, Marsha Ben3, Rita Cusmiani3 and Jacqueline Bennett1 1Prince of Wales Spinal Injury Unit, Prince of Wales Hospital, 2Rehabilitation Studies Unit, Sydney School of Medicine/Northern, University of Sydney, 3Royal Rehabilitation Centre Sydney, 4Neuroscience Research Australia (NeuRA) Sydney, Australia Question: Does functional electrical stimulation (FES) cycling increase urine output and decrease lower limb swelling and spasticity in people with recent spinal cord injury? Design: Randomised cross-over trial. Participants: Fourteen participants with a recent motor complete spinal cord injury were consecutively recruited from two spinal cord injury units in Sydney. Intervention: Participants were randomised to an experimental phase followed by a control phase or vice versa, with a 1-week washout period in between. The experimental phase involved FES cycling four times a week for two weeks and the control phase involved standard rehabilitation for two weeks. Assessments by a blinded assessor occurred at the beginning and end of each phase. Allocation was concealed and an intention-to-treat analysis was performed. Outcome measures: The primary outcome was urine output (mL/hr) and the secondary outcomes were lower limb circumference, and spasticity using the Ashworth Scale, and the Patient Reported Impact of Spasticity Measure (PRISM). In addition, participants were asked open-ended questions to explore their perceptions about treatment effectiveness. Results: All participants completed the study. The mean between-group difference (95% CI) for urine output was 82 mL/hr (–35 to 199). The mean between-group differences (95% CI) for lower limb swelling, spasticity (Ashworth), and PRISM were –0.1 cm (–1.5 to 1.2), –1.9 points (–4.9 to 1.2) and –5 points (–13 to 2), respectively. All point estimates of treatment effects favoured FES cycling. Participants reported many benefits from FES cycling. Conclusion: There were no clear effects of FES cycling on urine output, swelling and spasticity even though all point estimates of treatment effects favoured FES cycling and participants perceived therapeutic effects. 5SJBMSFHJTUSBUJPO: ACTRN12611000923965. [Ralston KE, Harvey -\" #BUUZ+ -FF## #FO. $VTNJBOJ3 #FOOFUU+ 'VODUJPOBMFMFDUSJDBMTUJNVMBUJPODZDMJOHIBTOPDMFBSFGGFDU POVSJOFPVUQVU MPXFSMJNCTXFMMJOH BOETQBTUJDJUZJOQFPQMFXJUITQJOBMDPSEJOKVSZBSBOEPNJTFEDSPTTPWFSUSJBM Journal of Physiotherapyo> Key words: Spinal cord injury, Functional electrical stimulation cycling, Physical therapy Introduction with FES cycling compress the lower limb vasculature thereby improving venous return and decreasing lower Functional electrical stimulation (FES) cycling is limb swelling (Elokda et al 2000, Faghri and Yount 2002, commonly prescribed for people with spinal cord injury for Man et al 2003, Sampson et al 2000). It is also claimed that a variety of reasons (Carlson et al 2009, Hicks et al 2011). the increased venous return associated with FES cycling Some of the proposed benefits of FES cycling include stretches the myocardium of the right atrium stimulating increased urine output, decreased lower limb swelling the expression of atrial natriuretic peptide. This peptide is and decreased spasticity (Elokda et al 2000, Faghri and known to have an excitatory effect on the kidneys, which Yount 2002, Krause et al 2008, Sampson et al 2000, Skold increases urine excretion (Dunn and Donnelly 2007) and et al 2002, van der Salm et al 2006). It is important to investigate the therapeutic effects of FES cycling on these What is already known on this topic: Functional variables because: increased urine output is associated with electrical stimulation of paralysed legs in people with a reduced incidence of urinary tract infection (Wilde and spinal cord injury increases venous return which Carrigan 2003); decreased lower limb swelling makes it may increase urine output and decrease lower limb easier for people with spinal cord injury to lift their legs swelling. Functional electrical stimulation may also and reduces incidence of pressure ulcers (Consortium for have short-term effects on spasticity. Spinal Cord Medicine Clinical Practice Guidelines 2001); and decreased spasticity has various functional and health What this study adds: This study provides unbiased benefits (Adams and Hicks 2005). point estimates of the effect of functional electrical stimulation on urine output, venous return and Anecdotal evidence suggests that FES cycling affects spasticity. These estimates indicate that our current renal function causing an increase in urine output and confidence in the effectiveness of functional electrical decrease in lower limb swelling (Man et al 2003). It is stimulation on these outcomes is not yet justified. hypothesised that the cyclic muscle contractions associated Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 237
Research potentially decreases lower limb swelling. However, it is not at least 20 minutes within a one-hour period. Participants known whether FES cycling is a sufficiently potent stimulus were excluded if: they had participated in a FES cycling to influence urine output or lower limb swelling. This has program in the preceding two weeks; ES was medically not been tested in a randomised controlled trial. contraindicated; or they had a limited ability to comply. All participants were deemed medically fit to participate by FES cycling is also advocated as a way to reduce spasticity their treating medical consultant. (Elbasiouny et al 2010, Krause et al 2008, Skold et al 2002, van der Salm et al 2006). Various theories exist on Intervention how this may occur. One theory is that repeated electrical stimulation (ES)-evoked contractions lead to muscle fatigue Participants in the experimental phase received a progressive, (Skold et al 2002). Another hypothesis is that the excitation individualised FES cycling program performed four times of the cutaneous afferents decreases the excitability of the a week for two weeks. The aim was to provide participants propriospinal interneurons and motoneurons (Elbasiouny et with 30 to 45 minutes of FES driven leg cycling within a al 2010), while others argue that ES applied to antagonistic one-hour session with the option of participants building muscles augments reciprocal inhibition of agonistic spastic up to this time from 20 minutes. However, all participants muscles (van der Salm et al 2006). However, similar to tolerated at least 30 minutes from the start. Three muscle the beliefs about FES cycling on urine output and lower groups were stimulated for each leg; quadriceps, hamstrings, limb swelling, it is not yet clear whether FES cycling and gluteals. Electrodes were placed over two points on each affects spasticity. There are some studies indicating an muscle to provide a maximal contraction. One participant immediate dampening of spasticity from one-off episodes did not tolerate stimulation of the quadriceps; therefore the of ES but these studies are vulnerable to bias and do not gastrocnemius was stimulated instead. FES cycling was provide convincing evidence of the effects of FES cycling performed using a leg FES cycling systema, with participants on spasticity (Krause et al 2008, Skold et al 2002, van der seated in their wheelchairs. A FES protocol based on that Salm et al 2006). Therefore, the research question for this recommended by others (Krause et al 2008) was used with study was: the following parameters: frequency 33Hz, wavelength 350h and stimulation amplitude of up to 140mA according Does a two-week FES cycling program increase urine to participants’ tolerance to ES. Resistance was set at the output and decrease lower limb swelling and spasticity highest level that still enabled participants to cycle for at in people with recent spinal cord injury? least 30 minutes. The initial sessions for each participant were supervised on a one-to-one basis by a physiotherapist Method with at least four years of experience in the management of spinal cord injury. Later sessions for participants were Design sometimes supervised by a physiotherapist aide working under the guidance of a physiotherapist. A 5-week cross-over randomised trial was undertaken, where participants received both experimental and control phases. The usual care that was provided during both intervention Each participant underwent the 2-week control phase and phases of the study consisted of standard inpatient the 2-week experimental phase. During the experimental physiotherapy and occupational therapy that is typically phase, participants received FES cycling for 2 weeks. provided to patients during their initial rehabilitation During the control phase, participants did not receive any following spinal cord injury. This includes interventions FES cycling. The order of the two phases was randomised directed at impairments such as poor strength, restricted with a 1-week washout period in between. Participants joint mobility, limited fitness, reduced dexterity, and pain. It continued to receive other usual care throughout the trial. also includes a strong focus on training of functional skills such as dressing, walking, transferring, using the hands, A blocked randomisation allocation schedule was and pushing a wheelchair. computer-generated by an independent person to ensure equal numbers of participants commenced with the FES Outcome measures cycling phase and control phase (Schulz et al 2010). Each participant’s allocation was placed in a sealed, opaque and All assessments were conducted at the beginning (baseline) sequentially numbered envelope and kept at an off-site and end of each two-week phase by trained assessors who location. Once a participant passed the initial screening were blinded to group allocation. The success of blinding process, an independent person was contacted, an envelope was determined by asking assessors at the completion of opened and allocation revealed. The participant was deemed each participant’s last assessment whether they had been to have entered the trial at this point. unblinded. Participants The primary outcome was urine output. Secondary outcomes were lower limb swelling measured as lower leg Fourteen participants with an upper motor neuron lesion circumference, and spasticity measured using the Ashworth following recent spinal cord injury were consecutively Scale and the Patient Reported Impact of Spasticity recruited from two Sydney spinal cord injury units over an Measure (PRISM). An additional secondary outcome 18-month period commencing July 2011. Participants were measure, Global Impression of Change, was collected at the included if they: had sustained a spinal cord injury (traumatic completion of the trial. or non-traumatic) within the preceding six months; were currently receiving inpatient rehabilitation; were over 16 Baseline urine output was measured prior to the years of age; were diagnosed with an American Spinal commencement of each trial phase with the participant Cord Injury Association Impairment Scale (AIS) of A, B sitting quietly and avoiding any activity. Urine output was or C with less than 5/50 lower limb strength according to again measured at the end of both experimental and control the International Standards for Neurological Classification phases, however at the end of experimental phase urine of Spinal Cord Injury; and could tolerate FES cycling for output was measured while participants simultaneously 238 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Ralston et al: Functional electrical stimulation cycling in SCI performed FES cycling. Urine output was measured each 5BCMF. Baseline characteristics of participants. time over a one-hour period. Prior to all one-hour collection periods, participants’ bladders were emptied via a catheter. Characteristics Randomised If intermittent self-catheterisations were used for bladder (n = 14) management, an indwelling catheter was temporarily inserted to ensure consistency between measurements. In Age (yr), median (IQR) 25 (22 to 32) addition, fluid intake was restricted for three hours prior Time since injury (d), median 118 (64 to 135) to the collection period according to normal recommended (IQR) daily intake for weight (Spinal Cord Medicine Consortium Gender, n (%) male 11 (79) 1998). Where possible, participants’ bladder management AIS, n remained constant throughout the trial although two 13 participants changed bladder management from indwelling A 1 catheters – one to a suprapubic catheter and the other to B 0 intermittent self-catherisations – for reasons unrelated to C the trial. Neurological level, n 3 C4 2 Spasticity was measured before and after the experimental C5 1 and control phases of the trial using the Ashworth Scale C6 2 (Cardenas et al 2007). Measurements were performed in the C7 1 supine position for quadriceps, hamstrings, plantarflexor, T3 2 and hip adductor muscles (0–4). Scores for each muscle T4 1 group of the left and right legs were tallied and treated T6 1 as one overall measure of lower limb spasticity (0–32) as T8 1 recommended by others (Hobbelen et al 2012). T10 Bladder management, n 3 Lower limb swelling was measured before and after the two IDC 3 phases of the trial using the ‘Leg-o-meter’, a reliable and valid SPC 8 tool that uses a tape measure to quantify leg circumference ISC (Berard and Zuccarelli 2000). Circumferential measures were taken 13 cm from the base of the heel, directly AIS = American Spinal Injury Association (ASIA) Impairment posterior to the medial malleoli. Scale, IDC = indwelling catheter, SPC = suprapubic catheter, ISC = intermittent self-catheterisation. Participants were asked to complete the Patient Reported Impact of Spasticity Measure (PRISM) questionnaire estimate of the likely SD for urine output or with which before and after the control and experimental phases. to set a minimally worthwhile treatment effect. Therefore, The questionnaire explores participants’ experiences of a pragmatic approach to determining the sample size abnormal muscle control or involuntary muscle movement was adopted. That is, we selected a sample size that was over the preceding week. It asks participants to rate their realistically achievable within a 2-year recruitment period abnormal muscle control or involuntary movement for 41 even though ultimately we recruited within a 1.5-year scenarios on a 5-point scale ranging from 0 (‘never true for period. We reasoned that an estimate of treatment effect me’) to 4 (‘very often true for me’) with a maximal possible even if imprecise from a trial with minimal bias would score of 164 reflecting severe spasticity. Its reliability has progress knowledge in this area and help sample size been established (Cook et al 2007). calculations for future trialists. At the end of the trial, participants were asked to rate their Results perceptions about the overall effects of FES cycling using a 15-point Global Impression of Change Scale anchored Flow of participants through the study at –7 by ‘markedly worse’ and at +7 by ‘markedly better’ (Schneider et al 1997). In addition, they were also asked to Fourteen participants entered and completed the study. rate the inconvenience of the FES cycling phase of the trial Their median (interquartile range) age was 25 years (22 on a 10-cm Visual Analogue Scale anchored at one end with to 32) and time since injury was 118 days (64 to 135). All 0 reflecting ‘not at all inconvenient’ and at the other end with participants had motor complete lesions (AIS A, B) with 10 reflecting ‘extremely inconvenient’. Participants were neurological levels ranging from C4 to T10, as presented also asked open-ended questions to explore any perceived in Table 1. Figure 1 demonstrates the flow of participants deleterious or beneficial effects of the FES cycling. through the trial. Data analysis Compliance with the trial method Change data (pre to post difference) for each phase were Primary and secondary outcomes were attained for every used to derive point estimates of the differences between participant with no drop outs. The assessors remained blind the experimental and control phases. The analysis did for all aspects of the trial. Participants received a median not address the possibility of an order or phase effect as of 8 FES cycling sessions (IQR 8 to 9) over a mean of 2 any potential for an order effect was accounted for by the weeks (SD 0.5). There was some variation because the FES blocked randomisation schedule and any potential for a cycling was continued until the assessment at the end of phase effect was minimised by the 1-week washout period. the 2-week FES cycling phase could be completed. These This approach is recommended by others (Senn 2002). assessments were sometimes delayed for a day or more because of difficulties with scheduling. Power calculations were not conducted because there were no previous studies upon which to base a sensible Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 239
Research People with spinal cord injury admitted to spinal injury units (n = 104) Excluded (n = 90) t NBKPSMPXFSMJNCQBUIPMPHZJOKVSZ O t non-compliant with rehabilitation (n = 7) t MPXFSMJNCNPUPSQPXFS O t -./MFTJPOEJEOPUUPMFSBUF&4 O t NFEJDBMMZVOmUDPHOJUJWFJNQBJSNFOU O t non-English-speaking background (n = 5) t < 8 weeks before discharge (n = 5) t declined to participate (n = 2) Eligible (n = 14) Measured urine output, swelling, spasticity and impact of spasticity Day 0 Randomised (n = 14) Day 14 (n = 7) (n = 7) Experimental intervention Control intervention t FES cycling t usual rehabilitation t usual rehabilitation Measured urine output, swelling, spasticity and impact of spasticity (n = 7) (n = 7) Washout period Day 22 Measured urine output, swelling, spasticity and impact of spasticity (n = 7) (n = 7) Control intervention Experimental intervention Measured urine output, swelling, spasticity, impact of spasticity, Day 36 global impression of change and inconvenience (n = 7) (n = 7) Figure 1. Design and flow of participants through the trial. ES = electrical stimuation, FES = functional electrical stimulation, LMN = lower motor neuron. Effect of intervention –0.1 cm (95% CI –1.5 to 1.2) for lower limb swelling, –1.9 points (95% CI –4.9 to 1.2) on the 32-point Ashworth Scale, The results for all outcomes are presented in Table 2, and –5 points (95% CI –13 to 2) on the 164-point PRISM. with individual participant data presented in Table 3 (see Here, negative values favour the experimental intervention eAddenda for Table 3). The mean between-group difference because they indicate a decrease in swelling and spasticity for urine output was 82 mL (95% CI –35 to 199), where with FES cycling. a positive value favours the experimental intervention because it indicates an increase in urine output with FES All but two participants reported improvements with the cycling. The other mean between-group differences were FES cycling on the Global Impression of Change Scale with 240 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Ralston et al: Functional electrical stimulation cycling in SCI 5BCMF. Mean (SD) of measures before and after the experimental and control interventions, mean (SD) difference within interventions, and mean (95% CI) difference between interventions, except Global Impression of Change and perception of inconvenience, which are presented as median with interquartile range. Small numerical anomalies are due to the effects of rounding. Outcomes Intervention Difference within Difference between interventions interventions Pre Post Post minus Pre Post minus pre Exp Con Exp Con Exp Con Exp minus Con (n = 14) (n = 14) (n = 14) (n = 14) (n = 14) (n = 14) Urine output (mL) 97 123 163 106 66 –16 82a (72) (91) (136) (68) (127) (105) (–35 to 199) Leg circumference (cm) 49.2 49.6 49.3 49.8 0.1 0.3 –0.1b Ashworth (0 to 32) (4.3) (3.7) (4.6) (4.1) (2.0) (1.5) (–1.5 to 1.2) PRISM (0 to 164) 5.6 6.1 2.8 5.1 –2.9 –1.0 –1.9b Global Impression of (4.6) (5.7) (2.3) (4.6) (3.9) (3.1) (–4.9 to 1.2) Change (–7 to +7) Perception of 24 23 22 26 –2 3 –5b inconvenience (0 to 10) (11) (10) (9) (20) (4) (12) (–13 to 2) 3 (3 to 4) 0.3 (0 to 3.8) Exp = experimental phase = Functional Electrical Stimulation (FES) cycling, Con = control phase = usual care, PRISM = Patient Reported Impact of Spasticity Measure. aA positive number favours FES cycling indicating an increase in urine output. bA negative number favours FES cycling indicating a decrease in swelling or spasticity. a median improvement of 3 points (IQR 3 to 4) on the scale were imprecise as reflected in the wide 95% CI associated from –7 to +7. The median perception of inconvenience with the between-group differences. This was particularly of the FES cycling was 0.3 points (IQR 0 to 3.8) on the a problem for urine output. To increase the precision of 10-point Visual Analogue Scale. There were two reports our point estimates we needed a larger sample size and/ of adverse effects. One related to an increase in spasticity or tighter inclusion criteria. We tried to minimise the need and the other related to precipitation of a bowel accident. for a large sample size by using a cross-over design. Our All but two participants cited one or more of the following research question was appropriate for a cross-over design therapeutic effects: decreases in swelling or spasticity; because any effects of FES cycling on urine output are improvements in circulation, urine output, bowel activity or probably short lived. We could have tightened our inclusion ‘muscle tone’; and increased feelings of general wellbeing criteria. For example, those with AIS A lesions may respond including improvements in ability to breathe, a sense of better and more consistently to FES cycling than those with making progress with physical activity and psychological AIS B, C or D lesions because they tolerate higher levels of benefits from seeing their legs move. stimulation. However, by restricting the inclusion criteria we would have also restricted the ability to generalise Discussion the results to a broad population. Setting the inclusion criterion of clinical trials is always a balance between these Despite widespread beliefs about the benefits of FES competing considerations. cycling on urine output, lower limb swelling and spasticity, we were unable to detect a convincing treatment effect There are no other studies investigating the effect of FES on any of these variables. However, our results cannot be cycling on urine output against which to compare our interpreted as evidence of no treatment effect because this results. At least one study provides indirect evidence to interpretation relies on defining a minimally worthwhile support the theory that FES cycling reduces swelling via its treatment effect and it is not clear what size treatment therapeutic effects on venous return. This study examined effect clinicians and people with spinal cord injury would the effect of ES contractions on lower limb swelling during consider sufficient to justify the time and cost associated static standing on a tilt table in able-bodied individuals with FES cycling. If people with spinal cord injury would (Man et al 2003). The authors reported a notable between- consider a treatment effect equivalent to 10% of mean initial group difference in lower limb swelling measured via values then our results could be used to indicate that FES water volumetry, with a mean between-group difference of cycling has no effect on lower limb swelling. Regardless, 39 mL (95% CI 17 to 61 – estimated from provided data). our results provide valuable data for future meta-analyses There are obvious limitations of extrapolating the indirect which may be the only way of answering questions about evidence from this study. Nonetheless, along with studies the effectiveness of FES cycling on these parameters in demonstrating an effect of ES cycling on venous return people with spinal cord injury. Our results and protocol also (Elokda et al 2000, Faghri and Yount 2002, Sampson et al provide useful information for future trials. 2000), the study by Man and colleagues indicates some basis for the rationale that FES cycling in people with spinal cord Our point estimates of treatment effects for some variables injury influences venous return and lower limb swelling; a Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 241
Research conclusion not supported by our leg circumference results. the discrepancy between participants’ reports of treatment The results from the small number of studies examining the efficacy and the results of the objective measures. The most effects of FES cycling on spasticity are similar to ours with likely explanation is that participants were not blinded and no clear indication of therapeutic effect (Krause et al 2008, therefore had expectations about treatment effectiveness. Skold et al 2002, van der Salm et al 2006). These expectations may have been due to preconceived ideas regarding the therapeutic benefits of FES cycling. The potential effect of FES cycling on urine output may However, the same effectiveness of FES cycling on have been missed because we only measured urine output spasticity was not reflected in the PRISM results; an over a one-hour period immediately after FES cycling. assessment of spasticity that also relies on self-report. This One hour may be too short. However this seems unlikely may be because the PRISM is structured and participants because naturetic peptide has an immediate effect on are asked to focus specifically on the implications of their the kidneys (Dunn and Donnelly 2007). If the release of spasticity over the last week. This may minimise bias. Of naturetic peptide in response to an increase in venous return course, the discrepancy between participants’ reports of is the main mechanism by which FES cycling increases treatment efficacy and the results of the objective measures urine output, then our time frame for measurements of may reflect participants’ ability to sense changes that our urine output should have been sufficient. Another possible measures were incapable of detecting. explanation for our failure to find a convincing treatment effect is our use of a short intervention period, namely In all, a cautious interpretation of our results is that two two weeks. A longer training period may have increased weeks of FES cycling does not have clear beneficial effects participants’ muscle bulk and stimulated strength (Baldi on urine output, lower limb swelling, or spasticity in people et al 1998) thereby enhancing the muscle pump effect with recent spinal cord injury, and that our confidence in the and venous return. Venous return may have been further therapeutic effects of FES cycling on these variables is not increased by the stimulation of additional lower limb yet justified. It is therefore not clear whether FES cycling muscles however stimulation of more than three muscle should be prescribed for these purposes. Q groups is problematic as this requires additional expensive equipment not routinely available in the clinical setting. Footnotes: aRT300 cycle, Restorative Therapies, USA. Future studies could manipulate some of these variables to determine their effect on urine output. eAddenda: Table 3 available at jop.physiotherapy.asn.au Only the immediate effects of FES cycling were investigated Ethics: The Ethics Committees of the University of and only at the impairment level. We acknowledge that urine Sydney, University of Wollongong and Royal Rehabilitation output, lower limb swelling and spasticity are surrogate Centre Sydney approved this study. All participants gave measures for what is important to people with spinal cord written informed consent before data collection began. injury, and clearly immediate effects are of little interest All applicable governmental and institutional ethical unless they are sustained. We however restricted the trial regulations regarding the use of human volunteers were in this way to increase statistical power. In addition, it is followed during the trial. potentially wasteful of resources looking for sustained effects of interventions on global measures of participation Competing interests: None declared. without first demonstrating immediate effects on surrogate measures. Support: Prince of Wales Hospital Foundation. Importantly, FES cycling is advocated in people with motor Acknowledgments: We thank the patients, and complete lesions for reasons other than its effect on urine physiotherapy, medical, and nursing staff of the Spinal output, lower limb swelling and spasticity. For example, it Units at the Royal Rehabilitation Centre Sydney and the is advocated on the basis that it increases cardiovascular Prince of Wales Hospital, Sydney. fitness, muscle bulk and lean muscle mass. There is also some evidence to suggest that FES cycling prevents bone Correspondence: Associate Professor Lisa Harvey, loss and contractures, and decreases adipose tissue and the Rehabilitation Studies Unit, Sydney School of Medicine/ risk of diabetes (Carlson et al 2009, Hicks et al 2011). We Northern, The University of Sydney, PO Box 6, Ryde, NSW, did not look at any of these variables because they were Australia. Email: [email protected] unlikely to be influenced by two weeks of FES cycling. References Interestingly, all but two participants when asked to rate change from the FES cycling on the Global Impression Adams MM, Hicks AL (2005) Spasticity after spinal cord injury. of Change Scale stated that it made them ‘somewhat’ Spinal Cord 43: 577–586. to ‘moderately’ better, as reflected by a median score of 3 points (IQR 3 to 4). Some argue that even a 1-point Baldi JC, Jackson RD, Moraille R, Mysiw WJ (1998) Muscle change on the Global Impression of Change Scale should atrophy is prevented in patients with acute spinal cord injury be considered clinically significant by definition (Schneider using functional electrical stimulation. Spinal Cord 36: 463– and Olin 1996, p. 278). While we do not fully agree with 469. this interpretation of clinical significance, it does indicate that some may interpret our results as convincing evidence Berard A, Zuccarelli F (2000) Test-retest reliability study of a of treatment effectiveness. When asked open-ended new improved Leg-O-Meter, the Leg-O-Meter II, in patients questions about the beneficial or detrimental effects of FES suffering from venous insufficiency of the lower limbs. cycling, most participants stated only beneficial effects Angiology 51: 711–717. including improvements in urine output and reductions in lower limb swelling and spasms. 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Ploegmakers et al: Reference values for grip strength in children Grip strength is strongly associated with height, weight and gender in childhood: a cross sectional study of 2241 children and adolescents providing reference values Joris JW Ploegmakers1, Ann M Hepping2, Jan HB Geertzen2, Sjoerd K Bulstra1 and Martin Stevens1 1Department of Orthopaedics, 2Department of Rehabilitation Medicine University of Groningen, University Medical Center Groningen The Netherlands Question: What are reference values for grip strength in children and adolescents based on a large and heterogeneous study population? What is the association of grip strength with age, gender, weight, and height in this population? Design: Cross-sectional study. Participants: Participants were recruited from schools in the northern provinces of the Netherlands. The study included healthy children and adolescents ranging in age from 4 to 15 years. Outcome measures: All children had their height (cm) and weight (kg) measured and were allowed a total of four attempts using the Jamar hand dynamometer: twice with each hand. Grip strength scores (kg) were recorded for the dominant and non-dominant hands. Results: The study population comprised 2241 children and adolescents. Reference values for both genders are provided according to age and dominance. Grip strength shows a linear and parallel progression for both genders until the age of 11 or 12, after which grip strength development shows an acceleration that is more prominent in boys. Conclusion: There is a significant difference in grip strength with each ascending year of age in favour of the older group, as well as a trend for boys to be stronger than girls in all age groups between 4 and 15 years. Weight and especially height have a strong association with grip strength in children. [Ploegmakers JJW, Hepping AM, Geertzen JHB, Bulstra SK, 4UFWFOT. (SJQTUSFOHUIJTTUSPOHMZBTTPDJBUFEXJUIIFJHIU XFJHIUBOEHFOEFSJODIJMEIPPEBDSPTTTFDUJPOBM TUVEZPGDIJMESFOBOEBEPMFTDFOUTQSPWJEJOHSFGFSFODFWBMVFTJournal of Physiotherapyo> Key words: Grip strength, Children, Jamar hand dynamometer, Reference values, Physiotherapy Introduction have shown up in the search. Although we found several studies focusing specifically on grip strength in children, Grip strength is used extensively in the assessment of hand most of them had not assessed height and weight as factors function. Because it is directly affected by the neural, of influence (Ager et al 1984, Bear-Lehman et al 2002, muscular and skeletal systems, grip strength is used in the Butterfield et al 2009, De Smet and Vercammen 2001, evaluation of patients with a large range of pathologies Mathiowetz et al 1986). This is remarkable in the case that impair the upper extremities, including rheumatoid of growing children, especially when weight and height arthritis, osteoarthritis, muscular dystrophy, tenosynovitis, are known to correlate with strength in children (Rauch stroke, and congenital malformations. Grip strength 2002, Häger-Ross and Rösblad 2002, Newman et al 1984). measurements also have an established role in determining Moreover, although some of these studies included a large treatment efficacy, such as in the evaluation of different number of children in total (with exception of Newman wrist orthoses, the effect of hand exercises in rheumatoid arthritis, and recovery after trauma. Also, they are used What is already known on this topic: Grip strength as an outcome measure after many different surgical is used widely in clinical practice and research to interventions. Grip strength measurements provide a well assess the impact of a variety of disorders on hand established and objective score that is reflective of hand function. Although robust data exist for predicting grip function and that is easily and quickly obtainable by a range strength in adults, the few studies that have generated of different health professionals. normative data in children and adolescents either had a limited sample size, used a measurement device Since comparison to normative data is important when that is no longer used in clinical practice, or did not making statements about specific patient groups or analyse factors such as hand dominance, height, or treatments, obtaining normative data for grip strength in weight. adults has been the subject of many studies. In contrast, normative data for children is far less readily available. What this study adds: Normative equations and To identify studies on this topic we searched PubMed, graphs were generated using data from 2241 children MEDLINE and EMBASE using combinations of the search and adolescents. Grip strength increases with age, terms: children, adolescents, grip strength, dynamometer, with a trend for boys to be stronger than girls in all Jamar hand dynamometer, JHD, normative data and age groups between 4 and 15 years. Weight and reference values. Reference lists of relevant articles were height have a strong association with grip strength in then screened to identify additional articles that might not children and adolescents. Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 255
Research et al 1984, varying between 81 and 736), the number of height (in cm) and weight (in kg) of each participating child children in each age group and/or the range of age groups is were then measured. often limited and relatively small for establishing reference values. Also, a variety of methods and instruments was Grip strength was measured using the Jamar® hydraulic used. For example, some studies did not differentiate hand dynamometera. A total of six calibrated dynamometers between scores of the dominant and non-dominant hand, were at the researchers’ disposal. The devices were replaced used a device that is no longer used in clinical practice, twice, at subsequent time intervals, with two used devices or scored the maximum instead of the mean of attempts. exchanged for two non-used devices after approximately Therefore, it can be concluded that there is a need for one-third, and again after two-thirds of the total number a study that assesses the development of grip strength in of children we aimed to recruit had been assessed. The children, based on large groups according to age and gender following standardised testing position for measuring grip and performed according to current standardised methods strength was used, as advocated by the American Society regarding measurement of grip strength. of Hand Therapists (ASHT): the participant is seated with shoulders adducted and neutrally rotated, elbow flexed at The primary aim of this study was to provide reference 90 deg, wrist between 0 and 30 deg extension, and between values for grip strength in children and to present these data 0 and 15 deg ulnar deviation (Balogun et al 1985, Fess graphically to allow easy comparison with patient outcomes 1992). The handle of the device was set to the second by a range of clinicians in daily practice. Therefore the position for all participants, with the exception of 4 and 5 research questions were: year olds, for whom the bar was set to the first position, and who were allowed to manually support the arm with 1. What are the reference values for grip strength in the other hand. Participants were allowed four attempts children aged 4–15 years according to age, gender using the dynamometer, two with each hand, and each and dominance based on a large, heterogeneous study individual attempt was scored. The starting hand was population? alternated between subjects and a 10-sec break was allowed between attempts. A Dutch translation of the Southampton 2. What is the association of gender, height, and weight grip strength measurement protocol was used as verbal with grip strength in children? encouragement (Roberts et al 2011). Encouragement was kept as consistent as possible for every participant in volume Method and tone, counting down from 3 to 0, followed by ‘squeeze as hard as you can … squeeze and let go’. Design Data analysis This cross-sectional study measured grip strength in a cohort of healthy children and adolescents. The data were Descriptive statistics were used to describe the main used to generate normative values for grip strength. characteristics of the participants. The Mann-Whitney U test was used to compare grip strength between genders. Participants In order to establish the correlation of gender, age, height, and weight with grip strength in more detail, we performed Children and adolescents ranging in age from 4 to 15 years a multilevel analysis adding them as fixed factors. As were included. Participants were recruited by approaching intercept, the school the child attended was added. Results schools in the four northern provinces of The Netherlands. were accepted to be significant when the p value was < 0.05. All children of participating school classes were invited to take part. Exclusion criteria were: pain or restriction Results of movement of a hand or arm, neuromuscular disease, generalised bone disease, aneuploidy, any condition In total 19 schools participated, located in 12 towns and that severely interfered with normal growth or required cities. Thirteen children were ineligible for participation hormonal supplementation, and children who could not be in the study. Two children were excluded because of Down instructed in how to use the dynamometer. syndrome, two children because they suffered from active juvenile arthritis, four because they had pre-existing pain All included subjects were assigned to a group based on of a hand or arm, and one because she received hormonal their calendar age at the time of the assessment, thereby therapy to improve growth. Another four children were creating nine subgroups in total. The study aimed to include excluded because they did not meet the inclusion criteria, at least 200 children in each age group, with a near to equal but no specific reason was recorded. Nine eligible children representation of boys and girls. were excluded because the form on which measurements were written was not filled in completely. In order to get Outcome measures an impression of how many children refused to participate we randomly recorded the number of children that refused Each measurement session started with a short lecture by to participate at half of the schools visited. Based on this the researchers to introduce themselves to the school class registration it can be estimated that about 1% of invited and to explain the procedures and the purpose of the study. children did not participate in the study. The reasons cited A demonstration of the use of the dynamometer was given, most commonly were unfamiliarity (children who just using the teacher as an example. Individually, dominance started school), problems with (self-perceived) body weight, was determined by asking which hand was used to write or simply ‘not feeling like it’. or, in the case of young children, used to perform activities such as cutting or painting. Children aged 4 and 5 years, The final study population comprised 2241 children and in whom hand dominance is not yet fully established, and adolescents (1112 boys and 1129 girls) ranging in age from any older children who displayed uncertainty regarding 4 to 15 years. Values for grip strength according to age, hand dominance, were asked to draw a circle. To avoid suggestion by the researcher, these participants had to pick up the pencil from the table themselves. The hand used to draw the shape was then scored as the dominant hand. The 256 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Ploegmakers et al: Reference values for grip strength in children Figure 1. Reference values for grip strength according to gender, dominance, and age. Scores are plotted as percentiles 3, 10, 50, 90, and 97. The upper and lower limits indicate the borders of reference values for strength at the corresponding age. The darker shaded areas represent the centralised 80% of scores. hand dominance, and gender are presented in Figure 1. Grip age of 11 for both hands. Regardless of this acceleration, strength in both hands increased with age, showing a nearly the difference in mean strength between all age groups was linear progression for boys until the age of 12. Above the significant for both hands and in both genders in favour of age of 12, the increase in strength shows acceleration in the the older group (p < 0.01), with exception for the values of dominant hand. A similar observation can be made for the the non-dominant hand between girls aged 13 and 14 where non-dominant hand after reaching the age of 13. For girls, p was 0.02. this acceleration was less prominent but began at the earlier Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 257
258 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. A more extensive overview of all the results, including 5BCMF. Number of participants, grip strength values for the dominant and non-dominant hands, height and weight, according to age Research additional details regarding the study population, is and gender. presented in Table 1. Boys were significantly stronger than girls with the dominant hand at ages 4 (p = 0.02), 5 (p = Age Boys Girls 0.04), 6 (p = 0.003), 8 (p = 0.001), 9 (p = 0.001), and 14 (p (yr) < 0.001). For the non-dominant hand this was true at ages 4 (p = 0.03), 6 (p = 0.02), 8 (p < 0.001), 9 (p < 0.001), 11 n Dominant Non-dominant Height Weight n Dominant Non-dominant Height Weight (p = 0.01), and 14 (p < 0.001). With the exception of the (kg) (kg) (cm) (kg) (kg) (kg) (cm) (kg) dominant hand at age 7, where both genders scored equal, there was a trend for boys to score higher than girls with mean (SD) range 19 (3) 109 5.1 (2) mean (SD) range 19 (3) both their dominant and non-dominant hand in all age 15 to 26 1 to 11 13 to 29 groups. The percentage difference in grip strength in favour 4 124 5.7 (2) 5.3 (2) 111 (5) 22 (3) 4.7 (2) 111 (5) 22 (3) 1 to 12 2 to 10 100 to 126 15 to 30 105 6.7 (2) 2 to 10 100 to 126 15 to 32 of boys fluctuated, from 0–14% at ages 4 to 13, rising to 2 to 15 26% at age 14. 5 102 7.5 (3) 6.8 (3) 117 (6) 25 (4) 6.0 (2) 118 (6) 25 (4) 2 to 14 3 to 14 103 to 138 17 to 44 108 9.0 (3) 1 to 12 102 to 131 16 to 39 In order to establish the association of gender, age, height, 28 (5) 3 to 18 29 (5) and weight with grip strength in more detail, we performed 6 123 10.2 (3) 9.4 (3) 125 (5) 20 to 54 8.3 (3) 124 (6) 17 to 40 a multilevel analysis adding them as fixed factors. Adding 5 to 18 4 to 17 111 to 139 32 (6) 98 12.9 (3) 2 to 16 100 to 137 the school the child attended as an intercept resulted in a 23 to 55 7 to 21 31 (6) better fit of the model for both the dominant and the non- 7 104 13.0 (4) 12.0 (3) 131 (6) 36 (7) 11.9 (3) 131 (6) 20 to 49 dominant hand data. For both the dominant and the non- 7 to 21 5 to 19 116 to 145 25 to 60 118 14.4 (3) 5 to 18 113 to 141 35 (7) dominant hand, the variables age, height, weight, and 38 (7) 8 to 22 24 to 53 gender had a significant association with grip strength (p 8 113 15.9 (4) 14.6 (3) 139 (6) 26 to 65 13.1 (3) 136 (6) = < 0.001), resulting in the following predictive equations: 8 to 25 8 to 23 124 to 155 43 (10) 119 16.7 (3) 7 to 21 122 to 151 41 (8) 27 to 74 9 to 26 25 to 63 9 116 18.2 (4) 16.8 (4) 142 (6) 48 (10) 15.1 (3) 141 (5) 10 to 29 8 to 33 126 to 162 30 to 73 103 19.1 (4) 7 to 23 126 to 154 44 (9) 52 (10) 9 to 29 28 to 79 10 109 19.6 (2) 18.1 (3) 147 (7) 39 to 85 17.2 (4) 149 (7) 48 (11) 12 to 29 9 to 28 129 to 161 60 (11) 113 20.6 (4) 8 to 29 132 to 167 32 to 110 38 to 89 10 to 35 11 113 22.0 (5) 20.6 (4) 154 (8) 19.1 (4) 154 (8) 49 (8) 9 to 35 8 to 33 134 to 172 106 24.2 (5) 11 to 30 135 to 181 33 to 89 15 to 39 55 (10) 12 96 24.7 (5) 22.9 (5) 159 (9) 22.3 (4) 160 (6) 42 to 103 13 to 36 13 to 35 140 to 180 97 26.4 (5) 13 to 33 144 to 178 14 to 39 13 66 28.2 (6) 25.8 (6) 166 (9) 24.5 (4) 163 (7) 17 to 45 17 to 42 150 to 189 53 29.1 (5) 17 to 36 138 to 176 16 to 43 14 46 36.0 (7) 33.5 (7) 175 (8) 26.6 (5) 169 (6) 24 to 51 22 to 51 155 to 193 15 to 36 157 to 183
Ploegmakers et al: Reference values for grip strength in children 5BCMF. Multilevel analysis of grip strength data. Hand Estimate SE DF t Wald Z p 95% CI Lower Upper Parameter –17.80 33.30 0.00 –20.59 1.16 1707.65 8.00 2.64 0.00 –22.85 –18.32 Dominant 1.09 0.14 2224.61 13.72 0.00 0.83 1.36 Intercept 0.17 0.13 2231.36 11.78 33.30 0.00 0.15 0.20 Male 0.14 0.12 2231.41 12.05 2.60 0.00 0.12 0.16 Height 0.85 0.07 2172.38 0.71 0.99 Weight –16.92 0.00 Age 10.23 0.31 8.58 0.01 9.64 10.85 Covariance 1.11 0.42 12.90 0.53 2.33 Residual 10.47 0.00 Intercept school –19.52 1.15 1832.86 11.21 0.00 –21.78 –17.25 1.17 0.14 2226.23 0.00 0.91 1.44 Non-dominant 0.16 0.13 2233.39 0.00 0.14 0.19 Intercept 0.12 0.12 2233.49 0.00 0.10 0.15 Male 0.79 0.07 2130.14 0.65 0.93 Height 0.00 Weight 10.29 0.31 0.01 9.70 10.91 Age 0.87 0.34 0.41 1.86 Covariance Residual Intercept school Dominant hand = –20.59 (+ 1.09 if male) + 0.85 * age (yr) sets in earlier, but is less prominent. At the age of 12 the + 0.17 * height (cm) + 0.14 * weight (kg) curves of height and weight according to gender also show a separation in favour of boys. In contrast, the height curve of Non-dominant hand = –19.52 (+ 1.17 if male) + 0.79 * age females is showing a flattening slope from that age onwards (yr) + 0.16 * height (cm) + 0.12 * weight (kg) – patterns consistent with those of the national growth study (TNO/LUMC 1998). Therefore, the authors predict A more extensive overview of these results is presented in that the grip strength of girls above the age covered in this Table 2. study will not increase much further since their average increase in growth after the age of 14 is only 5 cm, and their Discussion estimated gain in weight around 5 kg until the age of 21 (TNO/LUMC 1998). This theory is supported by the data To our knowledge, this is the largest study to generate of Newman et al (1984), which showed no further increase normative values of grip strength in children. Although in strength of girls after the age of 13. This is in agreement other studies have provided normative data, the subgroups with data retrieved from a literature review regarding grip according to age and gender in most studies were small for strength in adults, which showed that norms for females establishing reference values (Ager et al 1984, De Smet and aged 20 in six different studies varied from 28.3 to 35.6 Vercammen 2001, Molenaar et al 2010, Newman et al 1984). kilograms for the dominant hand, and from 24.2 to 32.7 Samples for normative data should be ‘large, random, and kilograms for the non-dominant hand (Innes 1999). For representative of the population’s heterogeneity’ (Portney females aged 40 results varied from 28.3 to 35.3 kilograms and Watkins 1993, Innes 1999). This study was designed for the dominant hand, and from 21.9 to 33.2 kilograms for to meet these criteria not only by including a large number the non-dominant hand. The 14 year old girls in our study of children, but also by ensuring that each subgroup when scored 29.1 and 26.6 kilograms respectively. In both cases broken down according to age and gender included a these scores fall within these ranges for adults. For boys, no sufficient number of children. The results of this study show reliable prediction of grip strength above the age of 14 can a significant difference in strength with each ascending year be made, as on average they are expected to grow around of age in favor of the older group, as well as a trend for 16 centimetres taller and gain 14 kilograms before reaching boys to be stronger than girls in all age groups between 4 the age of 21 (TNO/LUMC 1998). and 15 years. In addition, weight and height were strongly associated with grip strength in children. Comparing grip strength results with former studies in more detail proved to be difficult, due to differences The described curve of grip strength in boys – higher yet in methods between studies. For example, the study by parallel to those of girls until the age of 12 – is consistent Newman et al (1984) contained relatively large subgroups, with other studies, as is the acceleration of grip strength but it was performed with a different device that is no longer specifically for boys after the age of 12 (Ager et al 1984, commonly used. The study of Ager et al (1984) reported Butterfield et al 2009, Mathiowetz et al 1986, Newman et scores according to the right or left hand, and not according al 1984). Considering the strong correlation of height with to dominance. Where comparison was possible, the results strength, this is probably a result of the growth spurt. This of the current study where relatively high: 4–12% higher would also explain why the acceleration described in girls Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 259
Research than those of De Smet et al (2001) who allowed only one result of the exclusion criteria, meaning results can only be attempt with each hand, and 8–14% higher than those of applied to the healthy population and cannot be extrapolated Molenaar et al (2010) where three attempts were allowed. to other age groups. The study by Butterfield et al (2009) reported 4% lower to 6% higher scores. Besides differences in methods, the In summary, this study presents reference values for grip higher results may be a consequence of the ongoing trend strength in children. These reference values for both in the Netherlands, ie, height is still increasing over the the dominant and the non-dominant hand are provided decades (Fredriks et al 2000). This is supported by data graphically according to gender and age, to facilitate from Statistics Netherlands (Frenken 2007). Another comparison to patients’ values. These graphics also allow factor that must be taken into consideration is that the monitoring of progression over time. In addition the results Dutch population, and in particular those in the three most of this study show that gender, age, height, and weight are northern provinces, is known to be relatively tall (Frenken strongly associated with the development of grip strength 2007). in children. Finally, detailed equations are provided to give a more precise prediction regarding a specific patient when Besides including a large number of children, a relatively height and weight are known. Q large geographical area was covered and both rural and urban schools were included to ensure a broad diversity and Footnotes: aJamar® dynamometer, Lafayette Instrument heterogeneity of participants. A vast number of different Company, Lafayette, USA. instruments are available to measure grip strength. The Jamar hand dynamometer was selected because most Ethics: The study was conducted in accordance with the normative studies have used this device and therefore regulations of the METC Institutional Review Board of it allows data to be compared with other (and future) the University Medical Center Groningen. Children were studies (Innes 1999, Roberts et al 2011). Moreover, besides included in the study after permission of parents had been having a high test-retest and inter-investigator reliability, given. However, it was also ensured that each child knew it also has high reproducibility when used by children the examination was not mandatory, and children were not (Lindstrom-Hazel et al 2009, Mathiowetz et al 1984, included if they did not want to participate. Roberts et al 2011, Van den Beld et al 2006). To ensure all children were measured in the same manner, and again to Support: None. follow standardised methods, participants were measured according to the ASHT protocol (Innes 1999, Roberts et al Competing interests: There are no competing interests. 2011). However, we implemented three exceptions. First, for the 4 and 5 year olds, the handle of the device was set Acknowledgements: The authors thank all the children, to the first setting, which is considered to be less accurate their parents, and the schools for their contribution to this than the second (Bechtol 1954, Boadella et al 2005, Firrell study as well as the students who aided the researchers and Crain 1996, Hamilton et al 1994). These findings with measurements. The authors also thank PU Dijkstra, A result from studies that focus on adults, and young children Shepherd, RE Stewart, and WFA Klijn for their assistance. obviously have smaller hands. Therefore the distance to the handle of the device (3.8 cm) is relatively large compared Correspondence: JJW Ploegmakers, Department to their average hand size (Bear-Lehman et al 2002). In of Orthopaedics, University of Groningen, University practice, they could not reach the second setting adequately, Medical Center Groningen, The Netherlands. Email: and the first setting has also been used for adults with [email protected] small hands (Ruiz-Ruiz et al 2002). Second, it is preferred to use the mean of three attempts (MacDermid et al 1994, References Mathiowetz et al 1984). However, other studies showed that scoring fewer attempts, taking fewer attempts into Ager CL, Olivett BL, Johnson CL (1984) Grasp and pinch consideration, or even using the maximum attempt, does strength in children 5 to 12 years old. American Journal of not lead to significant differences compared with the mean Occupational Therapy 38: 107–113. of three attempts (Coldham et al 2006, Crosby and Wehbé 1994, Haidar et al 2004). Additionally, although fatigue Balogun JA, Akomolafe CT, Amusa LO (1985) Grip strength: does not seem to influence grip strength measurement in effects of testing posture and elbow position. Archives of adults, we could not find any studies regarding this matter Physical Medicine and Rehabilitation 66: 69–74. in children. Considering these factors we chose to allow two attempts with each hand. Finally, the ASHT-protocol Bear-Lehman J, Kafko M, Mah L, Mosquera L, Reilly B (2002) does not provide details regarding encouragement. Verbal An exploratory look at hand strength and hand size among encouragement was given to stimulate children to attempt preschoolers. Journal of Hand Therapy 15: 340–346. their very best. The content of encouragement was the same for all children, and the type and volume was kept as Bechtol CO (1954) Grip test: the use of a dynamometer with consistent as possible. Unfortunately, the goal of including adjustable handle spacings. Journal of Bone and Joint 200 children for each age group was not achieved in the two Surgery America 36: 820–832. oldest groups, owing mainly to the fact that participation of high schools was difficult to arrange. Also, we did not Boadella JM, Kuijer PP, Sluiter JK, Frings-Dresen MH (2005) systematically record exactly how many children refused to Effect of self-selected handgrip position on maximal participate. However, the available data indicate that only a handgrip strength. Archives of Physical Medicine and marginal proportion of children refused, which makes the Rehabilitation 86: 328–331. data highly representative. Other limitations are a direct Butterfield SA, Lehnhard RA, Loovis EM, Coladarci T, Saucier D (2009) Grip strength performances by 5- to 19-year olds Perceptual and Motor Skills 109: 362–370. Coldham F, Lewis J, Lee H (2006) The reliability of one vs. three grip trials in symptomatic and asymptomatic subjects. Journal of Hand Therapy 19: 318–327. 260 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Ploegmakers et al: Reference values for grip strength in children Crosby CA, Wehbé MA (1994) Hand strength: normative Mathiowetz V, Weber K, Volland G, Kashman N (1984) Reliability values. The Journal of Hand Surgery 19: 665–670. and validity of grip and pinch strength evaluations. Jounal of Hand Surgery (American Volume) 9: 222–226. De Smet L, Vercammen A (2001) Grip strength in children. Journal of Pediatric Orthopaedics B 10: 352–354. Mathiowetz V, Wiemer DM, Federman SM (1986) Grip and pinch strength: norms for 6- to 19-year-olds. American Fess E (1992) Grip strength. In: Clinical assessment Journal of Occupational Therapy 40: 705–711. recommendations (2 edn). Chicago: American Society of Hand Therapists, pp 41–45. Molenaar HM, Selles RW, Zuidam JM, Willemsen SP, Stam HJ, Hovius SE (2010) Growth diagrams for grip strength in Firrell JC, Crain GM (1996) Which setting of the dynamometer children. Clinical Orthopaedics and Related Research 468: provides maximal grip strength? The Journal of Hand 217–223. Surgery 21: 397–401. Newman DG, Pearn J, Barnes A, Young CM, Kehoe M, Fredriks AM, Van Buuren S, Burgmeijer RJF, Meulmeester Newman J (1984) Norms for hand grip strength. Archives of JF, Beuker RJ, Brugman E, et al (2000) Continuing positive Disease in Childhood 59: 453–459. secular growth change in the Netherlands 1955–1997. Pediatric Research 47: 316–323. Portney LG, Watkins MP (1993) Foundations of clinical SFTFBSDI BQQMJDBUJPOT UP QSBDUJDF /PSXBML 1FBSTPO Frenken F (2007) Vertraging in lengtegroei en Prentice Hall. gewichtstoename. CBS, Bevolkingstrends, 4e kwartaal 2007 [Deceleration in height growth and weight gain. Statistics Rauch F, Neu CM, Wassmer G, Beck B, Rieger-Wettengl G, Netherlands, Population Trends, 4th quarter 2007] 92–98. Rietschel E, et al (2002) Muscle analysis by measurement of maximal isometric grip force: new reference data and Häger-Ross C, Rösblad B (2002) Norms for grip strength in clinical applications in pediatrics. Pediatric Research 51: children aged 4–16 years. Acta Pædiatrica 91: 617–625. 505–510. Haidar SG, Kumar D, Bassi RS, Deshmukh SC (2004) Average Roberts HC, Denison HJ, Martin HJ, Patel HP, Syddall H, versus maximum grip strength: which is more consistent? Cooper C, et al (2011) A review of the measurement of grip The Journal of Hand Surgery: Journal of the British Society strength in clinical and epidemiological studies: towards a for Surgery of the Hand 29: 82–84. standardised approach. Age and Ageing 40: 423–429. Ruiz- Ruiz J, Mesa JLM, Gutiérrez A, Castillo MJ (2002) Hand size Hamilton A, Balnave R, Adams R (1994) Grip strength testing influences optimal grip span in women but not in men. The reliability. Journal of Hand Therapy 7: 167–170. Journal of Hand Surgery 27: 897–901. Innes E (1999) Handgrip strength testing: A review of the 5/0-6.$ (SPFJPOEFS[PFL #PIO 4UBnFV 7BO literature. Australian Occupational Therapy Journal 46: 120– Loghum 9000025389. [Dutch Organization for Applied 140. 4DJFOUJmD 3FTFBSDI -FJEFO 6OJWFSTJUZ .FEJDBM $FOUFS growth study 1997, Bohn Stafleu Van Loghum 9000025389] Lindstrom-Hazel D, Kratt A, Bix L (2009) Interrater reliability of students using hand and pinch dynamometers. American Van den Beld WA, Van der Sanden GAC, Sengers RCA, Verbeek Journal of Occupational Therapy 63: 193–197. ALM, Gabreëls FJM (2006) Validity and reproducibility of the Jamar dynamometer in children aged 4–11 years. Disability MacDermid JC, Kramer JF, Woodbury MG, McFarlane and Rehabilitation 28: 1303–1309. RM, Roth JH (1994) Interrater reliability of pinch and grip strength measurements in patients with cumulative trauma disorders. Journal of Hand Therapy 7: 10–14. Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 261
Appraisal Clinimetrics Ice-water (cold stress) immersion testing Description Trauma-induced cold intolerance (cold sensitivity) is used in clinical studies prior to establishment of reliable characterised by pain, stiffness, altered sensibility, or colour protocols. change associated with cold exposure (Campbell and Kay 1998), and is common after nerve injury or surgery (Irwin Instruments: Infrared skin thermometer, pool thermometer, et al 1997). The Immersion in Cold water Evaluation (ICE) stopwatch, insulated water container, and ice water. is a cold stress test administered through a standardised protocol where the hand is immersed in cold water and Interpretation: Failure of temperature and pain scores to the examiner monitors the pain response and re-warming return to baseline after ICE indicates cold intolerance. (Traynor and MacDermid 2008). The complete test description is available at http://www. Test description: The patient is allowed to acclimatise for youtube.com/watch?v=ktvjsqbIfUM 15 minutes in a room with temperature of 20° to 22° C. The hand digits are then immersed in 12° C water for 5 minutes, Reliability and validity: The reliability of digital skin followed by a 10-minute re-warming period for a total test temperature measurement is excellent with test-retest duration of 30 minutes. Pain is reported using the Numeric intraclass correlation coefficients (ICC) ranging from 0.81 Rating Scale (NRS) just prior to and after immersion, and to 0.86 in healthy subjects (Traynor and MacDermid 2008). at the end of the test. Skin surface temperature is measured Intra-rater ICCs of 0.79 to 0.82 have also been reported before and after immersion, and at the end of the recovery in patients with complex regional pain syndrome and in period. The ICE can be repeated for the unaffected or less healthy control subjects (Packham et al 2012). Subjective affected limb for better comparison. Variations of this reporting of cold intolerance (ie, using NRS) is also well protocol at different temperatures or timing have been supported (Traynor 2008, MacDermid et al 2009, Maxwell and Sterling 2013) but only moderately correlated. Commentary Cold responses are altered in many clinical conditions, such References as whiplash-associated disorders, complex regional pain syndrome, and hand vibration syndrome (Harada 2002, Campbell DA, Kay SP (1998) J Hand Surg Br 23: 3–5. Sterling et al 2003; Maxwell and Sterling 2013, Packham Harada N (2002) Int Arch Occup Environ Health 75: 14–19. et al 2012). Cold intolerance can also be idiopathic, such Irwin MS et al (1997): J Hand Surg Br 22: 308–316. as occurs with Raynaud’s phenomenon. There are multiple MacDermid J et al (2009): J Orthop Sports Phys Ther 39: 388. reasons and methods for assessing response to cold and no Maxwell S, Sterling M (2013) Man Ther 18: 172–174. single method has been shown to be superior. Packham TL et al (2012): J Hand Ther 5: 358–362. Sterling M et al (2003): Pain 104: 509–517. Benefits for clinicians: In comparison to costly quantitative Traynor R, MacDermid J (2008): Hand 3: 212–219. sensory testing, this test presents a reliable, feasible, and economical choice for clinicians. Limitations: The ICE is not tolerated by all patients and its value in comparison to cold pain threshold testing is not known. Test results may be impacted by seasonal temperature variations, gender, smoking, and alcohol intake. Contraindications include open wounds/ulcers on the digits, and digital arterial disease. Zakir Uddin, Joy MacDermid and Tara Packham School of Rehabilitation Science, McMaster University, Canada Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013 277
Farlie et al: Reporting the intensity of balance exercise Intensity of challenge to the balance system is not reported in the prescription of balance exercises in randomised trials: a systematic review Melanie K Farlie1,2, Lauren Robins1,2, Jennifer L Keating2, Elizabeth Molloy3 and Terry P Haines1,2 1Allied Health Research Unit, Monash Health, 2School of Primary Health Care, Faculty of Medicine Nursing and Health Sciences, Monash University, 3Health Professions Education and Educational Research, Faculty of Medicine Nursing and Health Sciences, Monash University Australia Question: How has balance challenge intensity been reported in trials of balance exercise interventions? Are there any instruments designed to measure the intensity of balance challenge in balance training exercises? Design: Systematic review of randomised trials of balance training exercises. Participants: Older adults, ie, the majority of subjects were aged over 55 years. Intervention: Balance exercise intervention, or multi-dimensional intervention that included a balance exercise intervention. Outcome measures: The included trials were examined for descriptions and instruments used to report the intensity of the challenge to the patient’s balance system provided by the balance exercise prescribed. The other included studies were examined for instruments that measure balance challenge intensity. Results: In most of the 148 randomised trials identified, measures of reported balance challenge ‘intensity’ were actually measures of some other aspect of the exercise, eg, aerobic intensity or a hierarchy of task difficulty without reference to the patient’s ability. Three potential systems of measuring the balance challenge intensity were identified. Two were not described in any detail. One was defined in terms of the limits of the patient’s postural stability, but this system appears not to have been validated. No adequate measures of balance challenge intensity were found among the other types of studies identified. Conclusion: The review highlights a serious gap in the methods used to prescribe, implement, and evaluate the effect of balance exercise programs. Comprehensive work in this area is required to develop a psychometrically sound measure of balance exercise intensity. <'BSMJF., 3PCJOT- ,FBUJOH+- .PMMPZ& )BJOFT51 *OUFOTJUZPGDIBMMFOHFUP UIFCBMBODFTZTUFNJTOPUSFQPSUFEJOUIFQSFTDSJQUJPOPGCBMBODFFYFSDJTFTJOSBOEPNJTFEUSJBMTBTZTUFNBUJDSFWJFX Journal of Physiotherapyo> Key words: Postural balance, Exercise, Exercise therapy, Systematic review Introduction exercise frequency, type, and time are relatively easy to quantify, quantifying exercise intensity is more complex. Age-related decline in balance occurs in both men and Quantification of exercise intensity has been achieved in women, beginning as early as 40 years of age (Nitz and the domain of strength training, where intensity is routinely Low Choy 2008, Nolan et al 2010). Balance control is measured using the 1-repetition maximum (1RM) method important for maintaining independence and safety. An (Thompson et al 2010). Aerobic training programs use extensive review of randomised controlled trials has intensity measures such as percentage of maximal oxygen reported that trials repeatedly demonstrate that exercise uptake or percentage of heart rate maximum to determine programs designed to challenge a person’s balance can the appropriate intensity for inducing a cardiovascular improve balance ability in older adults (Howe et al 2011). training effect (Thompson et al 2010). The Borg rating of A recent systematic review of exercise interventions to perceived exertion scale was first developed as a measure of prevent falls also concluded that exercise can prevent falls, aerobic exercise intensity (Borg 1982) and more recently has balance exercises were essential, and strength training and walking were optional (Sherrington et al 2011). A limitation What is already known on this topic: Exercise previously identified in this body of work is that outcomes of programs designed to challenge a person’s exercise programs that improve balance have been reported balance can improve balance ability in older adults. inconsistently (Howe et al 2011). These reviewers did not Exercises are normally prescribed by defining the comment, however, on whether the description of exercise frequency, intensity, type, and duration of exercise. prescription and dosage parameters had been reported Exercise needs to be performed near the limits of an consistently. individual’s capacity to induce a training effect. Physiological adaptations to exercise are specific to the What this study adds: Although numerous trials of type of exercise performed, but the principle of overload balance exercise interventions in older adults have dictates that exercise needs to be performed at or near been conducted, none has quantified the intensity of the limits of an individual’s capacity to induce a training the challenge to the individual’s balance system. No effect (Thompson et al 2010). A recommended exercise psychometrically validated tools exist to measure the prescription method is the FITT framework, which consists intensity of the challenge to an older person’s balance of the Frequency, Intensity, Type, and Time (ie, duration) system. of exercises prescribed (Thompson et al 2010). While Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 227
Research been validated as a measure of strength training intensity In the second phase, the titles and abstracts of randomised (Gearhart et al 2001). trials identified in the first phase were reviewed independently by two investigators (MF, LR) against In determining the optimum level of challenge of balance second phase eligibility criteria, as presented in Box 2. The exercises, recommendations commonly relate to the reference lists of the included trials were also searched for difficulty of the balance task, rather than to the intensity additional potentially eligible trials. The titles and abstracts of the activity relative to the ability of the individual of these trials were also reviewed against the criteria in Box (Thompson et al 2010, Tiedemann et al 2011). Therefore, 2. Results were compared to reach consensus on eligible although it is known a person is performing one task that trials. Where there was disagreement between the two may be more difficult than another, it is not clear how to investigators regarding eligibility for inclusion, a third quantify the challenge of that task to the balance capability investigator was consulted (TH) and disagreements resolved of that individual. Specialist practitioners in the field of through discussion. Two investigators (MF, LR) read the falls and balance have reported being unable to identify an full text of eligible trials and performed independent data ideal balance exercise intensity prescription method, other extraction. Results were then compared to merge relevant than to say that the balance exercises prescribed need to data extracted. Data extracted included demographics of be challenging (Haas et al 2012). Given that there are four trial participants and information on FITT parameters factors used to prescribe exercise, if one factor is missing for each exercise program. Where available, information or measured inconsistently, optimal prescription dosage on the FITT parameters was extracted for the exercise is confounded. To date, there has been no systematic intervention as a whole, as well as for balance-specific investigation of whether or how the intensity of balance components. The investigators extracted the words authors exercise prescription has been determined in trials of used to report balance intensity, as well as any instruments balance rehabilitation programs. used to measure balance challenge intensity. If a measure of balance intensity was described, a search for any reports of The research questions for this review were therefore: scale properties was conducted. 1. How has balance exercise intensity been reported and prescribed in trials of balance exercise interventions? #PY. Inclusion criteria for randomised controlled trials 2. Have any instruments been designed to measure the reporting balance exercise interventions. intensity of balance training exercises? Design Method t Randomised controlled trial Identification and selection of studies Participants A three-phase process was used to identify articles appropriate for inclusion in this review. In the first phase, t Older adults (age > 55 y) the lead investigator (MF) conducted a search in December 2011 to identify all systematic reviews published between Intervention 2006 and 2011 that included balance exercise interventions. Reviews published earlier than 2006 were not included as t Balance exercise intervention, either a balance it was reasoned that reviews published in the last five years specific exercise program, or a mixed exercise would include most, if not all, relevant trials previously program that included balance exercises reviewed in this area. Key search terms and the databases searched are presented in Table 1. The titles and abstracts Document properties of articles identified by the search were reviewed to identify eligible systematic reviews based on eligibility criteria, t Full text article as presented in Box 1. The reference lists of the eligible systematic reviews were searched for any additional t English language relevant review articles for which title and abstract were also reviewed against the same criteria. Citation details In the third phase, a literature scan was conducted were extracted for all randomised trials identified in all the independently by two investigators (MF, LR) to identify eligible systematic reviews. any instruments that reportedly measure balance challenge intensity. In particular, this search was intended to identify #PY. Eligibility criteria for systematic reviews of trials instruments that had not yet been used in any published reporting balance exercise interventions. randomised controlled trial. The search terms are presented in Table 2. Review design Assessment of the depth of literature identified t Publication date no earlier than 2006 t Systematic reviews of RCTs investigating a balance To test the comprehensiveness of this process in identifying relevant randomised trials, a capture-recapture analysis exercise training intervention was performed on the field of trials identified from the 23 systematic reviews included. Capture-recapture analysis is Participants a statistical analysis method used to estimate populations, more traditionally animal populations, where a total t Majority of trial participants were adults over 55 years population estimate can be made from the number of a Intervention species captured, tagged, and recaptured in a geographical area. This review aimed to identify all systematic reviews t A review of balance exercise intervention, or published from 2006 onwards that contained randomised t A review of multi-dimensional interventions (eg, falls controlled trials of balance exercise interventions, assuming that each systematic review intended to be exhaustive in prevention interventions) that included balance its search of the scientific literature. We have worked on exercise as an intervention the assumption that each systematic review in isolation is a ‘capture’ of trials from the total population of trials of balance exercise intervention and when a trial appeared in 228 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Farlie et al: Reporting the intensity of balance exercise 5BCMF. Description of the searches for systematic reviews. Key search terms Search filters Databases Search engines Google Scholar Population Intervention older adult* balance* Publication type: systematic review SCOPUS older person AND Publication type: meta-analysis Medlinea elderly exercis* Publication date: 2006-current CINAHL geriatric train* Language: English EMBASE aged physical intervention Cochraneb physical activ* a1946 to present and in-process and other non-indexed citations, bCochrane Database of Systematic Reviews 5BCMF. Description of the searches for tools measuring with others set in residential aged care (n = 31), hospital the intensity of balance exercises. settings (n = 6), combined community and residential aged care (n = 5), and combined community and hospital (n = Key search terms Databases Search 1). The number of participants in trials ranged from 13 to engines 3999 (mean = 204), with a range of mean ages from 59 to 88 years (mean = 77). The majority of trials (n = 135) were Construct 1 Construct 2 trials of exercise interventions only, with the remainder (n = 13) multifactorial falls prevention interventions that balance instrument SCOPUS Google included a balance exercise component. Exercise programs measure* Medlinea were primarily of mixed type of which balance exercise Google was one component (n = 137), while 11 trials investigated categ* CINAHL Scholar balance exercise only interventions. Some trials (n = 27) EMBASE used published exercise programs such as the Otago program (Accident Compensation Corporation 2003) or a1946 to present and in-process and other non-indexed citations the High Intensity Functional Exercise (HIFE) program (Littbrand et al 2006a). A small number of trials used Tai more than one systematic review, this trial was considered Chi interventions (n = 21). Details of the published exercise ‘recaptured’. programs used in the included trials are presented in Table 3. Results Description of information reported in reviewed trials Flow of studies through the review The FITT parameters reported for each exercise intervention The results of the search strategy for relevant systematic are displayed in Appendix 3 (see eAddenda for Appendix reviews and the trials subsequently identified from those 3). A large number of studies failed to report all four FITT reviews are illustrated in Figure 1. This search strategy elements of their exercise interventions (n = 102). These yielded 23 systematic reviews, which are listed in Appendix cells are marked ‘NR’ (not reported). A small number 1 (see eAddenda for Appendix 1). From these 23 systematic of studies (n = 25) reported balance exercise intensity reviews, 145 trials were extracted and an additional 3 trials parameters. To evaluate if the construct reported as balance were found by scanning the reference lists of eligible trials. challenge intensity was accurate, a decision tree was used, as These 148 trials are listed in Appendix 2 (see eAddenda for presented in Figure 2. First, reported data was deemed not to Appendix 2). be balance exercise intensity if it clearly constituted another FITT construct. For example, a measure of frequency or Capture-recapture analysis duration was reported for intensity in seven studies (Lord et al 1996, MacRae et al 1994, Rubenstein et al 2000, Sattin Analysis of the 23 systematic reviews identified in the et al 2005, Silsupadol et al 2006, Urbscheit and Wiegand first phase of the search using a capture-recapture analysis 2001, Wolf et al 2003). If an intensity measure was reported, tool (Thompson 2007) confirmed 145 unique randomised it was not considered to be a measure of balance challenge controlled trials were identified, and gave an estimate of intensity if it was an intensity measure of some other aspect 17 trials missing, equating to a group review yield of 90%. of exercise. For example, intensity using the Borg rating Three additional trials were found by scanning reference of perceived exertion of either aerobic exertion or mental lists of the original 145 eligible trials, leaving an estimated concentration was reported as balance exercise intensity 14 of 162 trials theoretically missed from this analysis. in four studies (Nelson et al 2004, Pereira et al 2008, van Uffelen et al 2008, Zhang et al 2006). Lastly, a hierarchy Characteristics of the studies identified of task difficulty, which was reported in 10 trials, was not considered to be a measure of balance challenge intensity. Of the 148 trials identified for inclusion in this review, just This was commonly the report of a narrowing of the base over one-third (n = 60) originated from North and South of support or an increase in complexity of tasks performed America, with the remainder originating in Europe (n = over time in the exercise program (Chin A Paw et al 2004, 47), the Asia-Pacific region (n = 42), and the Middle East Chin A Paw et al 2006, Davison et al 2005, Englund et (n = 1). Most trials were set in the community (n = 105) Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 229
Research Search of electronic databases for systematic Construct reported as balance intensity reviews (n = 228) Removal of duplicate publications (n = 74) Is it a measure of frequency? yes no Review of titles and abstracts (n = 154) Construct not balance exercise intensity Is it a type of exercise? yes Ineligible (n = 135) no t did not include RCTs of balance exercise Is it a unit of time? yes interventions (n = 106) no t not a systematic review or meta-analysis Is it intensity? no (n = 16) yes t not English language (n = 12) t withdrawn Cochrane review (n = 1) Is it a measure of intensity of yes a type of exercise other than Additional review articles found via scan of balance exercise (eg, reference lists (n = 4) aerobic intensity)? Systematic reviews included for identification of RCTs no of balance exercise interventions (n = 23) How is balance exercise intensity measured? RCTs included for extraction of exercise program Novel measure of Validated measure data based on title (n = 306) balance exercise of balance exercise intensity intensity Articles unable to be sourced (n = 5) Figure 2. Balance intensity decision tree. RCTs excluded after analysis of the full text (n = 156) al 2005, Hauer et al 2001, Hauer et al 2002, Helbostad t intervention not a balance exercise (n = et al 2004, Netz et al 2007, Sjösten et al 2007, Tinetti et al 1994). Where the element reported as balance exercise 77) intensity was deemed a misrepresentation of another FITT t not an RCT (n = 23) parameter, intensity of another type of exercise, or a report t duplicate data (n = 28) of task difficulty, the data in the balance intensity column of t abstract only (n = 12) Appendix 3 is italicised. t thesis (n = 5) t procedural paper (n = 5) Analysis of reports of balance challenge intensity t article not in English (n = 3) t economic analysis (n = 2) Where the reported intensity was not dismissed as a t follow-up study (n = 1) misrepresentation, this was considered a potential report of balance challenge intensity and examined further. In two Additional RCTs found via scan of reference instances the report was non-descript: ‘based on set criteria’ lists (n = 3) (Arai et al 2007) and ‘easy/medium/hard’ (Wolfson et al 1996). Of interest, two studies utilising the HIFE exercise RCTs included for data extraction (n = 148) program reported the balance exercise as high intensity. The definition of balance intensity was determined relative to the Figure 1. Flow of studies through the review. limits of postural stability (Littbrand et al 2006b, Rosendahl et al 2006). This was a novel intensity rating developed by the researchers for use in prescribing their exercise program (Littbrand et al 2006a). While this measure of balance challenge was not excluded by the process in Figure 2, the reliability and validity of this approach is unknown as no 230 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Farlie et al: Reporting the intensity of balance exercise 5BCMF. Characteristics of published exercise programs that include balance training. Program Reference Summary of program content (Included trials) Origin Otago Exercise ACC (2003) Mixed strength, aerobic, and balance exercises. Strength training: lower Program New Zealand MJNCFYFSDJTFTXJUIDVGGXFJHIUTCPEZXFJHIUSFTJTUBODF#BMBODFFY (n = 6) static and dynamic functional exercise Osteofit Carter et al (2002) Mixed strength, stretching, balance and co-ordination exercise. (n = 2) Canada 8–16 strength exercises, resistance band and free weights 4UBOEVQTUFQVQ Liss (1976) 7 levels of exercise: 1) sit to stand x 5, 2) step up x 5, 3) sit to stand x 10, 4) (n = 2) USA Step up x 10, 5) sit to stand x 15, 6) step up x 15, 7) repetitions increased relative to HR Square-stepping Shigematsu et al Square stepping exercise program – agility training, resistance band exercise program (2008) exercises, balance activities, single leg and double leg balance with (n = 2) Japan IFFMTUPFTSBJTFE UBOEFN FZFTPQFOBOEDMPTFE HIFE program Littbrand et al Strength exercises, balance exercises, combined strength and balance (n = 2) (2006a,b) exercises. Sweden Static and dynamic functional exercises with progressive decreasing Fallproof! support or more challenging surface (n = 1) Rose (2003) Static and dynamic balance challenges with sensory transitions. USA Walking on different surfaces, rocker board, foam, narrow beam. In Balance Tandem standing, SLS and standing feet together (n = 1) Faber et al (2006) Static and dynamic standing balance movements Functional fitness Netherlands for long-term care Lazowski et al Strength training-soft weights and resistance band. (n = 1) (1999) Balance training, flexibility exercises, walking, group games KTEP Canada (n = 1) Haines et al (2009) Multi-modal-strength and balance exercise program: functional exercises Australia and Tai Chi style exercises supporting evidence of this was presented by the authors or Three of the instruments – the Performance Oriented found by the investigators of this review. Mobility Assessment (Tinetti 1986), the Community Balance & Mobility scale (Howe et al 2006), and the Unified A measure of aerobic exercise intensity was reported Balance Scale (La Porta et al 2011) – measure balance in three studies. These programs used a Borg rating of performance but do not rate balance exercise intensity (ie, perceived exertion scale to measure the intensity of the they measure how many of a hierarchical set of challenges exercise intervention. One study of a balance rehabilitation can be performed rather than a rating of how difficult an intervention prescribed exercises that began at 11 (light) and individual finds it to perform a scale item). Two global progressed to 13 (somewhat hard) on the 6–20 Borg scale balance ratings were identified (Howe et al 2006, Leahy (Means et al 2005). In this study the balance intervention 1991). One, the functional balance grades first described by included strengthening, stretching, postural control, walking Leahy (1991), is a general rating of the balance and mobility and coordination exercises, and the Borg scale target was of an individual that does not measure the intensity of not specific to the balance exercises but rather a rating for balance exercise but describes balance as normal, good, the intensity of the exercise intervention in its entirety. A fair, poor, and zero with standard definitions. The second, Borg scale was also used to rate the mental concentration described by Howe et al (2006), is a general rating of demanded during Tai Chi exercise (Pereira et al 2008), with balance and mobility used in the process of validating the participants aiming for 1 or 2 on Borg’s Effort Subjective Community Balance & Mobility scale. Again it is not a Perception (ESP) scale (Pereira et al 2008 p. 123). An article measure of balance exercise intensity. No instruments to describing the ESP scale has not been published in English. rate the intensity of balance exercise were identified. The third study instructed participants to exercise at 7 to 8 on the 0–10 Borg scale during a strength and balance Discussion exercise program; again balance exercise intensity was not specifically targeted in this rating (Nelson et al 2004). A substantial number of clinical trials investigating balance exercise were identified in this review. The reporting of Analysis of potential measures of balance the intensity of balance exercises prescribed was, however, challenge intensity largely overlooked. This review therefore provides empirical and objective evidence of a serious gap in this wide field The searches for instruments to measure balance exercise of research and clinical practice. Of 148 randomised trials intensity yielded eight studies that reported seven outcome reporting balance exercise interventions, none reported a measures of interest. Scanning of reference lists yielded validated measure of balance exercise intensity. Instead, an additional instrument. Two of the instruments, the the most common approach adopted was to describe of Activities of Balance Confidence scale (Powell and Myers taxonomy of task difficulty that trial participants progressed 1995, Schepens et al 2010) and CONFbal (Simpson et al through as they performed activities of increasing difficulty 2009) measure the construct of balance confidence (ie, the (Chin A Paw et al 2004, Chin A Paw et al 2006, Davison confidence of an individual to perform a particular task). Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 231
Research et al 2005, Englund et al 2005, Hauer et al 2001, Hauer et One program that explicitly presented a rubric to guide al 2002, Helbostad et al 2004, Netz et al 2007, Sjösten et al balance exercise intensity prescription was identified 2007, Tinetti et al 1994). One could argue that this approach (Littbrand et al 2006a). This HIFE program includes a is sufficient to challenge participant balance capabilities and table (p. 8) that defines low, medium, and high intensity induce an overload effect. However, this approach provides exercise prescriptions. For the strength training exercises, no indication of how difficult the individual performing the repetition maximum principle is used. For balance the task found this at the time. There is an underlying exercise a three-point scale ranging from ‘no challenge’ assumption that all individuals have the same balance to ‘fully challenged’ postural stability is used. The capacity and are consistently challenged by the introduction authors provide a definition for full challenge of postural of a ‘subsequent task’ in the hierarchy. This is analogous to stability as ‘balance exercises performed near the limits of a strength-training program where participants were asked maintaining postural stability’ (Littbrand et al 2006a p. 8) to perform a leg press against resistance of 5 kg, 10 kg, and This attempt at standardisation carries some face validity 15 kg weights in successive weeks. Although we know the given that repetitive work at the limits of stability is likely resistance is increasing, we do not know what percentage to represent an overload, however the ordinal scaling limits of 1RM these weights represent for the participant. For a the usefulness of this rating of balance exercise intensity. If frail older adult this may be a very difficult activity, but the level of balance exercise intensity cannot be measured for a younger, fitter individual it may not, and it would not in a reliable and valid way then questions of how hard we be possible to monitor the exercise intensity level in either need to challenge balance in order to induce improvements individual in terms of a proportion of their capability. in balance cannot be answered. This issue is of particular relevance for the development and implementation of home Of the few studies that purported to report balance exercise exercise or unsupervised programs, as it has been found intensity explicitly, intensity was represented inaccurately. that clinicians often prescribe programs of lower challenge In other words, authors used other parameters as surrogates in the home environment compared to supervised situations for intensity. Some authors reported balance exercise (Haas et al 2012). intensity in terms of time spent balance training. For example Silsupadol et al (2009) state that the ‘duration and While still ordinal in nature, another rating scale that intensity of this training [was] chosen based on previous may inform a future measure of balance exercise intensity studies showing that 10-hour to 12-hour balance training is the Borg scale. Studies in this review that utilised the and 1-hour to 5-hour dual-task training programs were Borg scale, also known as the rating of perceived exertion effective’ (p. 382). Similarly Rubenstein et al (2000) scale, reported the intensity of interventions of mixed reported an increase in balance exercise difficulty by exercise types, attributing the rating to the program in its increasing the time spent training from 5 min to 15 min over entirety (Means et al 2005, Nelson et al 2004, Pereira et al the 12 weeks of their program, and Wolf et al (2003) who 2008). This intensity rating appears to apply more to the report increasing the intensity of their Tai Chi intervention aerobic and strength training elements of these exercise by increasing duration of sessions from 60 to 90 min over programs; researchers have not specifically applied this the course of a year. rating to how hard individuals were working at maintaining balance. The observation of these generalised ratings of Authors also reported an increase in task difficulty as a proxy exercise intensity across modalities are in accordance for balance exercise intensity. This was primarily done with with a previous review examining dosage and intensity of exercise programs that progressed through standardised multi-modal exercise programs that concluded ‘few studies levels of difficulty (Davison et al 2005, Tinetti et al 1994) with robust interventions prescribing individually assessed or with reference to task taxonomies (Helbostad et al 2004, intensities of each modality have been conducted’ (Baker et Silsupadol et al 2006), for example Gentile’s taxonomy of al 2007 p. 380). In particular, the Baker et al (2007) review movement tasks (Gentile 1987) or the task manipulations of 15 trials found that balance training exercise intensity described by Geurts et al (1991). Other authors discussed the was reported using the rating of perceived exertion in one principles used to increase task complexity such as reducing instance and otherwise was not reported (n = 9) or was the base of support or increasing complexity by making reported as ‘progressive’ without use of any intensity-rating ‘multi-factorial’ environmental changes to exercises (Chin instrument (n = 5), which is consistent with the findings of A Paw et al 2004, Chin A Paw et al 2006, Englund et al this much larger review. 2005, Hauer et al 2001, Hauer et al 2002). If task difficulty is used as the indicator for balance exercise intensity, The original rating of perceived exertion scale described exercise prescription across broad populations cannot be by Borg (1970) ranged from 6 to 20, with the intention monitored or graded to ensure training effects for individual that the ratings could be multiplied by 10 to estimate heart patients. If all patients had the same balance capacity at the rate between 60 and 200, respectively. This scale has beginning of a program, then a linear progression in task been shown to have linear relationships with heart rate difficulty through a program may represent an increase in and work intensity (Borg 1973, Borg 1982, Skinner et al balance exercise intensity for individuals from session to 1973). Initially, Borg designed the scale to measure exertion session. Apart from the fact that no group of participants during physical activity (Borg 1973) but it has been more is ever homogeneous, one would still be left with this widely applied and numerous variants have been reported. dilemma regarding the level at which the exercise intensity The Borg scale has been reported as a reliable and valid was pitched through the program. It would be unclear means of rating the intensity of cardiovascular exercise such whether all participants started the balance exercises at as treadmill running and cycling (Dunbar 1993), as well a low intensity and stayed low, or started at a moderate as strength training exercise through a linear relationship intensity and practised high intensity exercises by the end between proportion of repetition maximum and rating of of the intervention. perceived exertion (Gearhart et al 2001). Apart from the limitations of an ordinal scale and being a rating of overall 232 Journal of Physiotherapy 2013 Vol. 59 – © Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Farlie et al: Reporting the intensity of balance exercise exertion, there would be difficulty applying this instrument The review demonstrates overwhelmingly that the reporting in some populations due to cognitive impairment, language, of the intensity of balance exercise programs is grossly and literacy. Therefore, a scale is yet to be found that could inadequate. To date, the intensity prescription of balance be applied in these circumstances. exercises has not been clearly described or adequately measured in research studies. The use of taxonomies of The searches for scales of balance exercise intensity did not task difficulty as a proxy for balance exercise intensity does identify an appropriate rating scale. The instruments that not show how an individual experiences balance challenges. were found attempt to quantify aspects of balance from a The adaptation of the rating of perceived exertion to systems approach, using task performance criteria to assess measure balance exercise intensity may be worthy of balance performance rather than rating the intensity at further investigation. Comprehensive work in this area is which a task is completed. It is important to differentiate required to develop a psychometrically sound measure of the concept of increasing task difficulty along a predictable balance exercise intensity. Q trajectory from the measurement of the intensity, or difficulty, an individual experiences in trying to perform an eAddenda: Appendices 1, 2, and 3 available at jop. activity or task anywhere along that spectrum of simple to physiotherapy.asn.au complex tasks. Competing interests: Terry Haines is the director of The review has highlighted an important gap in the Hospital Falls Prevention Solutions Pty Ltd. He has authored methods used to prescribe, implement and evaluate the trials included in this review but he was not involved in the effect of balance exercise programs. At this time, it is evaluation of these trials for the purpose of this review. not clear if balance exercise intensity can be measured accurately. The implications of not yet having an accurate Support: Terry Haines was supported by a Career measure of balance exercise intensity is that only three Development Fellowship from the National Health and of the four fundamental exercise prescription factors that Medical Research Council (2010–2013). can be prescribed in balance exercise programs are able to be manipulated. Therefore the effectiveness, or not, of an Correspondence: Melanie Farlie, Allied Health Research intervention program cannot be evaluated or reproduced Unit, Monash Health, Australia. Email: melanie.farlie@ reliably if the intensity at which exercises are performed is monashhealth.org not known. If balance exercise intensity could be quantified then research could then compare higher and lower intensity References balance exercises while frequency, type and time of exercise could be held constant. We could then examine how intense Accident Compensation Corporation (2003) Otago exercise balance exercises need to be to induce a training effect. This QSPHSBN UP QSFWFOU GBMMT JO PMEFS BEVMUT XXXBDDDPO[ would inform balance rehabilitation exercise prescription. otagoexerciseprogram [Accessed February 4, 2012] If low intensity is effective it may be cost effective for older adults to exercise at home unsupervised, however if only the Arai T, Obuchi S, Inaba Y, Nagasawa H, Shiba Y, Watanabe S, highest intensities of exercises are effective there may need et al (2007) The effects of short-term exercise intervention to be investment in the health workforce to supervise older on falls self-efficacy and the relationship between changes adults completing more challenging exercise programs in physical function and falls self-efficacy in Japanese older to reduce the risk of incident or harm while achieving a people: A randomized controlled trial. American Journal of training effect. Physical Medicine and Rehabilitation 86: 133–141. 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