Journal of Physiotherapy 61 (2015) 21–27 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research A massive open online course (MOOC) can be used to teach physiotherapy students about spinal cord injuries: a randomised trial Mohammad S Hossain a,b, Md. Shofiqul Islam b, Joanne V Glinsky c, Rachael Lowe d, Tony Lowe d, Lisa A Harvey c a Centre for the Rehabilitation of the Paralysed; b Bangladesh Health Professions Institute, the Academic Institute of the Centre for the Rehabilitation of the Paralysed, Savar, Bangladesh; c John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School/Northern, University of Sydney, Australia; d Physiopedia, London, UK KEYWORDS ABSTRACT Rehabilitation Question: Does a massive open online course (MOOC) based around an online learning module about Spinal cord injury spinal cord injuries improve knowledge or confidence among physiotherapy students more than if Clinical trials physiotherapy students are left to work through the online learning module at their own pace. Which Methodology method of presenting the content leads to greater satisfaction among the students? Study design: Randomised controlled trial with concealed allocation and intention-to-treat analysis. Participants: Forty-eight physiotherapy students in Bangladesh. Intervention: Participants randomised to the control group were instructed to work at their own pace over a 5-week period through a physiotherapy-specific online learning module available at www.elearnSCI.org. Experimental participants were enrolled in a 5- week MOOC. The MOOC involved completing the same online learning module but experimental participants’ progress through the module was guided each week and they were provided with the opportunity to engage in online discussion through Facebook. Outcome measures: The primary outcome was knowledge, and the secondary outcomes were perceived confidence to treat people with spinal cord injuries and satisfaction with the learning experience. Results: The mean between-group difference for knowledge was 0.7 points (95% CI –1.3 to 2.6) on a 0 to 20-point scale. The equivalent results for perceived confidence and satisfaction with the learning experience were 0.4 points (95% CI – 1.0 to 1.8) and 0.0 points (95% CI –1.1 to 1.2) on a 0 to 10-point scale. Conclusion: The MOOC was no better for students than working at their own pace through an online learning module for increasing knowledge, confidence or satisfaction. However, students in the MOOC group highlighted positive aspects of the course that were unique to their group, such as interacting with students from other countries through the MOOC Facebook group. Trial registration: ACTRN12614000422628. [Hossain MS, Islam MS, Glinsky JV, Lowe R, Lowe T, Harvey LA (2015) A massive open online course (MOOC) can be used to teach physiotherapy students about spinal cord injuries: a randomised trial. Journal of Physiotherapy 61: 21–27] ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Introduction developed this physiotherapy-specific module. This module contains 14 lessons covering a range of topics including assess- Most countries around the world provide undergraduate or ment, goal setting, treatments for impairments, and strategies to graduate training programs for physiotherapists. A challenge for all train motor skills. Each lesson contains a short didactic overview of is to develop efficient ways of providing consistent high-quality the topic, interactive activities and a self-assessment quiz. The education as part of these programs. This is particularly challeng- interactive activities are where most of the learning content is ing for some of the specialty topics such as physiotherapy presented; they require students to regularly stop, think and management of spinal cord injuries, where smaller universities perform a learning task in accordance with adult learning and colleges often struggle to attract academic staff with principles. appropriate expertise. These problems are greater in countries where physiotherapy is a young profession. The online learning module provides an inexpensive way of delivering a consistent learning experience for all physiotherapy The International Spinal Cord Society sought to overcome this students at minimal cost. However, it is not clear whether students problem by developing an online educational resource for the can be left to work their own way through the module or whether multidisciplinary team, which contains a module that is specific for they need to be provided with a more structured and interactive physiotherapy students (and junior clinicians).1 Senior physio- online learning experience. Massive open online courses (MOOCs) therapy academics and clinicians from 30 countries, including provide a way of structuring students’ online learning experi- representatives from low-income and middle-income countries, ence.2–5 They are ‘massive’ because they sometimes have http://dx.doi.org/10.1016/j.jphys.2014.09.008 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
22 Hossain et al: MOOCs for educating physiotherapists in SCI thousands of students; they are ‘open’ because they are free; they screened by their teachers for inclusion and invited to participate. are ‘online’ because the course is delivered by the Internet; and This Institute has been providing undergraduate physiotherapy they are ‘courses’ because they have a curriculum and learning training for 15 years. The Bangladesh Health Professions Institute objectives.6 They have various formats, but most involve listening has approximately 40 students in each year, and is located at the to online lectures, completing tasks, reading articles and com- Centre for Rehabilitation of the Paralysed: a 120-bed spinal cord pleting self-assessments. Importantly, most have online forums injury centre. that provide students with the opportunity to engage with fellow students and teachers from around the world. They are becoming Physiotherapy students were included if they were over increasingly popular because they are inexpensive to run and 16 years of age, willing to participate and had regular Internet provide access for students from all countries to the same level of access. Potential students were excluded if they had insufficient education. English to provide consent, and complete the online modules and assessments. One teacher who was well acquainted with the A recent systematic review of MOOCs identified 17 quantitative students and was fluent in English rated the English skills of all studies on this style of learning.5 Most of the 17 studies were case students. He was asked to rate each student’s English on a 0 to 10- studies and the review did not include the only randomised point scale, where 0 represented ‘very poor’ and 10 represented controlled trial (unpublished) we have identified.7 There are, ‘very good’. The students were also asked to rate their own English however, a lot of publications written about the underlying learning skills on the same scale. theories of MOOCs and online education.8–11 Educational academics have expanded the older behaviourism, cognitivist and constructiv- Once the final number of students willing to participate was ism theories of learning to include theories of connectivism. known, a randomised allocation schedule was computer generated ‘Connectivism provides insight into learning skills and tasks needed by an independent person in Australia. The schedule was blocked for learners to flourish in a digital era.’ 9 Connectivism captures an and stratified by year of study (second-year student versus third- important aspect of MOOCs – the sense of community that they year student). The Bangladeshi site emailed the participants’ create and the opportunity that they provide for participants to details and year of study to Australia, where an independent engage online in order to learn from each other. person provided each participant’s allocation according to the random schedule. Each participant was individually emailed to While MOOCs are increasingly popular, it is not known whether reveal group allocation and to provide instructions about what they are any better than leaving students to work at their own pace they were expected to do. The participants were deemed to have through online educational material. Therefore, the purpose of entered the study at this point. the present trial was to compare two ways of providing online education about spinal cord injuries to physiotherapy undergrad- Intervention uate students in Bangladesh. Both ways were based on the physiotherapy-specific module of www.elearnSCI.org. However, Participants allocated to the experimental group were one way required students to work at their own pace over enrolled in a 5-week MOOC titled Physiotherapy Management of a 5-week period through the online module and the other way Spinal Cord Injuries (http://www.physio-pedia.com/Physiotherapy_ required students to enroll in a MOOC titled Physiotherapy Management_of_Spinal_Cord_Injuries). The MOOC was run through Management of Spinal Cord Injuries (details can be found at: Physio-pedia in collaboration with the International Spinal Cord http://www.physio-pedia.com/Physiotherapy_Management_of_ Society and was not solely for the participants of the trial; it was Spinal_Cord_Injuries). It was hypothesised that MOOCs provide open to physiotherapy students or physiotherapists from any physiotherapy students with greater knowledge about physiother- country. It was widely advertised and ultimately attracted apy management of spinal cord injuries, greater confidence in 3523 registrants from 108 countries. The MOOC required the managing people with spinal cord injuries and a more satisfying experimental participants to devote 3 hours per week to study. It learning experience than access to an online learning module alone. provided these participants with a course curriculum, objectives and a weekly study plan. In addition, these participants were invited to Therefore, the specific research questions for the present study complete a pre-course and post-course quiz; this was different to the were: knowledge assessment used as part of the trial. At the beginning of each week, these participants were emailed three to six tasks to Does a MOOC that is based around an online learning module complete. The tasks included completing lessons from the about spinal cord injuries improve knowledge or confidence physiotherapy-specific module of www.elearnSCI.org. By the end among physiotherapy students more than working through the of the course, the experimental participants moved through the online learning module at their own pace? 14 physiotherapy-specific lessons. The experimental participants were also required to do some additional reading and engage in an Which method of presenting the content leads to greater online Facebook discussion for all MOOC registrants. Checks were satisfaction among the students? made to ensure that all of the experimental participants joined the Facebook group. There were two designated teachers of the MOOC; Method both had extensive clinical and academic experience in the physiotherapy management of spinal cord injuries. The MOOC did Design not involve listening to either of the teachers (or anyone else) talk with electronic slide presentations, although it did involve viewing A 5-week randomised parallel controlled trial with a 1:1 short videos from the two teachers at the beginning of the course and allocation was undertaken through the Bangladesh Health Profes- then from one teacher each week. The videos outlined the content of sions Institute, Bangladesh. Undergraduate physiotherapy students the course and learning material for each week. The learning from Bangladesh were randomised to a control or experimental objectives and weekly plan of the MOOC were freely available condition. The control participants were instructed to move at their through the Physio-pedia website, although the details of each week own pace through the physiotherapy-specific module that forms were only released at the beginning of each week of the course. The part of www.elearnSCI.org. The experimental participants were experimental participants were emailed prior to the course, upon enrolled into a MOOC. Participants started the 5 weeks of study on completion of the course and each week throughout the course to 28 April 2014 and finished 5 weeks later. Everything related to the provide them with instructions. These emails were generic emails trial, including its content, was conducted in English. sent to all registrants of the MOOC. The Bangladeshi students who were part of this study were not provided with any special attention Participants and centre during the MOOC, but they were provided with assistance to register, and in some cases, assistance to set up email accounts. One Second-year and third-year undergraduate physiotherapy students from the Bangladesh Health Professions Institute were
Research 23 local Bangladeshi teacher who was aware of each participant’s The primary outcome measure was knowledge about the allocation provided the assistance. physiotherapy management of spinal cord injuries. Two 20-item multiple-choice tests were devised specifically for this trial. They The control participants were asked to move at their own pace were different to questions set as part of the MOOC and online through the physiotherapy-specific module of www.elearnSCI.org learning module. Initially, 20 pairs of questions, which were over a 5-week period. They, like the experimental participants, similar in content and complexity and based on the content of the were instructed to devote 3 hours per week to their studies. Checks physiotherapy-specific modules of www.elearnSCI.org, were were made to ensure that none of the control participants composed. Then one question of each pair was randomly allocated registered for the MOOC or joined the MOOC discussion forum to the pre-trial assessment and the other to the post-trial run through Facebook. Again, one local Bangladeshi teacher who assessment. This was done in order to ensure there were no was aware of each participant’s allocation provided some systematic differences between the pre-trial and post-trial participants with assistance to set up email accounts. assessments. Each question had four possible answers, although only one answer was correct. An example of six questions is The physiotherapy-specific module of www.elearnSCI.org, provided in Table 1. The total possible score was 20 points. The which both control and experimental participants were required smallest worthwhile treatment effect was arbitrarily set a priori as to move through, contains 1367 screens.1 The module is divided 4 points. That is, the experimental group needed to do better than into 14 lessons, each with a short didactic ‘overview’ and between the control group by 4 points to enable a conclusion that the MOOC two and seven activities, and a self-assessment. Interactive screens was superior to self-paced learning. that require students to regularly stop, think and perform a learning task are dispersed throughout. The interactive screens There were two secondary outcomes: perceived confidence to require students to enter text in response to questions, view videos treat people with spinal cord injuries and satisfaction with the and analyse movement through multiple-choice questions, select learning experience. Both outcome measures were designed appropriate exercises for particular problems, and constantly specifically for the purpose of the trial and comprised a series of reflect on content learnt through drop-and-drag activities, questions or statements that required students to respond on a scale matching exercises and various other interactive tasks. In addition, from 0 to 10 (see Tables 2 and 3). The scale to assess confidence was there are over 150 videos of people with spinal cord injuries, and anchored at one end with the words ‘not confident’ and at the other interviews with both physiotherapists and patients from a diverse end with the words ‘highly confident’. The scale used to assess range of countries. While both control and experimental partici- satisfaction was anchored at one end with the words ‘strongly pants moved through these online modules, only those in the disagree’ and at the other end with the words ‘strongly agree’. There experimental group were provided with a weekly study plan, were ten statements for perceived confidence, which were averaged course curriculum, objectives, and importantly, the opportunity to for each participant for a total possible score of 10 points. There were engage in an online Facebook discussion. four statements for satisfaction with the learning experience, which were similarly averaged for each participant for a total possible score Experimental and control participants continued with their of 10 points. Participants were also asked to estimate the average usual undergraduate training throughout the 5-week period. The number of hours they spent over the duration of the trial learning participants’ teachers were aware of the trial and encouraged these about spinal cord injuries and the positive and negative aspects of students to actively participate, but they were not aware of each the online teaching strategies used as part of the trial. participant’s allocation (except the one lead teacher). The students were told that the trial was not a formal part of their training and Data analysis individual scores collected as part of the trial would not be shared with their teachers and would not contribute to any formal exam A sample of 48 was selected for pragmatic reasons because results. They were, however, told that participation in the trial there were no prior data upon which to base a power calculation. might assist them with their formal studies. This was, however, estimated a priori as sufficient to determine a 4-point difference in knowledge, assuming: an alpha of 5%, a SD of All participants were told that the purpose of the trial was to 5 points, power of 80%, a dropout rate of 10% and a correlation with compare two styles of online learning. They were not told the baseline knowledge of 0.6. An intention-to-treat analysis was hypothesis or encouraged to believe that the MOOC was superior. performed. A mean between-group difference (95% CI) was Nor were the words ‘experimental’ or ‘control’ used in any calculated for each of the three outcomes based on the change correspondence or information provided to them. Participants scores (ie, post minus pre scores). were also asked not to discuss amongst themselves to which group they were allocated or what they were required to do. This was Results done in an attempt to blind the participants to the purpose of the trial; participants did, no doubt, discuss what they were doing Flow of participants through the study amongst themselves and guess the purpose of the trial. In addition, the control participants may have found information about the Eighty students were screened for inclusion. Thirty-two either MOOC on the Internet and all participants may have found declined to be involved or did not meet the inclusion criteria (see information about the trial from its online registration. Therefore, Figure 1). In total, 48 students (20 second-year students and in an attempt to gauge the success of blinding, the participants 28 third-year students) were randomised (19 males and were asked at the end of the trial the following question: ‘The 29 females). One participant was incorrectly classified as a hypothesis of this trial was that the experimental group would do second-year student when she was, in fact, a third-year student. better than the control group. Which group do you think you This was not detected until the trial was completed so, for the belonged to?’ purpose of all analyses, this mistake was ignored. The mean age of the participants was 21 years (SD 1). The participants in the two Outcome measures groups were similar on all key prognostic factors except confidence treating people with spinal cord injuries (see Tables 4 and 5). The One primary outcome and two secondary outcomes were participants in the experimental group had less confidence than measured in the present study. Participants were assessed 13 or those in the control group. Experimental group participants also 15 days prior to the start of the 5-week study period and then 1 or reported lower proficiency with English, although this was not 2 days after completion. All assessments were completed online. reflected in their teacher’s assessment of English proficiency. The Participants sat at computers in an exam-style setting to complete teacher scored both groups similarly (see Table 4). the assessments. They were given unlimited time and were directly supervised by a teacher who was blinded to participants’ allocation.
24 Hossain et al: MOOCs for educating physiotherapists in SCI Table 1 Example of six pairs of questions used as part of the knowledge quiz. The questions were designed in pairs and then one question from each pair was randomly allocated to the baseline test and the other to the test after the 5-week interventions. Baseline test 6-week test If a person has signs of autonomic dysreflexia, you should: The main sign of autonomic dysreflexia is: sit or stand the person up raised blood pressure clamp the catheter decreased blood pressure put on an abdominal binder raised temperature give the person some glucose. increased heart rate. The triceps muscle is primarily innervated at: The key muscle group innervated at C5 is: C4 elbow flexors C5 finger and thumb flexors C6 knee flexors C7. wrist extensors. A person with motor complete-thoracic paraplegia rolls by: It is difficult for a person with motor complete C5 tetraplegia to roll over inducing spasticity in the hip abductor muscles independently because of weakness in the: swinging the arms rapidly across the body to generate momentum pectoralis inducing spasticity in the hip flexor muscles wrist extensors externally rotating and flexing the shoulders. back extensors trapezius. What is the most common type of contracture for a person with spinal What is the most common type of contracture for a person with C6 tetraplegia cord injury who sits for prolonged periods of time in a wheelchair? who lies for prolonged times in bed? ankle dorsiflexion contracture elbow flexion and forearm supination ankle plantarflexion contracture elbow flexion and forearm pronation ankle inversion contracture elbow extension and forearm supination ankle eversion contracture. elbow extension and forearm pronation. The main implication of the latissimus dorsi muscle is that it enables The main implication of the biceps muscle is that it enables people with C5 people with C6 tetraplegia to: tetraplegia to: vertically lift the body during transfers vertically lift the body during transfers roll independently roll independently stand on a tilt table stand on a tilt table take a deep breath. perform hand to mouth activities. Neuropathic pain: A physiotherapist can help reduce susceptibility to later-life shoulder pain in people can be felt at, above, or below the level of the lesion who are wheelchair-dependent by: is only felt at the level of the lesion teaching patients good wheelchair propulsion techniques is due to soft tissue trauma in the shoulders avoiding shoulder strengthening exercises is uncommon following spinal cord injury. assisting with all activities all of the above. Table 2 Compliance with the protocol The statements used to assess participants’ confidence in managing people with spinal cord injuries. The instructions were: ‘Rate how confident you feel today if we Compliance with the trial protocol was good and all partici- asked you to do each activity.’ A 0 to 10-point scale was provided for each activity, pants were assessed at the allocated times. There were no dropouts anchored at each end by ‘not confident’ and ‘highly confident’. and all participants remained within their allocated group, except one participant from the control group who joined the Facebook Activity group of the MOOC for 1 week before detection. All participants were instructed to devote 15 hours in total (or 3 hours per week) to 1. Conduct a physiotherapy assessment of a person with spinal cord injury. their studies. The experimental participants reported devoting a 2. Recognise medical complications in a person with spinal cord injury. median of 11 hours (IQR 9 to 15) in total and the control 3. Manage contracture in a person with spinal cord injury. participants reported devoting a median of 10 hours (IQR 7 to 15) 4. Manage pain in a person with spinal cord injury. in total. Thirteen of the control students and 17 of the experimental 5. Treat respiratory complications in a person with spinal cord injury. students believed that they belonged to the experimental group. 6. Train strength in a person with spinal cord injury. This indicates reasonable success with blinding of the students to 7. Train bed mobility and transfers in a person with spinal cord injury. the purpose of the trial. 8. Train wheelchair skills in a person with spinal cord injury. 9. Train gait in a person with spinal cord injury. Effect of intervention 10. Train fitness in a person with spinal cord injury. The mean between-group difference in knowledge was Table 3 0.7 points (95% CI –1.3 to 2.6) on a scale from 0 to 20, with a The statements used to assess participants’ satisfaction with the learning positive score favouring the experimental group. The equivalent experience. The instructions were: ‘Think about everything you have been asked results for perceived confidence to treat people with spinal cord to do over the course of this trial to improve your understanding of spinal cord injuries and satisfaction with the learning experience were injuries. Rate the following four statements.’ A 0 to 10-point scale was provided for 0.4 points (95% CI –1.0 to 1.8) and 0.0 points (95% CI –1.1 to each statement anchored at each end by ‘strongly disagree’ and ‘strongly agree’. 1.2), respectively on a scale from 0 to 10, with a positive score favouring the experimental group (see Table 5). For individual Statement participant data, see Table 6 on the eAddenda. 1. The online education improved my knowledge about physiotherapy Discussion management of spinal cord injuries. 2. The online education improved my practical skills for treating people with A recent systematic review of MOOCs identified just 17 quanti- spinal cord injuries. tative studies on this style of learning.5 Most of the 17 studies were 3. The online education will help me with my studies of physiotherapy. 4. I am satisfied with the knowledge I gained from the online education.
1_erugiF([TD$I)G] Research 25 Figure 1. Design and flow of participants through the trial. MOOC = massive open online course. Table 4 case studies with data taken from participants of MOOCs. The Baseline characteristics of the participants. review did not include the only clinical trial (unpublished) that we have been able to identify.7 That trial focused on student Experimental (n = 24) Control (n = 24) engagement, not effectiveness. Therefore, the present study is the first trial to address the issue of whether MOOCs are an Gender, n female (%) 14 (58) 15 (63) effective way of providing education. The results of the present 21 (1) study indicate that the physiotherapy students did not gain more Age (yr), mean (SD) 21 (1) knowledge or confidence about the physiotherapy management of 10 (42) spinal cord injuries by participating in a MOOC than by progressing Year of training, n (%) 14 (58) at their own pace through the physiotherapy-specific content on www.elearnSCI.org. Nor were they more satisfied with the learning second 10 (42) 9 (7 to 10) experience. However, responses to the open-ended questions 3 (2 to 3) suggest that the MOOC students enjoyed engaging with students third 14 (58) from other countries on the Facebook group. 9 (38) English proficiency (0 to 10), median (IQR) 6 (25) The failure to demonstrate better outcomes with the MOOC is 7 (29) not due to an insufficient sample size. On the contrary, the upper self assessed 7 (5 to 8) 2 (8) end of the 95% CI associated with the mean between-group difference for knowledge (ie, –1.3 to 2.6 points) was below the teacher assessed 3 (3 to 3) 1 (5) pre-specified smallest worthwhile treatment effect of 4 points. In 1 (5) addition, the 95% CI was remarkably tight, which indicates good Previous spinal cord injuries clinical experience, n (%) 4 (17) 10 (42) none 7 (29) 8 (33) minimal 10 (42) moderate 7 (29) extensive 0 (0) Frequency of internet use for studies, n (%) never 1 (5) once a month 1 (5) once a week 3 (13) most days 11 (46) every day 8 (33) Table 5 Knowledge about, and confidence in managing people with, spinal cord injuries, and satisfaction with the learning experience. Mean (SD) of groups, mean (SD) difference within groups, and mean (95% CI) difference between groups. Outcome Groups Difference within groups Difference between groups Week 0 Week 6 Week 6 minus Week 0 Week 6 minus Week 0 Exp Con Exp Con Exp Con Exp minus Con (n = 24) (n = 24) (n = 24) (n = 24) 0.7 Knowledge (0 to 20) 9.2 9.1 9.0 8.3 –0.1 –0.8 (–1.3 to 2.6) Confidence (0 to 10) (2.1) (1.9) (3.1) (2.2) (3.7) (3.0) Satisfaction (0 to 10) 4.7 6.0 6.2 7.1 1.5 1.1 0.4 (3.0) (2.8) (2.4) (2.4) (2.5) (2.2) (–1.0 to 1.8) 8.1 8.1 (1.8) (2.2) 0.0 (–1.1 to 1.2) Exp = experimental group, Con = control group.
26 Hossain et al: MOOCs for educating physiotherapists in SCI precision in the estimate. These results indicate that, within the they may otherwise not have. MOOCs may be particularly useful limitations of the trial, there was no added benefit of the MOOC for some of the specialty areas such as spinal cord injuries. over self-directed completion of the online learning module. However, before jumping to conclusions about the effectiveness of However, these results need to be interpreted with caution MOOCs, their possible merits need to be better understood. While because the outcome measures may not have captured important the present study does not provide answers about the effectiveness differences. For example, the knowledge assessment was probably or otherwise of MOOCs, it does provide an example of how rigorous too difficult and may not have been sensitive to differences trial methodology can be used to answer questions about the between the two groups. Interestingly, there were some types of effectiveness of MOOCs and other online educational strategies. questions that all students consistently answered correctly, both at The randomised trial design is important for minimising bias, and the beginning and end of the trial. The confidence and satisfaction bias is a problem for educational research, as it is for any research questionnaires were also problematic because both had marked topic. However, if any trial, regardless of its scientific rigor, is going ceiling effects. Consequently, both the control and experimental to provide answers about the effectiveness of different approaches, students had high scores at the end of the trial. This may have more work needs to be performed in developing good outcome masked differences between groups. measures in education. It is possible that the control participants were very diligent in What is already known on this topic: Massive open online response to participation in the trial, thereby limiting any possible courses (MOOCs) offer efficient ways of providing training to benefits of the structure provided by the MOOC. Alternatively, large numbers of people. MOOCs could be utilised to enhance perhaps there was limited engagement by students of both groups. the training of undergraduate and/or graduate physiothera- Students may not have been motivated to devote time to this topic pists. An important aspect of MOOCs is the sense of commu- because it was not part of their formal curriculum and they may nity that they create, and the opportunity they provide for have had competing demands on their time from their usual people to engage online and learn from each other. studies. This latter hypothesis is supported by the within-group What this study adds: MOOCs for physiotherapy students results, which indicate no change in knowledge of either group. Of are feasible. However, they may not increase students’ knowl- course, without a control group that did not engage in any learning, edge about spinal cord injuries and confidence in treating it is difficult to know which interpretation explains the non- people with spinal cord injuries more than self-paced inde- significant findings. It might be interesting to repeat the study with pendent learning of the same material via an online educa- the MOOC embedded within the students’ curriculum. This may tional module. yield quite different results because students may be more motivated to learn if the content is part of their formal assessment. eAddenda: Table 6 can be found online at doi:10.1016/ j.jphys.2014.09.008. The Bangladeshi students who participated in this trial may have been limited by language. The course was run in English and Ethics: The study was approved by the Ethics Committee of the while all the Bangladeshi students spoke English, it was not their Centre for Rehabilitation of the Paralysed, Bangladesh. Participants first language. Interestingly, when asked, the students generally were provided with a participant information sheet and then reported good English skills. However, the students’ ratings of signed a consent form prior to participation in the study. their own English skills were consistently higher than the ratings provided by their teacher (who was fluent in English). While Competing interests: Physio-pedia receives sponsorship from language barriers would have affected both groups, it may have Elsevier, which in turn received publicity through the MOOC. particularly affected the MOOC students. The success of the Elsevier and LA Harvey may also have indirectly benefited through MOOC relied on following weekly instructions and reading the any sales generated of the course textbook (which was published Facebook discussion. Limited English skills may have prevented by Elsevier). the MOOC students from fully benefitting from the learning experience. Sources of support: The University of Sydney provided salary support to LA Harvey and JV Glinsky to run the MOOC and trial. One of the important aspects of the MOOC was the opportunity Elsevier sponsors Physio-pedia, but Physio-pedia did not receive any it provided for students to engage with other students and senior direct sponsorship or funding to run the MOOC. Bangladesh Health physiotherapists from around the world through the Facebook Professions Institute provided in-kind support to run the trial. group. The course coordinators posted between two and five discussion points each week, which students of the MOOC were Acknowledgements: The MOOC was based on the physiother- expected to comment on. Some of the Bangladeshi students stated apy-specific module of www.elearnSCI.org. This website was that they enjoyed this aspect of the course and the opportunity to the initiative of the International Spinal Cord Society. Over communicate with students and physiotherapists from different 40 physiotherapists in different countries compiled the physio- countries. However, this may not have provided the intended therapy-specific module. The contributions of all that made the educational experience for the Bangladeshi students because they website possible and specifically contributed to the physiothera- predominantly relied on their mobile phones to access the py-specific module is acknowledged. The contributions of Dr HS Facebook group and some of the discussion threads attracted Chhabra and Mr S Muldoon to the co-ordination of the entire close to 1000 posts, which would have been slow to load on mobile website are also acknowledged. The MOOC was also based on phones in Bangladesh. In addition, some students may have felt www.physiotherapyexercises.com. This was an initiative of reluctant to fully engage in the Facebook discussion because of Sydney-based physiotherapists, Peter Messenger and Paul Pattie. concerns about their English. The contributions of all those who contributed to this website are also gratefully acknowledged. MOOCs are a relatively new educational phenomenon and, in part, arose from a global push about a decade ago to provide Correspondence: Lisa Harvey, John Walsh Centre for Rehabili- education for all although the MOOC term was only coined in tation Research, Kolling Institute, Royal North Shore Hospital, 2008.2,4–7,12–14 Academics and teachers are divided about the Sydney, Australia. Email: [email protected] merits or otherwise of MOOCs; students also report mixed experiences.14 However, most agree that MOOCs will probably References never replace an experienced, knowledgeable and engaging teacher in front of a small class – nor will they effectively teach 1. Chhabra HS, Harvey LA, Muldoon S, Chaudhary S, Arora M, Brown DJ, et al. students practical skills; these need to be learnt elsewhere. www.elearnSCI.org: A global educational initiative of ISCoS. Spinal Cord. However, MOOCs might provide students with a different type of 2013;51:176–182. learning experience and one that has other benefits. They may also provide students with access to information and knowledge that 2. https://blogs.worldbank.org/edutech/insidetheweb/making-sense-of-moocs-a- reading-list Making sense of MOOCs - a reading list. Accessed on 1/4/2014. 3. ELI 7 Things You Should Know. http://www.educause.edu/library/resources/7- things-you-should-know-about-moocs-ii. Accessed on 16/6/2014.
Research 27 4. Ebben M, Murphy JS. Unpacking MOOC scholarly discourse: a review of nascent 11. Downes S. An Introduction to Connective Knowledge. In: Media, Knowledge & MOOC scholarship. Learning Media and Technology. 2014. http://dx.doi.org/ Education - Exploring new Spaces, Relations and Dynamics in Digital Media Ecologies. 10.1080/17439884.17432013.17878352. Proceedings of the International Conference held on June 25–26, 2007, Hug T, Editor. 2007. 5. Liyanagunawardena TR, Adams AA, Williams SA. MOOCs: A systematic study of the published literature 2008–2012. The International Review of Research in Open and 12. Hoy MB. MOOCs 101: An Introduction to Massive Open Online Courses. Medical Distance Learning. 2013;14:202–227. Reference Services Quarterly. 2014;33:85–91. 6. UK Department for Business Innovation and Skills (BIS).The maturing of the MOOC: 13. Koutropoulos A, Gallagher MS, Abajian SC, deWaard I, Hogue RJ, Keskin NO¨ , et al. Literature review of massive open online courses and other forms of online distance Emotive vocabulary in MOOCs: Context and participant retention. Journal of Open, learning. Department for Business Innovation and Skills: London; 2013. Distance and E-Learning. 2012: Available at http://www.eurodl.org/materials/ contrib/2012/Koutropoulos_et_al.pdf. Accessed on 02/09/2014. 7. Cassidy D, Breakwell N, Bailey J. Keeping them clicking: promoting student engagement in MOOC design (available online at http://icep.ie/wp-content/ 14. Zutshi S, O’Hare S, Rodafinos A. Experiences in MOOCs: The Perspective of uploads/2013/12/CassidyBreakwellBailey.pdf). 2013. Accessed on 16/06/2014. Students. American Journal of Distance Education. 2013;27:218–227. 8. Bell F. Connectivism: Its place in theory-informed research and innovation in Further reading technology-enabled learning. International Review of Research in Open and Distance Learning. 2011;12:98–118. www.wcpt.org/node/33154 www.elearnSCI.org 9. Siemens G. Connectivism: A learning theory for the digital age. http://www.elearn- www.physio-pedia.com/Physiotherapy_Management_of_Spinal_Cord_Injuries space.org/Articles/connectivism.htm. 2004. Accessed on 02/09/2014. 10. Kop R, Hill A. Connectivism: Learning theory of the future or vestige of the past? International Review of Research in Open and Distance Learning. 2008;9.
Journal of Physiotherapy 61 (2015) 45 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Smooth pursuit eye movement training improves recovery from functional neglect in individuals with postacute stroke Synopsis Summary of: Kerkhoff G, Bucher L, Brasse M, Leonhart E, Holzgraefe Neglect Index (scored from 0 to 3), the Help Index, the Barthel Index and M, Volzke V, et al. Smooth pursuit ‘‘bedside’’ training reduced disability rehabilitation phase (derived from the Barthel Index). The outcomes were and unawareness during the activities of daily living in neglect: a measured at baseline, immediately after completion of training and at 2- randomized controlled trial. Neurorehabil Neural Repair 2014;28:554- week follow-up. Results: A total of 24 participants completed the study. 563. Significant group  time interaction effects were found in the Functional Neglect Index and the Unawareness and Behavioral Neglect Index. Question: In people with postacute stroke, does smooth pursuit eye Immediately after the 4-week training period, the change in the movement training reduce disability and unawareness during activities Functional Neglect Index was significantly greater in the smooth pursuit of daily living? Design: Randomised, controlled trial and blinded eye movement-training group by 2.3 points. The change in the outcome assessment. Setting: An inpatient setting in Germany. Unawareness and Behavioral Neglect Index was also significantly greater Participants: Individuals with single right-hemisphere stroke with left in the smooth pursuit eye movement-training group by 0.3 points. visual neglect were eligible. Key exclusion criteria were: psychiatric, During the 2-week follow-up period, the improvement in the Functional ophthalmological or other neurological diseases. Randomisation of Neglect Index continued in the smooth pursuit eye movement-training 24 participants (11 to 66 days post-stroke) allocated 12 to the smooth group, but not in the visual scanning training group (mean pursuit eye movement-training group and 12 to the visual scanning difference = 1.8 points). The Help Index and Barthel Index did not training group. Interventions: Both groups underwent their respective demonstrate any significant group  time interaction effect. The treatment programs for 4 weeks (30 minutes per session, five sessions rehabilitation phase also did not show any between-group differences per week). In the smooth pursuit eye movement-training group, the at any time points. Conclusion: In the postacute phase after stroke, participants repeatedly followed the moving stimulus patterns by smooth pursuit eye movement training was more effective than visual making smooth pursuit eye movements from right to left. In the visual scanning training in improving functional neglect and reduced unaware- scanning training group, the participants viewed the stationary displays ness during activities of daily living. of stimuli and performed saccadic eye movements to scan the stimulus objects systematically in a specified direction, naming objects or Marco YC Pang counting certain stimuli. In both groups, the participants were asked Department of Rehabilitation Sciences, to keep their head stationary in a neutral position while performing the The Hong Kong Polytechnic University, Hong Kong eye movements. Outcome measures: The outcomes were the Functional Neglect Index (scored from 0 to 15), the Unawareness and Behavioral http://dx.doi.org/10.1016/j.jphys.2014.11.012 Commentary tasks. Without a reference to the standardised assessments, this meant that the severity of neglect (impairment level) at baseline was unclear. Increasing research evidence has demonstrated the effectiveness of neglect rehabilitation. To date, most of studies in this field have not been The smooth pursuit eye movement training did improve performance performed at the acute stage of stroke. Although the sample size in the in both the neglect tests, within-group changes in activities of daily living study by Kerkhoff et al was small, with 12 subjects in each arm (either measures were noted as well, and the effects could be long lasting. This is smooth pursuit eye movement training or visual scanning training), they encouraging, as a previous review concluded that there is insufficient were able to find significant differences after smooth pursuit eye evidence to support the effectiveness of most of the neglect-specific movement training compared to visual scanning training in measures of intervention approaches aimed at reducing disability and improving the Functional Neglect Index and the Unawareness and Behavioral independence.1 This study contributes to the evidence and neuroscience of Neglect Index after 4 weeks of training (a total of twenty 30-minute using a new treatment – smooth pursuit eye movement training – rather sessions). than the conventional visual scanning training, in the design of theory- based treatment in rehabilitation for post-stroke unilateral neglect. The challenge with smooth pursuit eye movement training is how to ensure that the head is kept in a neutral position while moving the eyes. Kenneth NK Fong In future, it will be interesting to use an eye tracker to investigate how the Department of Rehabilitation Sciences, eye gaze deviation changes behaviourally when doing smooth pursuit The Hong Kong Polytechnic University, Hong Kong eye movement to the contralesional side or saccadic eye movement in visual scanning. Reference The primary outcome measures of this study, namely the Functional 1. Bowen A, et al. Cochrane Database Syst Rev. 2007;CD003586. Neglect Index and the Unawareness and Behavioral Neglect Index, are uncommon, standardised assessment tools for people with unilateral http://dx.doi.org/10.1016/j.jphys.2014.11.007 neglect. Although the authors mentioned the Catherine Bergego Scale, they did not give reasons as to why they chose the Unawareness and Behavioral Neglect Index rather than the Catherine Bergego Scale for the behavioural 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 44 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Tai Chi improves balance and prevents falls in people with Parkinson’s disease Synopsis Summary of: Gao Q, Leung A, Yang Y, Wei Q, Guan M, Jia C, He C. Go (TUG) test were assessed. Over the subsequent 6 months, falls Effects of Tai Chi on balance and fall prevention in Parkinson’s were assessed via a falls diary and monthly phone calls. Results: disease: a randomized controlled trial. Clin Rehabil 2014;28: Seventy-six participants completed the study. BBS scores im- 748–753. proved significantly more in the Tai Chi group, by 3.8 points (95% CI 2.3 to 5.3). The UPDRS scores didn’t differ significantly. Change in Question: Does Tai Chi improve balance and functional TUG time was significantly better in the Tai Chi group, by mobility, and prevent falls in people with Parkinson’s disease? 1.4 seconds (95% CI 0.9 to 2.0). Tai Chi reduced the relative risk of Design: Randomised, controlled trial with blinded outcome falls significantly, to 0.44 (95% CI 0.22 to 0.89). Conclusion: Three assessment. Setting: A hospital and local community in China. months of Tai Chi improved balance and decreased the incidence of Participants: Adults aged over 40 years with idiopathic Parkin- falls in people with Parkinson’s disease. son’s disease who were independently mobile and had fallen during the past year. Randomisation allocated 40 participants to [95% CIs calculated by the Editor using data from the published the Tai Chi group and 40 to the control group. Interventions: Both paper. Note that the TUG result is statistically significant, but it was groups received usual medical treatment. The intervention group not significant in the published paper. This may have been due to participated in Yang style Tai Chi, which emphasises diagonal slight differences in the equations that were used.] weight shifts, awareness of body position and breathing. An experienced instructor guided the participants through three Mark Elkins 60-minute sessions per week for 12 weeks. The control group Editor, Journal of Physiotherapy undertook no Tai Chi exercise. Outcome measures: At the end of the intervention period, the Berg Balance Scale (BBS), the Unified http://dx.doi.org/10.1016/j.jphys.2014.11.010 Parkinson’s Disease Rating Scale (UPDRS) III and the Timed Up and Commentary population have also been demonstrated.4 However, the effect of Tai Chi on falls is arguably clinically worthwhile; for every four The major finding of this trial was that 3 months of Tai Chi people (95% CI 2 to 18) who undertake Tai Chi, one person avoids a improved balance and decreased the incidence of falls in people fall who otherwise would have fallen. with Parkinson’s disease. A recent systematic review about the effects of Tai Chi in Parkinson’s disease1 found similar results; These mainly complementary benefits suggest that people with however, the pooled estimate of the effect on functional mobility Parkinson’s disease may benefit from a combination of Tai Chi and was lower than that reported by Gao et al. Therefore, this trial is a other physiotherapy interventions. Studies that address adherence useful addition to this field of study. and satisfaction with Tai Chi could help with the clinical decision- making. Unfortunately, the authors did not describe in detail the traditional Chinese mind-body exercises that they used, thus Aline Scianni making it difficult to replicate in clinical practice. To apply such Department of Physiotherapy, Universidade Federal de Minas Gerais, exercises in a clinical setting would require an experienced instructor, which may be expensive or unfeasible in some countries. Belo Horizonte, Brazil Tai Chi appears to have complementary benefits to some other References physiotherapy interventions for Parkinson’s disease.2 In a recent systematic review,2 the effect of treadmill training on balance was 1. Ni X, et al. PLoS ONE. 2014;9(6):e99377. twice that reported for Tai Chi by Gao et al, where the mean 2. Tomlinson CL, et al. Cochrane Datab Syst Rev. 2013;9:CD002817. estimate and 95% CI did not exceed 10% of the Berg Balance Scale 3. Downs S, et al. J Physiother. 2014;60:85–89. range from 0 (high falls risk) to 56 (low falls risk).3 The effect of Tai 4. Lima LO, et al. J Physiother. 2013;59:7–13. Chi on the Timed Up and Go test reported by Gao et al was similarly small and of borderline statistical significance. The effects of http://dx.doi.org/10.1016/j.jphys.2014.11.008 exercise or general physiotherapy on the Unified Parkinson’s Disease Rating Scale are significant,2 which is again in contrast to Tai Chi in the Gao study. The beneficial effects of resistance training on strength, mobility and functional performance in this 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 42 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Trial Protocol The PACT trial: PAtient Centered Telerehabilitation Effectiveness of software-supported and traditional mirror therapy in patients with phantom limb pain following lower limb amputation: protocol of a multicentre randomised controlled trial Andreas Stefan Rothgangel a,b, Susy Braun b,c,d, Ralf Joachim Schulz e, Matthias Kraemer f, Luc de Witte c,d, Anna Beurskens b,g, Rob Johannes Smeets a,h a Department of Rehabilitation, Research School CAPHRI, Maastricht University; b Research Centre Autonomy and Participation of People with a Chronic Illness, Faculty of Health, Zuyd University of Applied Sciences; c Research Centre Technology in Care, Faculty of Health, Zuyd University of Applied Sciences, Heerlen; d Department Health Research Services, Research School CAPHRI, Maastricht University; e Department of Geriatrics, Cologne University; f Centre of Neurological Rehabilitation, St. Marien Hospital Cologne, Germany; g Department of Family Medicine, Research School CAPHRI, Maastricht University, Maastricht; h Adelante Centre of Expertise in Rehabilitation, Hoensbroek, The Netherlands Abstract Introduction: Non-pharmacological interventions such as mirror pain-related limitations in daily activities, global perceived effect, pain- therapy are gaining increased recognition in the treatment of phantom specific self-efficacy, and quality of life. Discussion: Several questions limb pain; however, the evidence in people with phantom limb pain is still concerning the study design that emerged during the preparation of this weak. In addition, compliance to self-delivered exercises is generally low. trial will be discussed. This will include how these questions were addressed The aim of this randomised controlled study is to investigate the and arguments for the choices that were made. effectiveness of mirror therapy supported by telerehabilitation on the intensity, duration and frequency of phantom limb pain and limitations in Trial registration: U.S. National Institutes of Health Clinical Trials Registry. daily activities compared to traditional mirror therapy and care as usual in Registration number: NCT02076490. Was this trial prospectively registered: people following lower limb amputation. Method: A three-arm multi-centre Yes. Date: 28.02.2014. Funded by: Ministry of Health, State of North Rhine- randomised controlled trial will be performed. Participants will be randomly Westphalia, Germany and the European Union through the NRW Ziel2 Program assigned to care as usual, traditional mirror therapy or mirror therapy as a part of the European Fund for Regional Development. Funder approval supported by telerehabilitation. During the first 4 weeks, at least number: 005-GW02-035. Anticipated completion: July 2015. Correspon- 10 individual sessions will take place in every group. After the first 4 weeks, dence: Andreas Rothgangel, Department of Rehabilitation Medicine, Research participants will be encouraged to perform self-delivered exercises over a School for Public Health and Primary Care CAPHRI, Maastricht University, period of 6 weeks. Outcomes will be assessed at 4 and 10 weeks after Maastricht, The Netherlands. Email: [email protected] baseline and at 6 months follow-up. The primary outcome measure is the average intensity of phantom limb pain during the last week. Secondary Full protocol: Available on the eAddenda at doi:10.1016/ j.jphys.2014.08.006 outcome measures include the different dimensions of phantom limb pain, http://dx.doi.org/10.1016/j.jphys.2014.08.006 ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved. Commentary successful this would represent a major advance in the management of this complex and difficult-to-manage condition. The researchers also plan to Phantom pain is common following limb amputation. Although data are conduct a cost-effectiveness and cost-utility analysis of the intervention. limited prognosis is regarded to be poor and there are few effective This will provide high quality information to guide policy makers and health treatment options.1 Mirror therapy has been investigated in 2 small trials care providers/consumers. and its effects on reducing pain intensity are promising. A significant concern with mirror therapy and related interventions such as graded motor This is a well-designed and high quality trial. Although neither the imagery for complex regional pain syndrome (CRPS) is that they often patients nor the therapist delivering the intervention will be blinded to require considerable therapist and patient time to achieve therapeutic allocation, efforts have been taken to minimise most other known sources of benefits. bias. This will lead to a high confidence in the findings. This three-arm randomised controlled study will investigate the James McAuley effectiveness of telerehabilitation-supported mirror therapy for phantom Neuroscience Research Australia (NeuRA) Sydney, Australia limb pain. The effectiveness of mirror therapy will be determined by comparing telerehabilitation supported mirror therapy to mirror therapy Reference and care as usual. The primary outcome is pain intensity. Secondary outcomes include duration and frequency of phantom limb pain and 1. Alviar MJM, et al. Cochrane Database Syst Rev. 2011;12:CD006380. http://dx.doi.org/ activities of daily living. These patient-centered outcomes are appropriate 10.1002/14651858.CD006380.pub2. for this patient group and reflect the patient’s main concerns. http://dx.doi.org/10.1016/j.jphys.2014.10.001 The study is powered to detect a two-point difference on an 11-point numerical rating scale of pain intensity. This is an ambitious between-group difference as pain interventions rarely achieve effects of this magnitude. If 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association.
Journal of Physiotherapy 61 (2015) 43 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers The use of positive expiratory pressure therapy does not appear to be effective in people hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) Synopsis Summary of: Osadnik CR, McDonald CF, Miller BR, Hill CJ, Tarrant B, self-reported symptom severity, measured using the Breathlessness, Cough Steward R, et al. The effect of positive expiratory pressure (PEP) therapy on and Sputum Scale at hospital discharge, 8 weeks, and 6 months following symptoms, quality of life and incidence of re-exacerbation in patients with discharge. Other outcomes included: functional limitation due to dyspnoea, acute exacerbations of chronic obstructive pulmonary disease: a multi- health-related quality of life, the need for ventilatory assistance, length of centre, randomised controlled trial. Thorax 2014;69:137-143. hospital stay and the number of acute exacerbations over the first 6 months following discharge. Results: A total of 88 participants completed the study. Question: In people who are hospitalised with an acute exacerbation of There were no between-group differences in the Breathlessness, Cough and chronic obstructive pulmonary disease (AECOPD), does the addition of Sputum Scale at hospital discharge (0.2 units, 95% CI –0.9 to 1.4), or at any positive expiratory pressure (PEP) therapy to usual medical care improve other time point. Those in the intervention group had less functional symptoms and reduce the incidence of future exacerbations? Design: Multi- limitation due to dyspnoea 8 weeks following discharge (between-group centre, randomised, controlled trial with concealed allocation and blinding of difference –0.4 units, 95% CI –0.5 to –0.3), but this was not maintained at outcome assessors. Setting: Two public tertiary hospitals in Melbourne, 6 months following discharge. There were no between-group differences in Australia. Participants: Adults who were hospitalised with AECOPD were the other outcomes at any time point. Conclusion: In people who are included if they had a history of chronic sputum production and were within hospitalised with AECOPD and are characterised by chronic sputum 48 hours of admission. Exclusion criteria were: a history of a chronic lung production, PEP therapy may produce a short-term reduction in functional condition more significant than their COPD, established airway clearance limitation due to dyspnoea, but not affect symptoms, health-related quality of routines, the need for an artificial airway, or a contraindication to PEP therapy. life, the need for ventilatory assistance, length of hospital stay or the future Randomisation allocated 46 people each to the intervention and control incidence of acute exacerbations. groups. Interventions: Participants in both groups received usual medical care in accordance with COPD-X guidelines and a standard exercise-training Kylie Hill program. Those in the intervention group performed additional PEP therapy School of Physiotherapy and Exercise Science, Curtin University via a facemask, in an upright position, three times a day (one session was supervised). During each session, the participants took 8 to 10 tidal volume http://dx.doi.org/10.1016/j.jphys.2014.11.009 breaths and used a slightly active expiration to achieve an expiratory pressure of 10 to 20 cmH2O, followed by one huff at low-lung volume, one huff from mid-lung volume and two strong coughs. This sequence was repeated five times each session. Outcome measures: The primary outcome was ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved. [3_TD$IF]4Commentary those who have significant bronchiectasis and, during an exacerbation, this group is likely to benefit from airway clearance techniques. Despite the limited evidence supporting their routine use,1 Australian physiotherapists use a variety of airway clearance techniques to treat These findings indicate that airway clearance techniques, in particular patients during acute exacerbations of chronic obstructive pulmonary PEP, should not be included as part of routine physiotherapy care for people disease (AECOPD).2 This lack of evidence calls for further clinical trials, as who are hospitalised with AECOPD. Given the benefits of exercise training in performing airway clearance techniques is time consuming and costly, if this clinical population,3 an alternative for people who experience difficulty purchasing devices. in clearing airway secretions may be huffing intermittently during exercise, which itself increases tidal volume and expiratory flow. The multi-centre, randomised, controlled trial by Osadnik et al investigated the effects of positive expiratory pressure (PEP) therapy during Jamie Wood AECOPD. This technique was chosen based on the theory that resistance DF_][ID1$T epartment of Physiotherapy, Sir Charles Gairdner Hospital, during expiration prevents dynamic airway collapse, moves the equal pressure point peripherally, and may reduce dynamic hyperinflation and Perth, Western Australia dyspnoea. References Choosing outcome measures for an airway clearance technique study can be difficult. The primary outcome measure used in this trial was the 1. Ides K, et al. COPD. 2011;8:196–205. Breathlessness, Cough and Sputum Scale, which is clinically relevant as these 2. Osadnik C, et al. Physiotherapy. 2013;99:101–106. symptoms impact on the daily life of those with COPD. Using expectorated 3. Puhan MA, et al. Cochrane Database Syst Rev. 2011;5:CD005305. sputum as an outcome measure has flaws and therefore was not included. The effect of PEP on health-related quality of life and healthcare utilisation was http://dx.doi.org/10.1016/j.jphys.2014.11.011 also investigated. This high-quality and adequately powered trial found that the addition of PEP to usual care conferred no short-term or long-term benefits to the person or healthcare service. It is worth noting that this trial excluded 1836-9553/Crown Copyright ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. All rights reserved.
Journal of Physiotherapy 61 (2015) 34–41 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research Eliciting older people’s preferences for exercise programs: a best-worst scaling choice experiment Marcia R Franco a, Kirsten Howard b, Catherine Sherrington a, Paulo H Ferreira c, John Rose d,e, Juliana L Gomes f, Manuela L Ferreira a a The George Institute for Global Health, Sydney Medical School; b Sydney School of Public Health; c Faculty of Health Science, The University of Sydney; d UniSA Business School, The University of South Australia, Adelaide; e Business School, Institute of Transport and Logistics Studies, The University of Sydney, Sydney, Australia; f Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil KEY WORDS ABSTRACT Exercise Question: What relative value do older people with a previous fall or mobility-related disability attach to Older people different attributes of exercise? Design: Prospective, best-worst scaling study. Participants: Two Patient preference hundred and twenty community-dwelling people, aged 60 years or older, who presented with a previous Best-worst scaling fall or mobility-related disability. Methods: Online or face-to-face questionnaire. Outcome measures: Utility values for different exercise attributes and levels. The utility levels were calculated by asking participants to select the attribute that they considered to be the best (ie, they were most likely to want to participate in programs with this attribute) and worst (ie, least likely to want to participate). The attributes included were: exercise type; time spent on exercise per day; frequency; transport type; travel time; out-of-pocket costs; reduction in the chance of falling; and improvement in the ability to undertake tasks inside and outside of home. Results: The attributes of exercise programs with the highest utility values were: home-based exercise and no need to use transport, followed by an improvement of 60% in the ability to do daily tasks at home, no costs, and decreasing the chances of falling to 0%. The attributes with the lowest utility were travel time of 30 minutes or more and out-of-pocket costs of AUD50 per session. Conclusion: The type of exercise, travel time and costs are more highly valued by older people than the health benefits. These findings suggest that physical activity engagement strategies need to go beyond education about health benefits and focus on improving accessibility to exercise programs. Exercise that can be undertaken at or close to home without any cost is most likely to be taken up by older people with past falls and/or mobility-related disability. [Franco MR, Howard K, Sherrington C, Ferreira PH, Rose J, Gomes JL, Ferreira ML (2015) Eliciting older people’s preferences for exercise programs: a best-worst scaling choice experiment. Journal of Physiotherapy 61: 34–41] ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Introduction interventions.8 Adherence to exercise programs among older people has been found to be greater among those with: concerns Falls and mobility-related disability among older people can about the interference of falls in social activities,9 certain lead to substantial healthcare costs, morbidity and mortality.1 intervention content (ie, balance or walking exercise),8 and two These important public health concerns are likely to worsen in the or fewer sessions per week.7 Although clinicians may use this near future, as the number of people aged over 65 years is expected information when planning exercise programs for this age group, to triple in the next 30 years.2 Evidence shows that appropriately designed exercise programs are effective in the prevention of falls when prescribing an intervention it is also important to take into and mobility-related disability amongst community-dwelling account patients’ preferences in the decision-making process.10,11 older people.3,4 In a patient-centered healthcare system, shared decision making The challenge for policy makers and clinicians is to engage older has been shown to increase adherence to healthcare interven- people in both commencing and adhering to exercise programs. tions.11 Evidence from a systematic review of qualitative studies12 Half of the world’s older population is considered to be physically investigating older people’s preferences and attitudes towards inactive.5 Participation of older people in structured exercise programs in this age group has also been reported to be participation in exercise programs shows that specific attributes of suboptimal.6–8 For instance, estimates of adherence to falls exercise programs, such as costs and transport to exercise venues, prevention programs, derived from systematic reviews, vary from 74% (95% CI 67 to 80) of participants adhering to group exercise are likely to drive their decision about whether or not to engage in intervention7 to 21% (95% CI 15 to 29) adhering to home exercise those programs, and these are now variables of concern. Nevertheless, studies investigating the relative values that people in this age group actually attach to these different attributes are lacking. Identification of highly valued attributes can help http://dx.doi.org/10.1016/j.jphys.2014.11.001 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
Research 35 clinicians and policy makers to increase participation and Study design adherence to exercise programs. The BWS case 2 (profile case) was used, in which participants The best-worst scaling choice experiment (BWS) method is a are presented with a series of different hypothetical scenarios, one variation of the widely applied discrete choice experiment at a time.19 Respondents were asked to make their choices within methodology.13–15 The BWS provides more information on each scenario by selecting the attribute that is best (ie, they were relative preferences of attributes with higher statistical efficien- most likely to participate in programs with this attribute) and that cy, due to the larger amount of choice data from each is worst (ie, least likely to participate), based on the levels respondent.16 BWS applications and analysis are described in presented. the literature.17,18 Briefly, in BWS, respondents are presented with one scenario at a time, and are asked to indicate their Establishing the attributes and levels preference over attribute levels within each scenario, rather than To determine the relevant attributes, an extensive qualitative between scenarios, as in the traditional discrete choice experi- ment. The BWS approach allows respondents to choose the best systematic review was conducted on the experiences and and the worst features (attribute levels) through a series of perspectives of older people participating in physical activity hypothetical but plausible choice scenarios. For example, for the (manuscript under review). The views of 5987 participants from attribute transport to exercise venues, three levels are presented: 132 studies led to the development of nine attributes: improve- no need to use transport, free transport provided and no transport ment in the ability to undertake daily tasks at home; improvement provided. The additional information provided by BWS can be in the ability to leave the house to undertake tasks or to socialise; used to evaluate the impact or relative importance of attribute exercise type; time spent on exercise per day; reduction in the levels, as they are compared on a common scale. This evaluation is chances of falling; frequency (times per week); transport type; not possible when using a traditional discrete choice experi- travel time; and out-of-pocket costs per exercise session. For each ment.17 Some authors have suggested that the BWS approach attribute, five different levels were selected to include a range of imposes less cognitive burden upon respondents than a reasonable values, which were either actual or hypothetical. The traditional discrete choice experiment.19 Table 1 Levels The aim of the present study was to explore older people’s Attributes and attribute levels. preferences in relation to the characteristics of exercise programs, No improvement and to examine the relative value placed on these particular Attribute Improvement of 10% attributes. To the authors’ knowledge, this is the first BWS study Improvement in the ability to Improvement of 30% conducted in the area of exercise for older people. The findings will undertake daily tasks at home (in Improvement of 50% therefore assist clinicians and policy makers to improve the comparison to no exercise) Improvement of 60% acceptability and implementation of different types of exercise programs amongst the older population. Improvement in the ability to No improvement leave the house to undertake Improvement of 10% The research question for this study was: tasks or to socialise (in Improvement of 30% comparison to no exercise) Improvement of 50% What is the relative value that older people with a previous fall Exercise type Improvement of 60% or mobility-related disability attach to different exercise attributes and levels? Time spent on exercise Exercise at your home, including balance and strength training Method Chances of falling (in comparison Exercise away from home, including to an average chance of falling balance and strength training The protocol for the present study has previously been each year of 40%) Exercise in a group, including published.20 The original aim of the study, as described in the balance and strength training protocol, was to undertake a discrete choice experiment to Frequency Tai Chi in a group setting investigate exercise programs designed to prevent falls. Before Yoga in a group setting commencing the study, this aim was expanded to include a BWS of Transport type exercise programs designed to minimise falls and mobility-related 10 minutes per day disability in older adults. The current BWS was conducted with the Travel time 30 minutes per day same sample recruited for the discrete choice experiment. The 60 minutes per day results of the discrete choice experiment will be reported Out-of-pocket costs 90 minutes per day elsewhere. 120 minutes per day Participant eligibility and recruitment 0% chance of falling (0 out of 100) 10% chance of falling (10 out of 100) Participants were community-dwelling people, aged 60 years 20% chance of falling (20 out of 100) or older, living in Australia, able to comprehend and read English 30% chance of falling (10 out of 100) fluently, who were without marked cognitive impairment. To be 40% chance of falling each year would eligible, participants needed to report either having had a history stay the same (40 out of 100) of falls (ie, experienced at least one fall since the age of 60 years); or a mobility-related disability (ie, self-reported difficulty in 1 day per week climbing a flight of stairs or walk 800 metres without assis- 2 days per week tance21,22). A comprehensive sampling approach was undertaken 3 days per week by: contacting eligible participants from six community groups 4 days per week and retirement villages in the Sydney metropolitan area; 5 days per week newspaper advertisements; and electronic sampling using an online panel of Australian participants (provided via Survey No need to use transport Sampling International). Data collection was conducted both Free transport provided online (for those with internet access) and in person. A web-based A small transport subsidy provided survey was developed using Research Electronic Data Capture A moderate transport subsidy provided (REDCap) tools.23 No transport or subsidy provided Less than 5 minutes About 15 minutes About 30 minutes About 45 minutes About 60 minutes Free of charge $5 per session $15 per session $50 per session $100 per session
36 Franco et al: Older people’s preferences for exercise programs choice of levels for each attribute were based on the description of and was constructed to allow for best-worst choices. In generating the current exercise programs available for older people in the design, it was assumed that the alternative chosen as best was Australia, as well as discussions held with experts in the fields deleted when constructing the pseudo worst-choice task. To of ageing, and discrete choice experiments. All attributes and their ensure plausibility, several constraints were imposed on the levels are listed in Table 1. attribute level combinations of the design, such as if the transportation alternatives attribute took the level of no need to To ensure the comprehension of the attribute levels, a pilot use transport, then the travel time attribute was constrained to take study was conducted, including face-to-face interviews with a level of less than 5 minutes or 15 minutes. 34 people aged 60 or older and living in Australia. The results indicated that the attribute descriptions and levels were under- As each attribute had five levels, the final design had 40 choice standable and that the participants were able to answer the tasks and was blocked into four blocks of 10 tasks to ensure that scenarios presented without reporting excessive difficulty. Param- each attribute level was presented to each respondent an equal eter estimates from analysis of the pilot data were used to inform number of times in the 10 tasks that they answered (ie, to maintain the final efficient design of the main study. level balance).26 Blocking the design has been shown in previous studies to promote participant completion rates and minimise Experimental design error due to fatigue.27 Each scenario description contained all nine A Bayesian D-efficient design was used, 24,25 assuming normally attributes at different levels across the 10 scenarios presented. Based on the levels presented in each scenario, participants were distributed priors. Priors for the design were obtained from the asked to select the attribute they considered to be the best (ie, they pilot study, where the parameter estimates were used as the mean were most likely to participate in programs with this attribute) and values, and the standard errors were used as the standard worst (ie, least likely to participate). In other words, participants derugi_([1)TD$FIG] eviation parameters. The design allowed for all main effects Figure 1. Example of a scenario presented to participants.
Research 37 were asked to select the pair of attribute levels that they Table 3 considered to be furthest apart on the utility scale.17 From these Participants’ preferences for attribute levels of exercise programs. choices, a mathematical function numerically describing the value that participants attach to different choices was estimated. More Attribute level Utility (95% CI)a p-valueb details about the study experimental design are provided in Appendix 1 on the eAddenda. An example of a scenario presented Improvement in the ability to undertake daily tasks at home to the participants is displayed in Figure 1. After presenting a scenario with nine different attribute levels, the instruction given 60% 2.26 (1.95 to 2.57) <0.001 to the participants was: ‘Considering these factors only, which one factor makes you most likely to participate in exercise programs, 30% 2.10 (1.78 to 2.43) <0.001 and which one factor makes you least likely to want to participate in exercise programs?’ 10% 1.91 (1.58 to 2.24) <0.001 Socio-demographics, such as age and gender, as well as health 50% 1.87 (1.55 to 2.19) <0.001 status and physical activity habits data were also collected. 0% 1.20 (0.89 to 1.51) <0.001 Data analysis Logistic regression analyses were conducted using a multi- Improvement in the ability to leave the house to undertake tasks or to socialise nomial logit model in statistical softwarea to estimate the utility 50% 2.17 (1.84 to 2.49) <0.001 weights that older people attach to different attribute levels of exercise programs. The regression outcome variable, attribute 30% 1.98 (1.65 to 2.31) <0.001 choice, was coded as 1 for a best attribute level, and –1 for a worst attribute level. All remaining attribute levels were coded 60% 1.98 (1.66 to 2.30) <0.001 0. The model calculated utility coefficients by summing the number of times an attribute level was chosen as best or worst. 0% 1.45 (1.13 to 1.77) <0.001 Statistically significant coefficients indicated the importance of that attribute level in determining overall utility and in 10% 1.37 (1.03 to 1.71) <0.001 influencing preferences. A larger coefficient indicated higher utility (ie, the attribute level was considered to be more Exercise type (all of them include balance and strength training) attractive to participants). at home 2.50 (2.22 to 2.78) <0.001 In a best-worst attribute task analysis, the values of all levels of all attributes are estimated relative to each other on a single in a group 1.87 (1.57 to 2.17) <0.001 scale.17 This is modelled by omitting one level of a single attribute (reference level), rather than omitting a level of every attribute, outside home 1.84 (1.54 to 2.14) <0.001 and allows a direct comparison of the relative utility (attractive- ness) of the levels across the different attributes, instead of just group yoga 1.49 (1.19 to 1.79) <0.001 within attributes. The reference level is usually the attribute level with the lowest utility. group Tai Chi 1.46 (1.15 to 1.76) <0.001 A secondary analysis was conducted to investigate the possible Time spent on exercise (min/day) differences in utility between younger and older participants, as defined by the median age (ie, people aged < 66 years versus 10 1.93 (1.61 to 2.25) <0.001 people aged 66 years), by estimating interactions between attribute levels and age. 30 1.86 (1.54 to 2.17) <0.001 Results 60 1.50 (1.19 to 1.81) <0.001 Between February and October 2013, 220 of the 319 eligible 90 1.09 (0.81 to 1.37) <0.001 participants provided valid answers for the BWS experiment (response rate of 69%). Each participant answered 10 scenarios, 120 0.84 (0.56 to 1.13) <0.001 giving a total of 2200 scenarios in the sample. Patient character- istics are presented in Table 2. Chance of falling 0% 2.20 (1.89 to 2.51) <0.001 10% 2.09 (1.76 to 2.42) <0.001 20% 1.96 (1.64 to 2.29) <0.001 40% 1.63 (1.32 to 1.95) <0.001 30% 1.61 (1.29 to 1.93) <0.001 Frequency (times per week) 3 1.94 (1.63 to 2.26) <0.001 2 1.88 (1.57 to 2.19) <0.001 4 1.77 (1.45 to 2.10) <0.001 5 1.76 (1.44 to 2.09) <0.001 1 1.68 (1.39 to 1.98) <0.001 Transport type none required 2.32 (2.01 to 2.64) <0.001 small subsidy 1.63 (1.31 to 1.95) <0.001 free 1.60 (1.27 to 1.92) <0.001 moderate subsidy 1.41 (1.08 to 1.74) <0.001 no subsidy 1.34 (1.03 to 1.66) <0.001 Travel time (min) less than 5 2.11 (1.81 to 2.41) <0.001 15 1.51 (1.20 to 1.82) <0.001 30 0.82 (0.51 to 1.13) <0.001 45 0.39 (0.07 to 0.70) 0.018 60 0.19 (-0.12 to 0.51) 0.225 Out-of-pocket costs per exercise session $0 2.24 (1.93 to 2.55) <0.001 $5 1.58 (1.27 to 1.89) <0.001 $15 1.08 (0.80 to 1.37) <0.001 $50 0.52 (0.26 to 0.79) <0.001 $100 (reference case) - - a A larger coefficient indicates higher utility (ie, the attribute level is more attractive to participants). b Statistically significant coefficients indicate the importance of that attribute level on determining overall utility and in influencing preferences. Table 2 n = 220 The attribute level with the lowest utility (reference level) was Characteristics of respondents (n = 220). out-of-pocket costs of AUD100. This level was omitted in the 115 (52) analysis and takes the value of zero on the utility scale. The logistic Characteristic 68 (6) regression results are presented in Table 3. The regression coefficients of best-worst pairs show the additional utility of each Gender, n female (%) 82 (37) attribute level over the reference level. The utility coefficients are Age (yr), mean (SD) 68 (31) also graphically represented in Figure 2. All attribute levels Age group (yr), n (%) 35 (16) contributed significantly, with the exception of travel time of 22 (10) 60 minutes. 60 to 64 10 (5) 65 to 69 The attribute levels with the highest utility were exercise at 70 to 74 3 (1) home and no need to use transport. An improvement of 60% in the 75 to 79 134 (61) ability to do daily tasks at home, exercise free of charge and decreasing 80 to 84 the chances of falling to 0% were ranked third, fourth and fifth, 85 + 118 (54) respectively. In contrast, the attribute levels with the lowest utility Difficulty in climbing a flight of stairs without were travel time of 60 minutes, travel time of 45 minutes, out-of- help reported, n (%) 153 (70) pocket costs of AUD50 and then travel time of 30 minutes, in that Difficulty in walking 800 meters without help 104 (47) order. reported, n (%) 101 (46) Falls since the age of 60 reported, n (%) Falls in the past 12 months reported, n (%) People currently doing exercise, n (%)
[I(F]iGgure_)2$DT38 Franco et al: Older people’s preferences for exercise programs 3.50 All (whole sample) > 66 years Home ≤ 66 years 3.00 10 % None 60 % 0% 50 % 2.50 60 % Home $0 2w 20 % Group 30 % 30 % $0 $0 None 50 % 10 min <5 min $5 3w 60 % <5 min 10 % 15 min <5 min $5 4w 0% 50 % $5 2.00 5 w 10 % 30 % 30 % 30 % 60 % $15 Level Scale UƟlity Weight 3w 1w 20 % None Out. Home $15 2w 40 % 0 % 10 % 10 % 60 % 50 % Group 30 min $15 50 % Out. T.Chi 10 min 30 % 0% 30 min $50 4w Mod. 10 % $50 5w Free 30 % 60 min 30 min 1w Small Small 60 % Out. $50 3w 0% No subs. 10% $100 $100 $100 5w 40 % 10 % Small Free Yoga 10 min Out of pocket costs 4w 30 % 20 % Free 0% 1.50 1 w 2w 40 % Yoga 60 min 15 min T.Chi 30 % 50 % Yoga Group Mod. No subs. 60 min No subs. 0% T.Chi 90 min 15 min Mod. 0% 0% 90 min 120 min 30 min 1.00 10 % 90 min 120 min 30 min 30 min 120 min 0.50 45 min 45 min 60 min 45 min 60 min 60 min 0.00 Chance of falling Type of transport Improvement in home Improvement in outdoor Type of exercise Time spent exercising Travel Ɵme Frequency daily acƟviƟes acƟviƟes and socialising per day AƩributes Figure 2. Utility weights given to the various levels of the hypothetical attributes of an exercise program by older people with a history of falling or mobility-related disability. Abbreviations: Mod. = moderate subsidy, No subs. = no subsidy, Out. = outside the home, Small. = small subsidy, T.Chi = Tai Chi. Importantly, certain within-attribute differences were greater utility were travel time of 45 minutes, out-of-pocket costs of AUD50, than others. As can be seen from Figure 2, the levels of out-of-pocket exercising 120 minutes per day and travel time of 30 minutes. costs, travel time and time spent on exercise per day are further apart on the utility scale, showing the largest difference between Discussion attribute levels. This means that a change from a low-cost to a high-cost program, from a short to a long travel time, or from The present study’s findings suggest that aspects of exercise exercising for short periods in a day instead of longer periods programs, such as exercise venue, travel time and out-of-pocket costs would considerably influence older people’s preferences. In are highly valued by older people. Surprisingly, only two health contrast, participants ranked the levels of frequency (days per benefits (ie, reduction in the chances of falling to 0% and an week) and reduction in the chances of falling somewhat equally, improvement of 60% in the ability to undertake tasks inside home) indicating limited additional value for participants on moving were listed among the five most-highly valued attributes. between these levels. Therefore, it seems that older people place higher values on exercise characteristics than on their actual benefits and, therefore, The secondary analysis results for older and younger respon- their decision on whether or not to engage in exercise programs is dents are presented in Table 4 and also shown graphically in less influenced by the improvements in the health outcomes that Figure 2. As for the whole sample, the reference level was out-of- they provide. These findings have substantial impact on the pocket costs of AUD100. Most attribute levels contributed planning and development of exercise provision and promotion significantly, with the exception of travel time of 45 minutes and strategies. Accordingly, the findings suggest that unless accessi- 60 minutes for both age subgroups. In addition, out-of-pocket costs bility to exercise programs is optimised, policy makers and of AUD50 did not contribute significantly for the subgroup of healthcare professionals will still face important barriers in participants aged 66 or younger. increasing uptake and compliance to exercise among the older population. Amongst the participants aged older than 66 years, the two attribute levels with the highest utility were exercise at home and The two attribute levels with the highest utility identified in the improvement of 60% in the ability to undertake daily tasks at present study, exercise at home and no need to use transport, give home. These attributes were followed by no need to use transport, support to the idea that easy access to exercise programs is improvement of 50% in the ability to leave the house to undertake tasks generally preferred. In agreement with that, the attribute levels or to socialise and decreasing the chances of falling to 10%, in that with the lowest utility (ie, least preferred) concerned travel times order. Similar to the rankings of the whole sample, for the and out-of-pocket costs, reflecting participants’ aversion to travel subgroup of people aged 66 and older, the attribute levels with the long distances and to pay for high-cost exercise programs. In the lowest utility were travel time of 60 minutes, travel time of context of chronic conditions, provision of healthcare services at 45 minutes, out-of-pocket costs of AUD50 and travel time of home or close to home has recently gained growing attention in 30 minutes. different countries.28–30 For instance, care provided in the community or at home for people with heart failure and For the subgroup of people aged 66 or younger, the attribute multimorbid chronic diseases has shown beneficial effects on levels that were more positively valued were in the following outcomes, including improvements in quality of life and functional order: no need to use transport, exercise free of charge, exercise at home, decreasing the chances of falling to 0% and travel time of less than 5 minutes. In contrast, the attribute levels with the lowest
Research 39 Table 4 p-valueb Interaction terms between attribute levels and age subgroups. < 0.001 Attribute Age > 66 yr p-valueb Age 66 yr < 0.001 Level Utility (95% CI)a Utility (95% CI)a < 0.001 < 0.001 Improvement in the ability to undertake daily tasks at home < 0.001 0% 1.25 (0.80 to 1.71) < 0.001 1.18 (0.77 to 1.59) < 0.001 < 0.001 1.67 (1.23 to 2.11) < 0.001 10% 2.23 (1.74 to 2.72) < 0.001 1.76 (1.33 to 2.19) < 0.001 < 0.001 1.50 (1.08 to 1.93) < 0.001 30% 2.55 (2.07 to 3.03) < 0.001 1.86 (1.46 to 2.27) < 0.001 50% 2.35 (1.88 to 2.82) < 0.001 1.23 (0.81 to 1.66) < 0.001 < 0.001 1.01 (0.56 to 1.46) < 0.001 60% 2.80 (2.34 to 3.26) < 0.001 1.57 (1.13 to 2.01) < 0.001 < 0.001 1.77 (1.33 to 2.20) < 0.001 Improvement in the ability to leave the house to undertake tasks or to socialise < 0.001 1.48 (1.06 to 1.91) < 0.001 0% 1.73 (1.25 to 2.21) < 0.001 2.03 (1.66 to 2.39) < 0.001 < 0.001 1.71 (1.32 to 2.10) < 0.001 10% 1.84 (1.33 to 2.35) < 0.001 1.40 (1.01 to 1.80) < 0.001 < 0.001 1.42 (1.02 to 1.82) < 0.001 30% 2.52 (2.03 to 3.01) < 0.001 1.23 (0.82 to 1.63) 0.001 50% 2.69 (2.21 to 3.17) < 0.001 1.65 (1.23 to 2.08) < 0.001 1.77 (1.35 to 2.19) < 0.001 60% 2.65 (2.16 to 3.13) < 0.001 1.32 (0.91 to 1.72) < 0.001 < 0.001 1.02 (0.65 to 1.39) < 0.001 Exercise type (all of them include balance and strength training) < 0.001 0.60 (0.24 to 0.97) < 0.001 < 0.001 at home 3.13 (2.71 to 3.54) < 0.001 1.90 (1.49 to 2.31) < 0.001 1.62 (1.17 to 2.06) < 0.001 in a group 2.02 (1.57 to 2.47) < 0.001 1.59 (1.15 to 2.02) < 0.001 < 0.001 1.22 (0.80 to 1.64) < 0.001 outside home 2.47 (2.02 to 2.92) < 0.001 1.41 (1.00 to 1.82) < 0.001 < 0.001 group yoga 1.60 (1.15 to 2.05) < 0.001 1.50 (1.11 to 1.88) < 0.001 1.47 (1.06 to 1.87) < 0.001 group Tai Chi 1.76 (1.31 to 2.21) < 0.001 1.70 (1.28 to 2.12) < 0.001 < 0.001 1.56 (1.13 to 1.99) < 0.001 Time spent on exercise (min/day) < 0.001 1.56 (1.12 to 1.99) < 0.001 < 0.001 10 2.29 (1.82 to 2.77) < 0.001 2.04 (1.63 to 2.44) < 0.001 1.51 (1.08 to 1.94) < 0.001 30 1.99 (1.51 to 2.46) < 0.001 1.66 (1.24 to 2.08) < 0.001 < 0.001 1.12 (0.70 to 1.55) 60 1.75 (1.29 to 2.21) < 0.001 1.17 (0.74 to 1.59) 0.003 0.121 90 1.17 (0.75 to 1.59) < 0.001 1.88 (1.50 to 2.26) 0.724 < 0.001 1.22 (0.81 to 1.62) 120 1.16 (0.74 to 1.57) < 0.001 0.63 (0.22 to 1.04) < 0.001 0.33 (-0.09 to 0.74) < 0.001 Chances of falling 0.033 0.07 (-0.33 to 0.48) < 0.001 0.109 0% 2.61 (2.16 to 3.06) 2.03 (1.63 to 2.43) 0.026 < 0.001 1.39 (0.99 to 1.79) - 10% 2.69 (2.21 to 3.17) < 0.001 0.95 (0.57 to 1.33) < 0.001 0.40 (0.05 to 0.76) 20% 2.46 (1.98 to 2.94) 0.001 - 30% 2.12 (1.64 to 2.61) - 40% 1.93 (1.45 to 2.41) Frequency (times per week) 1 1.93 (1.49 to 2.38) 2 2.42 (1.97 to 2.88) 3 2.26 (1.80 to 2.72) 4 2.06 (1.57 to 2.55) 5 2.04 (1.55 to 2.53) Transport type none required 2.71 (2.25 to 3.18) small subsidy 1.71 (1.23 to 2.20) free 1.61 (1.13 to 2.09) moderate subsidy 1.79 (1.30 to 2.29) no subsidy 1.58 (1.12 to 2.05) Travel time (min) less than 5 2.42 (1.97 to 2.88) 15 1.90 (1.44 to 2.35) 30 1.07 (0.61 to 1.53) 45 0.49 (0.04 to 0.95) 60 0.37 (-0.08 to 0.81) Out-of-pocket cost per exercise session (compared to $100 reference category) $0 2.52 (2.07 to 2.97) $5 1.83 (1.38 to 2.29) $15 1.27 (0.84 to 1.70) $50 0.68 (0.28 to 1.08) $100 (reference case) - a Larger coefficients indicate higher utility (ie, were considered to be more attractive to participants). b Statistically significant coefficients indicate the importance of that attribute level in determining overall utility and in influencing preferences. measures of activities of daily living. These approaches have also suggesting that home exercise is not a suitable single intervention resulted in cost savings, by reducing the number of unplanned in this very high-risk group.32 hospitalisations and emergency department visits.30 Similarly, it can be argued that, based on older people’s preferences, the Participants’ rankings also revealed that high importance was provision of exercise programs in the local community or at home placed on differences between the levels of out-of-pocket costs, is an approach likely to facilitate participation. Fortunately, travel time and time spent exercising per day. Participants reported home-based balance and strengthening exercise, group exercise being most likely to take up exercise programs that can be and Tai Chi (that could be implemented in community settings) undertaken at or close to home and programs without a cost. While can be effective in preventing falls among older people living in it was expected that participants would be unwilling to pay for the community, as shown in a recent Cochrane review.4 A recent high-cost exercise programs and travel for a long time to attend an randomised controlled trial has also shown that an effective fall- exercise venue, the value allocated to time spent on exercise per day preventive option for this age group is to integrate simple was surprising. Interestingly, participants mostly preferred exercises that target balance and muscle strength into everyday exercising only 10 minutes per day and progressively ranked more routines, by using strategies such as standing on one leg while highly, shorter periods of exercise. Unfortunately, a total of waiting for the kettle to boil.31 However, another recent trial 10 minutes of exercise per day is unlikely to be sufficient for found that home exercises enhanced mobility but increased fall broader health benefits.33 However, performing multiple short rates in older people who had recently been in hospital, bouts of exercise throughout the day may be an attractive option to older people. In fact, this approach is in accordance with existing
40 Franco et al: Older people’s preferences for exercise programs guidelines, which suggest that accumulating bouts of exercise Source(s) of support: Marcia Franco is a PhD candidate produce health benefits.34,35 supported by the CAPES Foundation, Ministry of Education of Surprisingly, the levels related to improvements in health outcomes, while still important, had less impact on older people’s Brazil. Catherine Sherrington is supported by a research fellowship preferences than the levels of other attributes. A possible interpretation is that improvement in health outcomes might be funded by the Australian National Health and Medical Research valued differently by different subgroups of older people; the secondary analysis suggests that this might be the case. For Council (NHRMC). This project was not directly supported by any instance, for participants aged 66 or older (ie, median sample age), three out of the top five attribute levels concerned health benefits, other external grants or funds. including improvements in ability to undertake tasks at home and outside home as well as reduction in the chances of falling. In Acknowledgements: Nil. contrast, for the subgroup of participants aged 66 or younger, only one aspect related to health improvements (ie, reduction in the Correspondence: Marcia Rodrigues Costa Franco, The George chances of falling) was amongst the top five attribute levels. Future studies appropriately powered for subgroup analysis are necessary Institute for Global Health, Sydney, Australia. Email: mrcfranco@ to confirm these findings. georgeinstitute.org.au One limitation of the present study is that, although people with obvious cognitive impairment were excluded, the cognitive ability References of each participant was not measured. Although a pilot study was conducted to ensure that participants were able to understand the 1. National Injury Prevention (NIP) Plan. Priorities for 2001–2003. ACT: Common- attribute levels and comprehend the questions in each scenario, it wealth Department of Health and Aged Care 2001; Canberra, Australia. was difficult to determine to what extent different levels of cognitive impairment might have influenced participants’ choices. Another 2. World Health Organization (WHO). Global Health and Aging. http://www.who.int/ limitation is that data collection was restricted to only one country. ageing/publications/global_health.pdf [accessed 14/11/2013]. Older people’s preferences may vary across countries and health systems, and may even be influenced by local factors, such as 3. Crocker T, Forster A, Young J, Brown L, Ozer S, Smith J, et al. Physical rehabilitation socioeconomic and urban environments, as well as healthcare for older people in long-term care. Cochrane Database Syst Rev. 2013;2:CD004294. accessibility. Further research is required to assess the consistency of these findings in different countries and healthcare contexts. 4. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, et al. Interventions for preventing falls in older people living in the community. Cochrane The results from the present study suggest that, in order to Database Syst Rev. 2012;9:CD007146. enhance exercise uptake in older people with past falls and/or mobility impairment, physiotherapists should advocate for the 5. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U, et al. Global provision of low-cost exercise opportunities close to where people physical activity levels: surveillance progress, pitfalls, and prospects. Lancet. live and should prescribe home-based exercises to be performed in 2012;380(9838):247–257. multiple short bouts. 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What is already known on this topic: Appropriately designed exercise programs prevent falls and mobility-related 8. Simek EM, McPhate L, Haines TP. Adherence to and efficacy of home exercise disability among older people living in the community. How- programs to prevent falls: a systematic review and meta-analysis of the impact of ever, many older people do not join or complete structured exercise program characteristics. Prev Med. 2012;55(4):262–275. exercise programs. Some attributes of exercise programs, such as cost and transport, are likely to influence participation 9. Batra A, Page T, Melchior M, Seff L, Vieira ER, Palmer RC. Factors associated with the by older people, but the relative importance of such attributes completion of falls prevention program. Health Educ Res. 2013;28(6):1067–1079. is unknown. What this study adds: Older people who had fallen or had 10. Laine C, Davidoff F. Patient-centered medicine. A professional evolution. JAMA. mobility-related disability reported that they would be most 1996;275(2):152–156. likely to participate in an exercise program that: they could do at home, required no transport, improved their ability to do 11. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the home-based daily activities by 60%, incurred no cost, and empirical literature. Soc Sci Med. 2000;51(7):1087–1110. eliminated their risk of falling. Physiotherapists may be able to improve adherence to exercise programs for older people by 12. Bunn F, Dickinson A, Barnett-Page E, Mcinnes E, Horton K. A systematic review of improving accessibility rather than by focusing on the health older people’s perceptions of facilitators and barriers to participation in falls- benefits. prevention intervention. Ageing Soc. 2008;28:449–472. Footnote: aNLOGIT 4.0, Econometric Software Inc., USA. 13. Howard K, Salkeld G, Pignone M, Hewett P, Cheung P, Olsen J, et al. Preferences for eAddenda: Appendix 1 can be found online at doi:10.1016/ CT colonography and colonoscopy as diagnostic tests for colorectal cancer: a j.jphys.2014.11.001 discrete choice experiment. Value Health. 2011;14(8):1146–1152. Ethics approval: The University of Sydney Human Ethics Committee approved this study (Protocol number: 14404). All 14. Molassiotis A, Emsley R, Ashcroft D, Caress A, Ellis J, Wagland R, et al. Applying participants gave informed consent before data collection began. Best-Worst scaling methodology to establish delivery preferences of a symptom Competing interests: All authors declare that they have no supportive care intervention in patients with lung cancer. Lung Cancer. 2012; conflict of interest. 77(1):199–204. 15. Morton RL, Snelling P, Webster AC, Rose J, Masterson R, Johnson DW, et al. Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease. CMAJ. 2012;184(5):E277–E283. 16. Lancsar E, Louviere J, Donaldson C, Currie G, Burgess L. Best worst discrete choice experiments in health: methods and an application. Soc Sci Med. 2013;76(1):74–82. 17. Flynn TN, Louviere JJ, Peters TJ, Coast J. Best–worst scaling: What it can do for health care research and how to do it. J Health Econ. 2007;26(1):171–189. 18. Louviere JJ, Islam T. A comparison of importance weights and willingness-to-pay measures derived from choice-based conjoint, constant sum scales and best-worst scaling. J Bus Res. 2008;61:903–911. 19. Flynn TN. Valuing citizen and patient preferences in health: recent developments in three types of best-worst scaling. Expert Rev Pharmacoecon Outcomes Res. 2010;10(3):259–267. 20. Franco MR, Ferreira ML, Howard K, Sherrington C, Rose J, Haines TP, et al. How big does the effect of an intervention have to be? Application of two novel methods to determine the smallest worthwhile effect of a fall prevention programme: a study protocol BMJ Open. 2013;3(2). 21. Guralnik JM, Ferrucci L, Pieper CF, Leveille SG, Markides KS, Ostir GV, et al. Lower extremity function and subsequent disability: consistency across studies, predic- tive models, and value of gait speed alone compared with the short physical performance battery. J Gerontol A Biol Sci Med Sci. 2000;55(4):M221–M231. 22. Sherrington C, Lord SR, Close JC, Barraclough E, Taylor M, Cumming RG, et al. Mobility-related disability three months after aged care rehabilitation can be pre- dicted with a simple tool: an observational study. J Physiother. 2010;56(2):121–127. 23. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009; 42(2):377–381. 24. Bliemer MCJ, Rose JM, Hess S. Approximation of bayesian efficiency in experimen- tal choice designs. J Choice Model. 2008;1(1):98–127. 25. Chaloner K, Verdinelli I. Bayesian Experimental Design: A Review. Stat Sci. 1995; 10(3):273–304. 26. Reed Johnson F, Lancsar E, Marshall D, Kilambi V, Muhlbacher A, Regier DA, et al. Constructing experimental designs for discrete-choice experiments: report of the ISPOR Conjoint Analysis Experimental Design Good Research Practices Task Force. Value Health. 2013;16(1):3–13.
Research 41 27. Hensher DA, Rose JM, Greene WH. Applied choice analysis: a primer. Cambridge: rate of falls in older people (the LiFE study): randomised parallel trial. BMJ. Cambridge University Press; 2005. 2012;345:e4547. 32. Sherrington C, Lord SR, Vogler CM, Close JCT, Howard K, Dean CM, et al. A post- 28. Health service framework for older people 2009–2016: improving health and wellbeing hospital home exercise program improved mobility but increased falls in older together. Government of South Australia, Department of Health, Statewide people: a randomised controlled trial. Plos One. 2014;9(9):e104412. Service Strategy Division (2009). http://www.sahealth.sa.gov.au/wps/wcm/ 33. Recommendations on physical activity for health for older Australians. Australian connect/cd478e804278955d8b07ab182b8de443/hsframeworkolderpeople09-16- Government Department of Health and Ageing. http://www.health.gov.au/internet/ clincalnetworks-sahealth-0905.pdf?MOD=AJPERES&CACHEID=cd478e804278955 main/publishing.nsf/Content/phd-physical-rec-older-guidelines [accessed 16/02/ d8b07ab182b8de443 [accessed 21/01/14]. 2014]. 34. Glazer NL, Lyass A, Esliger DW, Blease SJ, Freedson PD, Massaro JM, et al. Sustained 29. Long term conditions collaborative: improving care pathways. The Scottish Govern- and shorter bouts of physical activity are related to cardiovascular health. Med Sci ment, Health Delivery Directorate, Edinburgh (2010). http://www.scotland.gov. Sports Exerc. 2013;45(1):109–115. uk/Resource/Doc/309257/0097421.pdf [accessed 21/01/14]. 35. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, et al. Physical activity and public health in older adults: recommendation from the American 30. Health Quality Ontario. In-home care for optimizing chronic disease management College of Sports Medicine and the American Heart Association. Med Sci Sports in the community: an evidence-based analysis. Ont Health Technol Assess Ser. Exerc. 2007;39(8):1435–1445. 2013;13(5):1–65. 31. Clemson L, Fiatarone Singh MA, Bundy A, Cumming RG, Manollaras K, O’Loughlin P, et al. Integration of balance and strength training into daily life activity to reduce
Journal of Physiotherapy 61 (2015) 28–33 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research Kinesio Taping does not decrease swelling in acute, lateral ankle sprain of athletes: a randomised trial Guilherme S Nunes a, Valentine Zimermann Vargas a, Bruna Wageck a, Daniela Pacheco dos Santos Hauphental a, Clarissa Medeiros da Luz a, Marcos de Noronha a,b a Department of Physiotherapy, Center of Health and Sport Sciences, Santa Catarina State University, Brazil; b La Trobe University, Rural Health School, Bendigo, VIC, Australia KEYWORDS ABSTRACT Bandages Question: Does Kinesio Taping reduce swelling in athletes who have suffered an acute, lateral ankle Ankle injuries sprain? Design: Randomised controlled trial with concealed allocation, intention-to-treat analysis and Lymphatic system blinded assessment. Participants: Thirty-six athletes who participated regularly in one of seven Oedema different sports modalities and suffered an acute ankle sprain. Intervention: The experimental group Sprains and strains received Kinesio Taping application for 3 days, which was designed to treat swelling. The control group received an inert Kinesio Taping application. Outcome measures: For the comparison between groups, the swelling was measured via volumetry, perimetry, relative volumetry and two analyses of the difference in volume and perimetry between ankles of each participant. Data were collected immediately after the 3 days of intervention and at follow-up, which was 15 days post intervention. Results: At 3 days after intervention, there were no differences between groups for swelling in volumetry (MD –2 ml, 95% CI –28 to 32); perimetry (MD 0.2 cm, 95% CI –0.6 to 1.0); relative volumetry (MD 0.0 cm, 95% CI –0.1 to 0.1); and the other analyses. At day 15 follow-up, there were no significant between-group differences in outcomes. Conclusion: The application of Kinesio Taping, with the aim of stimulating the lymphatic system, is ineffective in decreasing acute swelling after an ankle sprain in athletes. Trial registration: Brazilian Registry of Clinical Trials, RBR-32sctf. [Nunes GS, Vargas VZ, Wageck B, dos Santos Hauphental DP, da Luz CM, de Noronha M (2015) Kinesio Taping does not decrease swelling in acute, lateral ankle sprain of athletes: a randomised trial. Journal of Physiotherapy 61: 28–33] ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Introduction that – unlike traditional strapping tape – has some inherent extensibility. Some proponents of Kinesio Taping claim that the Ankle sprain is one of the most common sports-related injuries.1 Kinesio Taping technique, when applied at the ankle, is expected to A study that analysed the occurrence of ankle sprains, in the United stimulate the drainage of the oedema present in the interstitial States between 2003 and 2006, calculated that there were around space towards less-congested lymphatic channels, thus reducing 3 million ankle sprains during that period and half of them were the swelling.7 related to sport.2 For high-performance athletes, an ankle sprain can not only limit activities but also generate financial consequences due Some recent studies have shown positive results after the to absence from participation.3 Perhaps the most significant application of Kinesio Taping when compared to placebo taping8 or consequences of an ankle sprain in the acute phase are the pain to other manual techniques that treat swelling, such as manual and swelling commonly seen in this injury.1,3,4 When such a lymphatic drainage.9 Aguilar-Ferra´ ndiz and colleagues8 reported a condition is not treated properly in the acute phase, it can progress to positive effect of Kinesio Taping on lower-limb swelling in post- synovitis, tendinopathy, joint stiffness, muscle weakness, joint menopausal women with chronic venous insufficiency. In this instability, and persistent pain and swelling.3,4 After an ankle sprain, controlled trial, Kinesio Taping decreased extracellular liquid in around 60% of cases are likely to present with symptoms up to the lower limbs, pain and severity of disease, while improving 18 months after the injury,5,6 increasing the chance of recurrence.3 function.8 However, that study only included participants with chronic venous insufficiency, so it is not possible to extrapolate the Among the acute consequences of an ankle sprain, swelling is effects of Kinesio Taping for oedema from an acute ankle sprain. one of the symptoms that requires the most immediate attention Other studies have attempted to investigate the effect of Kinesio because it is related to the progression of the inflammation and can Taping in swelling;9,10 however, the quality of those studies is be a limiting factor during rehabilitation.3 Among the techniques questionable, as blinding of assessors and comparison to a control used to reduce or contain the swelling, Kinesio Taping seems to be or placebo group were not always present. Therefore, there is a lack gaining popularity among some rehabilitation professionals.7 The of good-quality studies that have investigated whether Kinesio Kinesio Taping technique involves the use of adhesive elastic tape Taping is effective in treating acute swelling. http://dx.doi.org/10.1016/j.jphys.2014.11.002 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
Research 29 Therefore, the research question for this study was: not included in the study if they: had a fracture; had an open wound; had systemic lower-limb swelling related to cardiac, Is Kinesio Taping effective in reducing swelling in athletes who kidney or venous diseases; or were suspected to be pregnant. have suffered an acute, lateral ankle sprain? The interventions and assessments were conducted at Clı´nica Method Escola de Fisioterapia of Universidade do Estado de Santa Catarina and at the participants’ training sites. An initial assessment was Design conducted to confirm that the participant met the inclusion/ exclusion criteria. After the initial assessment, both ankles were In this parallel-group, randomised, controlled trial, participants shaved and cleansed, and the volume of the ankles was assessed were randomly allocated to an experimental group or a control (see Volumetry under Outcomes measures, below). Participants group. The experimental group received a Kinesio Taping were then allocated to either the experimental group or the control application designed to treat swelling, while the control group group. There were two post-intervention assessments: one at received a sham intervention (ie, an inert Kinesio Taping 3 days after the Kinesio Taping application and one at a follow-up application).7 The randomisation was performed in a concealed assessment 15 days after the Kinesio Taping application. An fashion using opaque, sealed envelopes, which were prepared by a assessor who was blinded to group allocation performed both researcher who was not involved in the recruitment or assessment post-intervention assessments. of participants. The Kinesio Taping applications were left in situ for 3 days; participants were measured at baseline, 3 days, and 15 days Intervention (Figure 1). The experimental group received the Kinesio Taping application Participants, therapists and centres called a ‘fan cut’.7 The participants were positioned in supine and marked at 13 cm above the lateral malleolus and at 10 cm above Thirty-six athletes from the metropolitan area of a state capital the medial malleolus of the affected ankle. Participants were then in Brazil took part in the present study. The participants attended asked to perform a plantar flexion and 5 deg inversion of the ankle, practice sessions and competitions for their respective sports on a so that the length of the Kinesio Tape to be applied could be regular basis. They were athletes who participated in one of seven measured (ie, the distance from the lateral skin mark to the fifth exercise modalities: 17 soccer, five athletics, four volleyball, three toe) (Figure 2A). The Kinesio Tape that was applied to the medial basketball, two rugby, two swimming, two dance and one ankle was the same length as the one applied to the lateral ankle. European handball. The Kinesio Tape was applied starting from the skin marks to the metatarsal region of the foot, with an elastic tension of 20%.7 The To be included, participants had to report a lateral ankle sprain Kinesio Tape was divided into four strips and applied with a that had occurred between 48 and 96 hours before the first distance of approximately 1 cm between strips. The lateral Kinesio Taping application commenced along the fibula and the strips were gu[(rei_F]1)GDI$Tassessment, with visible swelling of the ankle. Participants were placed in the following order: posterior to the lateral malleolus Assessed for eligibility (n = 36) Day 0 Measured volumetry and perimetry Randomised (n = 36) Lost to follow- up (n = 0) (n = 18) (n =18) Experimental group Control group Lost to follow-up • Kinesio Taping • Inert Kinesio • ankle in plaster Taping application application cast (n = 2) designed to treat ankle swelling Day 3 Measured volumetry and perimetry Lost to follow-up (n = 18) (n = 16) • not able to be Lost to follow-up measured due to • refused to return re-sprained ankle (n = 2) (n = 4) • refused to return (n = 3) Measured volumetry and perimetry Day 15 (n = 13) (n = 12) Figure 1. Flow of participants through the study.
G[i]guFre_2)TD$I(30 Nunes et al: Kinesio taping for drainage of ankle swelling Figure 2. Kinesio Taping application. A – how the Kinesio Taping was measured and cut; B – application of 1st strip; C – application of 2nd strip; D – application of 3rd strip; E – application of 4th strip; F – full Kinesio Taping application; G – application to the control group. (Figure 2B), on the lateral malleolus (Figure 2C), anterior to the by the chair, forearms on the thigh, knees bent around 90 deg, and the lateral malleolus (Figure 2D) and towards the hallux (Figure 2E). sole of the foot that was not being assessed fully in contact with the The medial Kinesio Tape application was slightly diagonal to the floor in neutral plantar flexion/dorsiflexion. The participant was then tibia and the strips were applied in the following order: posterior required to slowly insert the foot to be assessed into the acrylic box to the medial malleolus, on the medial malleolus, anterior to the until the sole of the foot made full contact with the bottom of the box, medial malleolus and towards the fifth toe.7 The undivided start and to hold the position in silence as much as possible. In that section of the Kinesio Tape was applied with the ankle in a neutral position, the water that overflowed through the escape hole was position, and the strips were applied with the ankle in maximum collected in a separate container. The container was kept in place until plantar flexion and inversion of approximately 5 deg. Therefore, the all dripping stopped. The overflow was then weighed using an final presentation of the application had the strips of the lateral and electronic scaleb with a precision of 1 g. To ensure consistency in the medial Kinesio Taping application crossing each other (Figure 2F). measurement, the distance between the feet, the distance between the chair and the acrylic box, the position of the foot in the box, and The control group received a 15-cm strip of Kinesio Tape in an ‘I’ the water temperature were recorded. These distances were used shape. The application started on the tibial tuberosity and was every time a participant was assessed. At each assessment, both feet applied along the tibia (Figure 2G), with the tension applied to the were assessed twice in an alternating fashion, with the first side Kinesio Tape at 20%. randomly decided. For the analysis, the mean of the two measures were used. This procedure has an intra-rater and inter-rater intraclass For both groups, an investigator, who was not involved in the correlation coefficient between 0.98 and 0.99.12 assessment, applied the Kinesio Taping and removed it before the assessment on Day 3. Along with the Kinesio Taping Perimetry application, both groups received instructions on how to apply This procedure was performed with a measuring tape ice and elevate the lower limb in order to decrease the pain for 20 minutes, three times a day, during the 3 days of Kinesio positioned around the ankle in a figure-eight fashion.12 The Taping application.11 participant was positioned in prone with the ankle in neutral position. The following reference landmarks were used to position Outcome measures the measuring tape: the tibialis anterior tendon, the navicular tuberosity (going under the foot), the base of the fifth metatarsal, Volumetry the tibialis anterior tendon again, the medial malleolus, the An acrylic box (14 x 34 x 30 cm) with a simple water escape hole Achilles tendon, the lateral malleolus, and the tibialis anterior tendon again. On each assessment day, each foot was assessed (2.5 cm in width and positioned at 22 cm from the floor of the box) three times in an alternating fashion, with the first foot randomly was used to assess ankle/foot volume.12–15 The acrylic box was decided. For the analysis, the mean of the three measures was used. filled with water at 30 deg C (Æ 2 deg C).12,16 Water temperature was This procedure also had an intra-rater and inter-rater intraclass measured with a digital infrared thermometera and the room correlation coefficient between 0.98 and 0.99.12 temperature was also maintained around 25 deg C. The participant was instructed to remain comfortably seated with the back supported
Research 31 Data analysis Day 3 minus Day 0 Day 15 minus Day 0 For one primary analysis of volumetry, the absolute values from Difference between groups Exp minus Con 9 (–22 to 40) the injured ankles were used. For that, the data given in g were 0.1 (–0.7 to 0.9) converted into ml, assuming 1 g is equivalent to 1 ml.16,17 The 0.0 (–0.1 to 0.1) second primary analysis of volumetry used the ankle volume as a percentage of the body mass, measured in g (ankle volume/body 6 (–25 to 38) mass) x 100, and was termed relative volumetry. For the secondary –0.1 (–0.9 to 0.6) analyses, the raw data for perimetry from the injured ankle were used, and the difference between the injured and the healthy Exp minus Con 2 (–28 to 32) ankles for each participant for both volumetry and perimetry were 0.2 (–0.6 to 1.0) also calculated. Analysis of Variance (ANOVA) linear mixed models 0.0 (–0.1 to 0.1) were used to compare the effect of Kinesio Taping on swelling –5 (–31 to 22) between the groups. 0.1 (–0.5 to 0.7) A level of significance of p 0.05 was adopted for all tests, and Day 15 minus Day 0 Exp Con Exp Con –52 (43) data were analysed on an intention-to-treat basis. The ‘last 0.0 (1.1) observation carried forward’ approach was used for missing data. –0.1 (0.1) –37 (55) The sample size for the present study was calculated to ensure –0.7 (1.1) power of 80% and an alpha of 5%. It was calculated that 16 participants in each group would identify a difference of Difference within groups –43 (48) 2 cm between the groups in the perimetry measures, given an 0.0 (1.2) anticipated SD of 2 (sufficient data to perform sample size 0.0 (0.1) calculation on the primary outcomes were not available). The –30 (36) minimum difference between groups was chosen to be 2 cm –0.8 (1.0) because Kinesio Taping is a low-cost and fast intervention with virtually no risk involved; therefore, a small difference would be Day 3 minus Day 0 –37 (38) sufficient to warrant its application.18 The 2 cm was chosen 0.1 (0.8) because it is half the SD of baseline measures of perimetry from 0.0 (0.1) previous studies.19–21 –27 (38) –0.7 (0.6) Results –36 (49) 0.2 (1.4) 0.0 (0.1) –31 (40) –0.5 (1.0) Flow of participants, therapists and centres through the study Exp (n = 18) Con (n = 18) Exp (n = 18) Con (n = 16) Exp (n = 13) Con (n = 12) 1660 (222) 55.0 (3.5) Of the 36 participants, two could not be assessed after the Day 15 2.2 (0.3) intervention because they followed medical instructions to immobilise the ankle with a cast. Both were in the control group, 57 (76) as shown in Figure 1. A further nine participants were unavailable 0.9 (0.9) for the Day 15 assessment. Table 2 1586 (133) Con = control group, Exp = experimental group, I-NI = injured minus non-injured, shading = primary outcomes. The characteristics of the participants in each group are Mean (SD) of groups, mean (SD) difference within groups, and mean (95% CI) difference between groups. 54.4 (2.7) a Relative Volumetry = (volumetry/body mass) x 100 (ie, volumetry mass in relation to body mass). summarised in Table 1 and in the first two columns of data in 2.2 (0.3) Table 2. The groups were well matched with respect to demographic data and baseline scores on the outcome measures. 31 (31) 0.4 (0.3) Effect of intervention 1675 (234) 55.1 (3.8) Groups Day 3 2.3 (0.3) 66 (76) 0.9 (0.9) After 3 days, the ANOVA showed no difference between groups 1593 (150) for volumetry, perimetry or relative volumetry. When the data for 54.6 (2.7) volumetry and perimetry were analysed as the difference between 2.2 (0.3) the injured and non-injured sides, there was still no effect of Kinesio Taping after 3 days. Similarly, there was no significant 30 (37) difference between groups after 15 days for any outcomes. 0.7 (0.5) Summary data are presented in Table 2 and individual participant data are presented in Table 3 on the eAddenda. 1712 (232) 55.0 (4.1) Day 0 2.3 (0.3) 93 (84) 1.6 (1.4) Discussion In the present study, Kinesio Taping was applied as an adjunct 1629 (138) 54.4 (3.0) therapy to reduce swelling after a lateral ankle sprain because, 2.2 (0.3) according to the creators of this treatment,7 Kinesio Taping can 61 (42) 1.2 (0.9) Table 1 Volumetry (ml) Characteristics of participants at baseline (n = 36). Perimetry (cm) Relative volumetry (%) a Characteristic Exp (n = 18) Con (n = 18) Volumetry I-NI (ml) Perimetry I-NI (cm) Gender (male), n (%) 15 (83) 13 (72) Outcome Age (yr), mean (SD) 24 (5) 23 (6) Height (cm), mean (SD) 176 (7) 177 (8) Weight (kg), mean (SD) 74 (9) 75 (13) Time since injury (hr), mean (SD) 75 (21) 73 (17) Con = control group, Exp = experimental group.
32 Nunes et al: Kinesio taping for drainage of ankle swelling stimulate the reabsorption of the interstitial liquid via the lymphatic system was insufficiently powerful to make any lymphatic system. The creators of Kinesio Taping believe that difference in this population. This could explain the lack of such liquid reabsorption is possible due to the decrease in pressure positive results in the present study and the presence of positive in the epidermis that the Kinesio Taping supposedly creates, which results in studies that have investigated the effect of Kinesio Taping consequently decreases pressure in the lymphatic vessels and in populations of non-athletes.8,9 increases the lumen of these vessels.7 The decrease in pressure, according to the creators of Kinesio Taping, is the consequence of Another explanation is that Kinesio Taping is ineffective and micro-waves that are formed by the Kinesio Taping during active that the positive finding in the study by Aguilar-Ferra´ ndiz et al8 movement where the Kinesio Taping is applied.7 Furthermore, the was due to chance, bias or confounding. A recent systematic review explanation given by the creators of Kinesio Taping is that it also identified 12 randomised controlled trials of Kinesio Taping for creates some friction on the skin, which is similar to the manual various musculoskeletal conditions.25 All of these trials demon- techniques that are widely used in physiotherapy.7 Despite strated either no effect of Kinesio Taping or a clinically trivial effect. applying Kinesio Tape directed by the creators of the tape, the Randomised trials published more recently than this review have experimental intervention with Kinesio Taping did not show any further indicated a general lack of effect from Kinesio Taping for benefit in terms of a decrease in swelling after an acute ankle more,26 although perhaps not all,27 musculoskeletal conditions. sprain when compared to a sham taping technique. The application of Kinesio Taping with the aim of stimulating The lack of an effect from Kinesio Taping seen in the present the lymphatic system is not effective in decreasing acute swelling study differs from the result of the trial by Aguilar-Ferra´ ndiz et al,8 after an ankle sprain in athletes. Further investigation should in which a reduction in swelling in the Kinesio Taping group was consider the application of Kinesio Taping for more than 3 days and reported. In that study, Kinesio Taping was applied in post- at different phases of the inflammatory process. The Kinesio Taping menopausal women with chronic swelling due to chronic venous technique has become a popular treatment among athletes; insufficiency and it reduced extracellular liquid from the lower however, its real effects are still being investigated. limbs.8 One explanation for this discrepancy is that the effects of Kinesio Taping are limited to swelling related to chronic What is already known on this topic: Depending on the conditions, without an active inflammatory phase affecting the measurement of swelling used, Kinesio Taping may have an swelling. Another explanation is that Aguilar-Ferra´ ndiz et al8 effect on chronic swelling due to chronic venous insufficiency; measured the swelling reduction via bio-impedance. In a different however, the effect on acute swelling is unknown. study by the same research group, Kinesio Taping did not show any What this study adds: Among athletes with a recent ankle positive effect in reducing swelling in lower limbs of post- sprain, an application of Kinesio Tape recommended by the menopausal women with chronic venous insufficiency.22 For that developer for the reduction of ankle swelling did not signifi- second study, the reduction in swelling was calculated using a cantly reduce swelling, as measured by volumetry or perime- mathematical model that converted perimetry into volume. These try. A further 12 days after the Kinesio Tape was removed, no conflicting results reinforce the possibility that the effects of effect of the Kinesio Taping on the swelling was evident. Kinesio Taping on swelling are limited to the cellular changes of chronic conditions and not the actual volume of the segment as a Footnotes: aIncoterm thermometer, model Scantemp, Brazil. whole. That possibility casts doubts on the clinical relevance of bBD-500, Brazil. measuring swelling at a cellular level only. eAddenda: Table 3 can be found online at doi:10.1016/ Another possibility that needs to be considered is the structural j.jphys.2014.11.002. differences of the swelling. Aguilar-Ferra´ ndiz et al8 reported that Kinesio Taping decreases the extracellular liquid in people with Ethics approval: The Human Research Ethics Committee of chronic venous insufficiency. In conditions such as chronic venous Universidade do Estado de Santa Catarina (number 138/2011) insufficiency, it is expected that the swelling is a consequence of approved this study. All participants gave written informed hydrostatic pressure changes and therefore has low levels of consent before data collection began. protein or transudate.23,24 In the present study, the participants had acute ankle sprains with an active inflammatory process and Competing interests: Nil. an exudate with a higher quantity of protein.24 Thus, it is also Source(s) of support: Nil. possible that the effects of Kinesio Taping on swelling are limited to Acknowledgements: The authors would like to acknowledge a transudate; perhaps due to the higher mobility presented by this Lailah Fernandes de Noronha for her participation in revising the type of swelling. manuscript. Correspondence: Mr Guilherme S Nunes, Department of With regard to Kinesio Taping application time, it is recom- Physiotherapy, Santa Catarina State University, Brazil. Email: mended that it be applied continuously for 3 to 5 days, while the tape [email protected] still holds its elastic properties.7 That recommendation was followed in the present study; however, it is possible that the time of References application used was insufficient to generate the positive results seen in other studies because in some of these studies, the time of 1. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: application was longer than 3 days.8,9 In a study that applied Kinesio summary and recommendations for injury prevention initiatives. J Athlet Train. Taping for 10 consecutive days, starting at Day 5 after placing an 2007;42(2):311–319. external fixation around the thigh, the results showed a reduction in swelling of that area.9 It should be noted, however, that the quality of 2. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont Jr PJ. The epidemiology of that study is questionable, as it did not have a comparison group or ankle sprains in the United States. J Bone Jt Surg. 2010;92(13):2279–2284. any blinding. In the study by Aguilar-Ferra´ ndiz et al,8 the Kinesio Taping was applied three times a week, for 4 weeks, which could 3. Lynch SA, Renstro¨ m PA. Treatment of acute lateral ankle ligament rupture in the have increased the possible effect of Kinesio Taping. However, in the athlete. Conservative versus surgical treatment. Sports Med. 1999;27(1):61–71. present study, the time of application was not increased because the aim was to investigate the effect of Kinesio Taping solely on the acute 4. Bleakley CM, O’Connor SR, Tully MA, Rocke LG, Macauley DC, Bradbury I, et al. phase of an ankle sprain. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964. The fact that we investigated the effect of Kinesio Taping on athletes is also worthy of consideration, because athletes usually 5. Braun BL. Effects of ankle sprain in a general clinic population 6 to 18 months after have a faster metabolism than non-athletes.24 It is possible that the medical evaluation. Arch Fam Med. 1999;8(2):143–148. stimulus generated by the Kinesio Taping on the skin and 6. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19(10):653–660. 7. Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the Kinesio Taping Method. Tokyo, Japan: Kenı´-kai information; 2003. 8. Aguilar-Ferra´ ndiz ME, Castro-Sa´ nchez AM, Matara´ n-Pen˜ arrocha GA, Guisado-Bar- rilao R, Garcı´a-Rı´os MC, Moreno-Lorenzo C. A randomized controlled trial of a mixed Kinesio taping-compression technique on venous symptoms, pain, periph- eral venous flow, clinical severity and overall health status in postmenopausal women with chronic venous insufficiency. Clin Rehabil. 2014;28(1):69–81.
Research 33 9. Białoszewski D, Woz´ niak W, Zarek S. Clinical efficacy of kinesiology taping in 20. Hall RC, Nyland J, Nitz AJ, Pinerola J, Johnson DL. Relationship between ankle reducing edema of the lower limbs in patients treated with the Ilizarov method- invertor H-reflexes and acute swelling induced by inversion ankle sprain. J Orthop preliminary report. Ortopedia Traumatologia Rehabilitacja. 2009;11(1):46–54. Sports Phys Ther. 1999;29(6):339–344. 10. Tsai H-J, Hung H-C, Yang J-L, Huang C-S, Tsauo J-Y. Could Kinesio tape replace the 21. Boyce SH, Quigley MA, Campbell S. Management of ankle sprains: a randomised bandage in decongestive lymphatic therapy for breast-cancer-related lymphede- controlled trial of the treatment of inversion injuries using an elastic support ma? A pilot study Support Care Cancer. 2009;17(11):1353–1360. bandage or an Aircast ankle brace. Brit J Sports Med. 2005;39(2):91–96. 11. Ogilvie-Harris DJ, Gilbart M. Treatment modalities for soft tissue injuries of the 22. Aguilar-Ferra´ ndiz ME, Castro-Sa´ nchez AM, Matara´ n-Pen˜ arrocha GA, Garcı´a- ankle: a critical review. Clin J Sport Med. 1995;5(3):175–186. Muro F, Serge T, Moreno-Lorenzo C. Effects of kinesio taping on venous symptoms, bioelectrical activity of the gastrocnemius muscle, range of ankle 12. Petersen EJ, Irish SM, Lyons CL, Miklaski SF, Bryan JM, Henderson NE, et al. motion, and quality of life in postmenopausal women with chronic venous Reliability of water volumetry and the figure of eight method on subjects with insufficiency: a randomized controlled trial. Arch Phys Med Rehabil. 2013; ankle joint swelling. J Orthop Sports Phys Ther. 1999;29(10):609–615. 94(12):2315–2328. 13. Man IO, Lepar GS, Morrissey MC, Cywinski JK. Effect of neuromuscular electrical 23. Labropoulos N, Giannoukas AD, Nicolaides AN, Veller M, Leon M, Volteas N. The stimulation on foot/ankle volume during standing. Med Sci Sports Exerc. role of venous reflux and calf muscle pump function in nonthrombotic chronic 2003;35(4):630–634. venous insufficiency. Correlation with severity of signs and symptoms. Arch Surg. 1996;131(4):403–406. 14. Brijker F, Heijdra YF, Van Den Elshout FJ, Bosch FH, Folgering HT. Volumetric measurements of peripheral oedema in clinical conditions. Clin Physiol. 2000; 24. Hall JE, Guyton AC. Textbook of Medical Physiology. 12nd ed. Philadelphia, Pa: 20(1):56–61. Saunders; 2010. 15. Da Luz CM, da Costa Proenc¸a RP, de Salazar BRO, do Nascimento Galego G. Working 25. Parreira PdCS. Costa LdCM. Hespanhol Junior LC, Lopes AD, Costa LOP. Current conditions at hospital food service and the development of venous disease of lower evidence does not support the use of Kinesio Taping in clinical practice: a limbs. Int J Environ Health Res. 2013;23(6):520–530. systematic review. J Physiother. 2014;60:31–39. 16. Man IOW, Morrissey MC, Cywinski JK. Effect of neuromuscular electrical stimulation 26. Parreira PdCS. Costa LdCM. Takahashi R, Hespanhol Junior LC, da Luz Junior MA, da on ankle swelling in the early period after ankle sprain. Phys Ther. 2007;87(1):53–65. Silva TM, Costa LOP. Kinesio Taping to generate skin convolutions is not better than sham taping for people with chronic non-specific low back pain: a randomised 17. Pople S. Complete Physics. Oxford: Oxford University Press; 1999. trial. J Physiother. 2014;60:31–39. 18. Herbert R, Jamtvedt G, Hagen KB, Mead J. Practical Evidence-Based Physiotherapy. 27. Shakeri H, Keshavarz R, Arab AM, Ebrahimi I. A randomised clinical trial of kinesio- 2nd ed. Oxford: Elsevier Health Sciences UK; 2011. taping on DASH in patients with subacromial impingement syndrome. J Novel 19. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related Therapeut. 2013;3:169. quality of life: the remarkable universality of half a standard deviation. Med Care. 2003;41(5):582–592.
Appraisal Journal of Physiotherapy 61 (2015) 49–50 Media Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Motion analysis in the clinic: There’s an app for that Motion analysis has proven to be a useful tool for physiothera- Differences between the programs include the filing systems pists to assess movement patterns during functional tasks. Motion and import/export ability. Ubersense, Coach’s Eye, VStrator and analysis provides both the clinician and researcher the potential to KCapture are all able to import and export to third-party programs gain insight into the pathomechanical changes in movement, as such as Dropbox or Twitter, whereas the other apps require files to well as the possibility of tracking functional rehabilitation. be shared using their program extensions. Ubsersense and Traditional motion analysis relies on the use of expensive and PostureScreen also offer in-app tutorials and exercise prescription, bulky equipment; however, there has been increasing develop- whereas the others have access to blogs for user tips and patient ment of motion-analysis apps available for iPad, iPhone and demonstrations. These features are relatively small differences and android devices that require less time and equipment. depend primarily on user preference. In contrast, the ][4FID$Tn_ umber of frames captured per second and the range of tools offered are more There are over 15 general motion-analysis apps for various important considerations when choosing programs. hand]ID$-T_1[F held devices. If a clinician is interested in a specific sport, then there are over 250 apps available. This review critiques seven The frequency at which consecutive unique images are motion-analysis apps: Ubersense (Ubersense Inc. USA); Dartfish produced is ‘frames per second’ (FPS). Shooting at 30 FPS gives Express (Version 3.0.2 Dartfish, Switzerland); Coach’s Eye (Tech- no artifact at slow speed, but can result in blurring on movements Smith Corporation, USA); PostureScreen (PostureCo, Inc, USA.); faster than walking at comfortable speeds. A frequency of 50 to Motion Analyzer for Rehab (Pokapoka Lifecare Co., Ltd, Japan); 60 FPS is equivalent to high-end high-definition TV systems; 120 to VStrator (Improve Your Game, LLC, USA); and KCapture (Spark 250 FPS is typically used to capture three-dimensional running Motion LLC, USA). The latter four have been designed with specific gait. Only Ubersense, Dartfish Express and Coach’s Eye are capable features that are useful for medicine and healthcare, including: of shooting 60 FPS; the remainder capture at 30 FPS. In these password-protected patient files, posture grids and Borg Scales. three apps, the FPS is automatically set to the maximum that the However, some of these features in Motion Analyzer for Rehab are device being used is capable of. in Japanese. All of these apps offer gross motion analysis. Similar to any two-dimensional or three-dimensional analysis technology, The second difference between programs is the tools available – there are several factors that need to be controlled in order to make particularly the ability to draw angles and vectors. In addition to the data reliable and valid. These can be classified into the program, above three apps, KCapture offers the ability to draw angles that are the device and assessor skill. automatically calculated. KCapture also has a unique ruler function. The remaining apps permit circles and lines to be drawn but offer no [2_TD$IF]Program way of quantifying the angle or distance of these circles/lines. Ubersense and VStrator are both free to download and use. All _5D$FTI]D[ evice the other apps have a download fee ranging from AUD6.49 to AUD329.99. In addition to its download fee, Coach’s Eye requires Frequency (FPS) is also a primary consideration when discuss- in-app purchases (AUD6.49) to access vital tools, such as drawing ing the device to be utilised during motion capture. Despite some vectors and angles. apps being capable of capturing at 60 FPS, it is ultimately dependent on the camera in the device. According to Apple’s There are many similar features between the apps: all have the website (www.Apple.com/au/), iPad mini and air, iPhone 5S and ability to record video and capture stills; however, the ability to do 5C, iPhone 6 and iPod touch are the only devices capable of these tasks is not always intuitive and may be limited. For example, recording at 60 FPS, provided they have IOS 7. This implies that any VStrator only records 15 seconds of video in each take, which app run on iPad or iPad 2 is going to capture at 30 FPS, resulting in makes capturing motion from longer tasks or slower patients more image blurring during faster motions. difficult. Further, while VStrator is usable in any hand-held device, its display was designed for iPhone and, therefore, the image is A second consideration of the device is the frame of reference. small and grainy when captured using an iPad or tablet. For changes over time (including between takes) to be reliably PostureScreen advertises that it is capable of motion capture; compared, the frame of reference needs to be identical. This however, this is only available on iPad and there are few details on includes noting the distance from the patient, height of the lens how to access this feature from the home screen. All programs also and position of the camera, which cannot be moved between takes offer slow motion and zoom features. Slow-motion speeds vary and must be kept orthogonal to the plane of movement. A change from program to program: Ubersense offers three slow-motion in 1 _6[D$Td]IF eg in the reference frame can result in up to 2 FD$]T_7[dI eg in speeds; Dartfish Express has two slow-motion options; and the kinematic error.1 Without identical frames of reference, side-by- remaining apps have a single slow motion. T_FI[F3D]$ urthermore, all of the side comparisons are invalid. apps have the ability to compare two videos side by side – this tool is particularly useful if tracking participants over time; however, IFA$D]T_8[ ssessor skill its clinical utility is highly dependent on the assessor’s motion- capture skills, as is discussed later. The largest source of error in motion analysis results from marker placement. Marker placement error accounts for up to 14 dF]DI$_T[9 eg 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association.
50 Appraisal Media difference in kinematic data.2 While in-app drawing tools have their validity and reliability is highly dependent on the device not been assessed for reliability, the lack of pre-placed joint they are loaded on and the skill of the practitioner using them. markers possibly increases this error further. A recent study reported that training examiners in marker placement led to Kathryn Mills improved reliability of three-dimensional kinematic data.3 This Discipline of Physiotherapy, Macquarie University, Australia suggests that practising marker placement prior to capturing data, such that joint centres can be easily identified, may improve T_1IF$DR][2 eferences the utility of the drawing tools. 1. Areblad M, et al. J Biomech. 1990;23:933–940. In summary, motion analysis is now cheaper and more 2. Gorton GE, et al. Gait Posture. 2009;29:398–402. accessible than at any previous point in clinical practice. Numerous 3. Osis ST, et al. Comput Methods Biomech Biomed Engin. 2014;1–9. apps exists that may be of value to the clinician. Ubersense, Dartfish Express and Coach’s Eye offer the T_$Dg[I]1F0 reatest utility at the http://dx.doi.org/10.1016/j.jphys.2014.11.014 lowest price. However, even with the capabilities of these apps, Statement regarding registration of clinical studies and systematic reviews from the Editorial Board of Journal of Physiotherapy The Editorial Board of Journal of Physiotherapy reminds readers observational studies. While registration of these other study of our policy that prospective registration is mandatory for types is not yet mandatory, it is encouraged. Similarly, we randomised trials that began participant recruitment after 1 encourage the registration of systematic reviews, which is possible January 2006. Prospective registration means that the protocol for at www.crd.york.ac.uk/PROSPERO/. Authors should provide the a trial is registered on a publicly accessible register before data name and address of the register and the trial registration number collection begins on the first participant. Also, the submitted trial on submission. Readers can find out more about our policy here: report must be consistent with the registered protocol. We will http://www.sciencedirect.com/science/article/pii/ accept registration in any register that satisfies the International S1836955312701224. Committee of Medical Journal Editors requirements. Registers that meet these requirements can be found here: http://www.who.int/ http://dx.doi.org/10.1016/S1836-9553(14)00174-X ictrp/network/primary/en/. Some of these registers now allow the registration of protocols for other clinical studies, such as
Journal of Physiotherapy 61 (2015) 1–2 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Editorial Should research costs be reported when studies are published? Mark Elkins Editor, Journal of Physiotherapy Visser and colleagues recently proposed the idea that research- immense,3–5 few report intervention costs. In a random sample of ers include the costs of their research in the published report of a 100 trials published in 2013 and indexed on the Physiotherapy study. They also discussed several reasons why this might be a Evidence Database (PEDro; www.pedro.org.au), only six reported valuable approach.1 This editorial considers that proposal from the data about the cost of the intervention. Where intervention costs perspective of physiotherapy research, with the intention of are not reported in a study, local or national guidelines for cost generating discussion about whether this is an approach that calculations in healthcare could provide an estimate.6,7 The value should be encouraged in our profession. of benchtop or physiological research would be more difficult to estimate, as the findings may be seminal and, therefore, of Currently, researchers routinely list any sources of financial immense value in the long term but not apparent immediately. support when they publish the report of a research study. Including the total funds obtained would be a simple extension Although physiotherapists have had increasing success in of this transparent reporting. Clinical physiotherapists who are not securing research funds,8 many clinical physiotherapists under- involved in research may be unaware of the costs of conducting, for take research alongside their clinical role with partial or no funding example, a clinical trial or an observational study; therefore, because they are interested in answering a question that is reporting the amount of funding would increase awareness of the pertinent to their practice. A culture of routinely reporting research costs involved. The amount of funding received may not, however, funding would highlight this voluntary contribution to the be exactly the same as the costs of the study. Often, a research profession and to patient welfare. grant or philanthropic donation is supplemented by voluntary contributions by the researchers, clinical colleagues and students. From the perspective of privacy law, there would be no In some cases, conversely, the research study may be completed impediment to identifying the amounts received from commercial under budget. Theoretically, this information could also be and charitable organisations because privacy law only applies to an reported where applicable. individual’s personal information and not to information about an entity. However, individual philanthropic donors would have the In addition to increasing awareness, reporting of research right to anonymity. This right could be upheld, should those funding would allow any reader (eg, other researchers, clinicians, individuals wish, by stating the amount received from any funding bodies, philanthropic donors and patients) to decide individual donor(s) without identifying them. whether the research funds were well spent. Studies are often replicated or repeated with only slight modification, so readers In a blog post on the topic of reporting research costs,9 Visser could, for example, compare the costs of two similar studies. writes that before his involvement in research, he thought that Another potential benefit of reporting the costs of research is that decisions about research design were always purely scientific. other researchers could get an idea of the amount of money they However, he writes that now most decisions (eg, choosing a might need to complete a similar study. research method for a new clinical study) are highly dependent ‘on practical considerations, such as the availability of financial For research that has direct financial implications – such as a resources’ and that ‘as a result of cutbacks in government spending clinical trial that identifies a cost saving due to an intervention – and research funding for medical research, this financial factor publication of the amount of funding would give readers the becomes increasingly important in the decision-making process’. opportunity to compare the costs of the research to the potential Financial considerations are important in research, but it would be savings in healthcare. For example, a recent clinical trial showed hazardous to take this line of argument to the point where poor that an injury-prevention program, consisting of 10 exercises research design is justified or excused by stating that limited funds designed to improve stability, muscle strength, co-ordination and were available. Unless researchers can afford a study design that flexibility of the trunk, hip and leg muscles (known as The11), was will contribute unbiased data to answering their nominated study cost-effective in adult, male amateur soccer players.2 The program question, they should consider answering a different question or collaborating to pool resources. reduced injury costs per player by a mean of s201. The total cost of implementing the program was s287 per team. If the authors had Currently, researchers routinely include the sources of financial or ‘in-kind’ support when they publish the report of a study. The published the cost of the research, it would not be hard to calculate inclusion of the total funds received would therefore be simple. how quickly this research would pay for itself, in terms of reduced Additional details could be considered: the amount received from injury costs, and then go on saving money indefinitely. Ideally, the each source specifically, whether the funds were fully expended, reporting of research costs should facilitate this sort of analysis an estimate of the cost of any voluntary contributions or ‘in-kind’ with cost-effectiveness data about the interventions that are support, the proportion of funds (if any) that were paid to collected in the study and presented in the published report. participants, and so on. The amounts spent on different aspects of However, while researchers often report the financial burden of the the study (eg, grant application, staffing, consumables, payments disorder they are investigating, especially when that cost is http://dx.doi.org/10.1016/j.jphys.2014.11.006 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
2 Editorial to participants, data analysis and publication fees) could even be Correspondence: Mark Elkins, Department of Respiratory included. This would highlight the journals that charge high fees Medicine, Royal Prince Alfred Hospital, Camperdown, Australia. for publication. As extra details are added, however, financial Email: scientifi[email protected] reporting would become more onerous and some details would arguably be of interest to few readers, so it may be a question of References finding a balance between complexity and value. 1. Visser BJ, et al. Methods Inf Med. 2014;53:329–331. We should think carefully about whether this is something that 2. Krist MR, et al. J Physiother. 2013;59:15–23. we as a profession want to introduce. Journal of Physiotherapy has 3. Holland AE. J Physiother. 2014;60:181–188. not introduced this policy but alerts readers to the fact that it is 4. Snowdon D, et al. J Physiother. 2014;60:66–77. being discussed in the healthcare literature. 5. Sterling M. J Physiother. 2014;60:5–12. 6. New South Wales Ministry of Health: Costs of Care Standards 2009/10. Viewed Ethics approval: Not applicable. Competing interests: Nil. 17 August 2014, from http://www0.health.nsw.gov.au/policies/gl/2011/pdf/ Source(s) of support: Nil. GL2011_007. pdf. Acknowledgements: I thank Timothy Pilgrim for advice about 7. Hakkaart-van Roijen L, et al. Geactualiseerde versie. Amsterdam: College voor Australian privacy law and Rob Herbert for helpful comments on Zorgverzekeringen; 2010. the first draft of this editorial. 8. Hodges P. Aust J Physiother. 2009;55:149–150. 9. Visser BJ. How much money do we waste on research? Viewed 17 August 2014, from http://www.equator-network.org/2014/08/12/how-much-money-do-we-waste- on-research/.
Journal of Physiotherapy 61 (2015) 45 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Smooth pursuit eye movement training improves recovery from functional neglect in individuals with postacute stroke Synopsis Summary of: Kerkhoff G, Bucher L, Brasse M, Leonhart E, Holzgraefe Neglect Index (scored from 0 to 3), the Help Index, the Barthel Index and M, Volzke V, et al. Smooth pursuit ‘‘bedside’’ training reduced disability rehabilitation phase (derived from the Barthel Index). The outcomes were and unawareness during the activities of daily living in neglect: a measured at baseline, immediately after completion of training and at 2- randomized controlled trial. Neurorehabil Neural Repair 2014;28:554- week follow-up. Results: A total of 24 participants completed the study. 563. Significant group  time interaction effects were found in the Functional Neglect Index and the Unawareness and Behavioral Neglect Index. Question: In people with postacute stroke, does smooth pursuit eye Immediately after the 4-week training period, the change in the movement training reduce disability and unawareness during activities Functional Neglect Index was significantly greater in the smooth pursuit of daily living? Design: Randomised, controlled trial and blinded eye movement-training group by 2.3 points. The change in the outcome assessment. Setting: An inpatient setting in Germany. Unawareness and Behavioral Neglect Index was also significantly greater Participants: Individuals with single right-hemisphere stroke with left in the smooth pursuit eye movement-training group by 0.3 points. visual neglect were eligible. Key exclusion criteria were: psychiatric, During the 2-week follow-up period, the improvement in the Functional ophthalmological or other neurological diseases. Randomisation of Neglect Index continued in the smooth pursuit eye movement-training 24 participants (11 to 66 days post-stroke) allocated 12 to the smooth group, but not in the visual scanning training group (mean pursuit eye movement-training group and 12 to the visual scanning difference = 1.8 points). The Help Index and Barthel Index did not training group. Interventions: Both groups underwent their respective demonstrate any significant group  time interaction effect. The treatment programs for 4 weeks (30 minutes per session, five sessions rehabilitation phase also did not show any between-group differences per week). In the smooth pursuit eye movement-training group, the at any time points. Conclusion: In the postacute phase after stroke, participants repeatedly followed the moving stimulus patterns by smooth pursuit eye movement training was more effective than visual making smooth pursuit eye movements from right to left. In the visual scanning training in improving functional neglect and reduced unaware- scanning training group, the participants viewed the stationary displays ness during activities of daily living. of stimuli and performed saccadic eye movements to scan the stimulus objects systematically in a specified direction, naming objects or Marco YC Pang counting certain stimuli. In both groups, the participants were asked Department of Rehabilitation Sciences, to keep their head stationary in a neutral position while performing the The Hong Kong Polytechnic University, Hong Kong eye movements. Outcome measures: The outcomes were the Functional Neglect Index (scored from 0 to 15), the Unawareness and Behavioral http://dx.doi.org/10.1016/j.jphys.2014.11.012 Commentary tasks. Without a reference to the standardised assessments, this meant that the severity of neglect (impairment level) at baseline was unclear. Increasing research evidence has demonstrated the effectiveness of neglect rehabilitation. To date, most of studies in this field have not been The smooth pursuit eye movement training did improve performance performed at the acute stage of stroke. Although the sample size in the in both the neglect tests, within-group changes in activities of daily living study by Kerkhoff et al was small, with 12 subjects in each arm (either measures were noted as well, and the effects could be long lasting. This is smooth pursuit eye movement training or visual scanning training), they encouraging, as a previous review concluded that there is insufficient were able to find significant differences after smooth pursuit eye evidence to support the effectiveness of most of the neglect-specific movement training compared to visual scanning training in measures of intervention approaches aimed at reducing disability and improving the Functional Neglect Index and the Unawareness and Behavioral independence.1 This study contributes to the evidence and neuroscience of Neglect Index after 4 weeks of training (a total of twenty 30-minute using a new treatment – smooth pursuit eye movement training – rather sessions). than the conventional visual scanning training, in the design of theory- based treatment in rehabilitation for post-stroke unilateral neglect. The challenge with smooth pursuit eye movement training is how to ensure that the head is kept in a neutral position while moving the eyes. Kenneth NK Fong In future, it will be interesting to use an eye tracker to investigate how the Department of Rehabilitation Sciences, eye gaze deviation changes behaviourally when doing smooth pursuit The Hong Kong Polytechnic University, Hong Kong eye movement to the contralesional side or saccadic eye movement in visual scanning. Reference The primary outcome measures of this study, namely the Functional 1. Bowen A, et al. Cochrane Database Syst Rev. 2007;CD003586. Neglect Index and the Unawareness and Behavioral Neglect Index, are uncommon, standardised assessment tools for people with unilateral http://dx.doi.org/10.1016/j.jphys.2014.11.007 neglect. Although the authors mentioned the Catherine Bergego Scale, they did not give reasons as to why they chose the Unawareness and Behavioral Neglect Index rather than the Catherine Bergego Scale for the behavioural 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
50 Appraisal Media difference in kinematic data.2 While in-app drawing tools have their validity and reliability is highly dependent on the device not been assessed for reliability, the lack of pre-placed joint they are loaded on and the skill of the practitioner using them. markers possibly increases this error further. A recent study reported that training examiners in marker placement led to Kathryn Mills improved reliability of three-dimensional kinematic data.3 This Discipline of Physiotherapy, Macquarie University, Australia suggests that practising marker placement prior to capturing data, such that joint centres can be easily identified, may improve T_1IF$DR][2 eferences the utility of the drawing tools. 1. Areblad M, et al. J Biomech. 1990;23:933–940. In summary, motion analysis is now cheaper and more 2. Gorton GE, et al. Gait Posture. 2009;29:398–402. accessible than at any previous point in clinical practice. Numerous 3. Osis ST, et al. Comput Methods Biomech Biomed Engin. 2014;1–9. apps exists that may be of value to the clinician. Ubersense, Dartfish Express and Coach’s Eye offer the T_$Dg[I]1F0 reatest utility at the http://dx.doi.org/10.1016/j.jphys.2014.11.014 lowest price. However, even with the capabilities of these apps, Statement regarding registration of clinical studies and systematic reviews from the Editorial Board of Journal of Physiotherapy The Editorial Board of Journal of Physiotherapy reminds readers observational studies. While registration of these other study of our policy that prospective registration is mandatory for types is not yet mandatory, it is encouraged. Similarly, we randomised trials that began participant recruitment after 1 encourage the registration of systematic reviews, which is possible January 2006. Prospective registration means that the protocol for at www.crd.york.ac.uk/PROSPERO/. Authors should provide the a trial is registered on a publicly accessible register before data name and address of the register and the trial registration number collection begins on the first participant. Also, the submitted trial on submission. Readers can find out more about our policy here: report must be consistent with the registered protocol. We will http://www.sciencedirect.com/science/article/pii/ accept registration in any register that satisfies the International S1836955312701224. Committee of Medical Journal Editors requirements. Registers that meet these requirements can be found here: http://www.who.int/ http://dx.doi.org/10.1016/S1836-9553(14)00174-X ictrp/network/primary/en/. Some of these registers now allow the registration of protocols for other clinical studies, such as
Journal of Physiotherapy 61 (2015) 48 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinical Practice Guidelines Subacromial pain syndrome Guideline for diagnosis and treatment of subacromial pain syndrome Date of latest update: May 2014. Date of next update: Not stated. and reports recommendations for eight clinical questions related Patient group: Individuals who have subacromial shoulder pain. to the management of individuals with subacromial pain Intended audience: Healthcare providers who manage musculo- syndrome. These questions cover evidence regarding: prognosis; skeletal shoulder complaints. Additional versions: Nil. Expert prevention; physical diagnostic tests; imaging diagnostic tests working group: The expert working group was comprised of a (eg, ultrasound, MRI); instruments with which to measure nine-member multi-disciplinary committee representing medical treatment outcomes (eg, questionnaires); non-operative treat- professionals and physical therapists. Funded by: Not indicated. ment (eg, corticosteroid injections, extracorporeal shockwave Consultation with: The guidelines were developed in consultation therapy, exercise therapy, electrotherapy); surgical treatment with representatives from: the Orthopedic Society, the (eg, with an intact rotator cuff, for a torn rotator cuff, and for biceps Netherlands Association of Physical Therapy, the Netherlands tendon tenotomy or tenodesis); and patient advice. The guidelines Association of General Practitioners, the Netherlands Society of finish with a clear list of ‘do’s’ and ‘don’ts’ in the treatment Rehabilitation Medicine, the Netherlands Association of Occupa- algorithm of this condition, based on the evidence synthesis. Over tional Medicine, and the Netherlands Society of Radiology. 80 references are supplied to support these recommendations. Approved by: Netherlands Orthopedic Society. Location: The guidelines are available as an open access journal article: Diercks R, Sandra G Brauer et al. Guideline for diagnosis and treatment of subacromial pain The University of Queensland, Australia syndrome. Acta Orthopaedica 2014; 85 (3): 314-322. http:// www.ncbi.nlm.nih.gov/pubmed/24847788. http://dx.doi.org/10.1016/j.jphys.2014.11.004 Description: These guidelines are published in an eight-page journal article that provides evidence, discusses considerations Stroke KNGF Clinical Practice Guideline: Stroke phase (0 to 24 hours) through to the chronic phase (after 6 months). The guidelines include evidence for general treatment principles Date of latest update: April 2014. Date of next update: For review (eg, intensity of exercise, motor learning principles, self manage- in 2020. Patient group: Individuals who have had a stroke. ment, falls prevention), diagnostic processes (eg, recommended Intended audience: The guidelines are primarily intended for assessment tools), functional prognoses (eg, prognostic determi- physical therapists treating patients with a stroke; however, they nants of functional recovery), therapeutic processes (in the pre- may be consulted by physicians, nursing staff, allied health mobilisation phase, mobilisation phase, and cognitive rehabilita- professionals, researchers and patient caregivers. Additional tion) and evaluation, monitoring, and record-keeping associated versions: The current guidelines are an update of the KNGF with these steps. Evidence from 467 randomised trials is included Guideline Stroke (2004). Additional documents include a six-page in this guideline to formulate 138 recommendations, with summary document and a quick reference card. Expert working the majority focussed on specific physical therapy interventions. group: The expert working group was comprised of a 19-member A 12-page supplement at the end of the document contains all committee of physical therapists, human movement scientists, and recommendations and the level of evidence underpinning these. a policy advisor, all from the Netherlands. Funded by: Royal Dutch The specific references for each recommendation are not provided Society for Physical Therapy (Koninklijk Nederlands Genootschap in this document. voor Fysiotherapie, KNGF). Consultation with: The guidelines were developed in consultation with representatives from Sandra G Brauer 15 professional organisations involved in the interdisciplinary The University of Queensland, Australia treatment of patients with stroke, including medical, allied health and consumer organisations. Approved by: Royal Dutch Society for http://dx.doi.org/10.1016/j.jphys.2014.11.005 Physical Therapy (KNGF). Location: The guidelines and additional documents are available in Dutch and English at: http:// www.fysionet-evidencebased.nl. Description: These guidelines are published in a 72-page document and synthesise levels of evidence available for the physical therapy management of stroke from the hyper acute 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association.
Journal of Physiotherapy 61 (2015) 48 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinical Practice Guidelines Subacromial pain syndrome Guideline for diagnosis and treatment of subacromial pain syndrome Date of latest update: May 2014. Date of next update: Not stated. and reports recommendations for eight clinical questions related Patient group: Individuals who have subacromial shoulder pain. to the management of individuals with subacromial pain Intended audience: Healthcare providers who manage musculo- syndrome. These questions cover evidence regarding: prognosis; skeletal shoulder complaints. Additional versions: Nil. Expert prevention; physical diagnostic tests; imaging diagnostic tests working group: The expert working group was comprised of a (eg, ultrasound, MRI); instruments with which to measure nine-member multi-disciplinary committee representing medical treatment outcomes (eg, questionnaires); non-operative treat- professionals and physical therapists. Funded by: Not indicated. ment (eg, corticosteroid injections, extracorporeal shockwave Consultation with: The guidelines were developed in consultation therapy, exercise therapy, electrotherapy); surgical treatment with representatives from: the Orthopedic Society, the (eg, with an intact rotator cuff, for a torn rotator cuff, and for biceps Netherlands Association of Physical Therapy, the Netherlands tendon tenotomy or tenodesis); and patient advice. The guidelines Association of General Practitioners, the Netherlands Society of finish with a clear list of ‘do’s’ and ‘don’ts’ in the treatment Rehabilitation Medicine, the Netherlands Association of Occupa- algorithm of this condition, based on the evidence synthesis. Over tional Medicine, and the Netherlands Society of Radiology. 80 references are supplied to support these recommendations. Approved by: Netherlands Orthopedic Society. Location: The guidelines are available as an open access journal article: Diercks R, Sandra G Brauer et al. Guideline for diagnosis and treatment of subacromial pain The University of Queensland, Australia syndrome. Acta Orthopaedica 2014; 85 (3): 314-322. http:// www.ncbi.nlm.nih.gov/pubmed/24847788. http://dx.doi.org/10.1016/j.jphys.2014.11.004 Description: These guidelines are published in an eight-page journal article that provides evidence, discusses considerations Stroke KNGF Clinical Practice Guideline: Stroke phase (0 to 24 hours) through to the chronic phase (after 6 months). The guidelines include evidence for general treatment principles Date of latest update: April 2014. Date of next update: For review (eg, intensity of exercise, motor learning principles, self manage- in 2020. Patient group: Individuals who have had a stroke. ment, falls prevention), diagnostic processes (eg, recommended Intended audience: The guidelines are primarily intended for assessment tools), functional prognoses (eg, prognostic determi- physical therapists treating patients with a stroke; however, they nants of functional recovery), therapeutic processes (in the pre- may be consulted by physicians, nursing staff, allied health mobilisation phase, mobilisation phase, and cognitive rehabilita- professionals, researchers and patient caregivers. Additional tion) and evaluation, monitoring, and record-keeping associated versions: The current guidelines are an update of the KNGF with these steps. Evidence from 467 randomised trials is included Guideline Stroke (2004). Additional documents include a six-page in this guideline to formulate 138 recommendations, with summary document and a quick reference card. Expert working the majority focussed on specific physical therapy interventions. group: The expert working group was comprised of a 19-member A 12-page supplement at the end of the document contains all committee of physical therapists, human movement scientists, and recommendations and the level of evidence underpinning these. a policy advisor, all from the Netherlands. Funded by: Royal Dutch The specific references for each recommendation are not provided Society for Physical Therapy (Koninklijk Nederlands Genootschap in this document. voor Fysiotherapie, KNGF). Consultation with: The guidelines were developed in consultation with representatives from Sandra G Brauer 15 professional organisations involved in the interdisciplinary The University of Queensland, Australia treatment of patients with stroke, including medical, allied health and consumer organisations. Approved by: Royal Dutch Society for http://dx.doi.org/10.1016/j.jphys.2014.11.005 Physical Therapy (KNGF). Location: The guidelines and additional documents are available in Dutch and English at: http:// www.fysionet-evidencebased.nl. Description: These guidelines are published in a 72-page document and synthesise levels of evidence available for the physical therapy management of stroke from the hyper acute 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association.
Journal of Physiotherapy 61 (2015) 3–9 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research Supervised exercise reduces cancer-related fatigue: a systematic review Jose´ F Meneses-Echa´ vez a, Emilio Gonza´ lez-Jime´ nez b, Robinson Ramı´rez-Ve´ lez a a Faculty of Physical Culture, Sport and Recreation, Santo Toma´s University, Colombia; b Department of Nursing, Faculty of Nursing, University of Granada, Melilla, Spain KEYWORDS Question: Does supervised physical activity reduce cancer-related fatigue? Design: Systematic review with meta-analysis of randomised trials. Participants: People diagnosed with any type of cancer, Physical exercise without restriction to a particular stage of diagnosis or treatment. Intervention: Supervised physical Cancer activity interventions (eg, aerobic, resistance and stretching exercise), defined as any planned or Fatigue structured body movement causing an increase in energy expenditure, designed to maintain or enhance health-related outcomes, and performed with systematic frequency, intensity and duration. Outcome measures: The primary outcome measure was fatigue. Secondary outcomes were physical and functional wellbeing assessed using the Functional Assessment of Cancer Therapy Fatigue Scale, European FID]O$T3_[ rganisation for Research and Treatment of Cancer Quality of Life Questionnaire, Piper Fatigue Scale, Schwartz Cancer Fatigue Scale and the Multidimensional Fatigue Inventory. Methodological quality, including risk of bias of the studies, was evaluated using the PEDro Scale. Results: Eleven studies involving 1530 participants were included in the review. The assessment of quality showed a mean score of 6.5 (SD 1.1), indicating a low overall risk of bias. The pooled effect on fatigue, calculated as a standardised mean difference (SMD) using a random-effects model, was –1.69 (95% CI –2.99 to –0.39). Beneficial reductions in fatigue were also found with combined aerobic and resistance training with supervision (SMD = –0.41, 95% CI –0.70 to –0.13) and with combined aerobic, resistance and stretching training with supervision (SMD = –0.67, 95% CI –1.17 to –0.17). Conclusion: Supervised physical activity interventions reduce cancer-related fatigue. These findings suggest that combined aerobic and resistance exercise regimens with or without stretching should be included as part of rehabilitation programs for people who have been diagnosed with cancer. Registration: PROSPERO CRD42013005803. [Meneses-Echa´ vez JF, Gonza´ lez-Jime´ nez E, Ramı´rez-Ve´ lez R (2015) Supervised exercise reduces cancer-related fatigue: a systematic review. Journal of Physiotherapy 61: 3–9] ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Introduction exhaustion related to cancer or cancer treatment that is not The number of people diagnosed worldwide with cancer has proportional to recent activity and interferes with usual function- been estimated to be as high as 10 million, with another 25 million having survived cancer.1 In Colombia, the National Cancer Institute ing’. Cancer-related fatigue also has a severe impact on daily reported that malignant tumours are the third biggest cause of mortality, increasing their mortality burden from 6 ]_[F5$TDtI o 15% in the activities, social relationships, reintegration and overall quality of six decades before 2002.2 This increase in cancer diagnoses is an life.6 Some evidence suggests that cancer-related fatigue may be a important public health problem, with the number of new cases predictor of survival for people with cancer.7 diagnosed in 2020 expected to be approximately 1.7 million.3 Physical activity has been proposed as an effective non- Cancer-related fatigue is a common problem for people with cancer. Approximately 80 to 100% of people with cancer report that pharmacologic intervention to promote psychological wellbeing they experience cancer-related fatigue.4 Furthermore, many during and following cancer treatment.8 A growing body of people continue to experience fatigue for months or years after successful treatment.4 Several concepts of cancer-related fatigue evidence indicates that physical activity improves muscle strength have been published in the biomedical literature. Stone and and body composition in people with cancer.9,10 Recent systematic colleagues found that 75% of DTI$F6p_][ eople with various solid tumours (among whom 48 out of 95 had metastatic disease) had a reviews examining the effect of physical activity on psychological significantly increased cancer-related fatigue score compared with a matched control population.4 The Colombian National Cancer and functional outcomes have tended to study particular types of Institute2 and the National Comprehensive Cancer Network5 define cancer-related fatigue as ‘a distressing, persistent, subjec- cancer instead of all cancer types, with lung and breast cancer tive sense of physical, emotional and/or cognitive tiredness or being the most widely studied.11–13 A recent Cochrane systematic review14 about exercise and cancer-related fatigue concluded that aerobic exercise reduces cancer-related fatigue and encouraged further research of other exercise modalities; however, this review only included data published before March 2011 and did not examine supervised physical activity interventions in isolation from unsupervised interventions. Supervision plays an important role in the effects of exercise interventions in chronically ill people.15,16 This value of supervision http://dx.doi.org/10.1016/j.jphys.2014.08.019 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
4 Meneses-Echa´vez et al: Supervised physical exercise for cancer-related fatigue has been attributed to improvements in adherence and intensity,17 and abstract were examined and full text was obtained if there was perhaps because of greater encouragement or confidence to work ambiguity regarding eligibility. When the two authors could when the help of a health professional is at hand. A supervising not reach an agreement, a third author DIF$T_01[a] rbitrated in cases of health professional may also help to individualise the exercise disagreement (EG-J). Additionally, the authors searched for other regimen to the specific condition of the person, such as the complex r]FID$T_1[ elevant trials listed in the reference lists of the retrieved articles, sequelae of cancer and its treatment.17,18 Whitehead and Lavel- and D2$_1IFiT][ n journals specialised in oncology for other possible relevant leand19 and Spence et al20 reported that breast and colon cancer trials (ie, Cancer, Journal of Clinical Oncology, Breast Cancer Research, survivors prefer supervised exercise training over unsupervised Journal of Oncology Practice and The Lancet Oncology). No language exercise. In light of this, Lin et al21 compared the effects of a restrictions were applied. supervised exercise intervention with those of usual care for 12 weeks in colorectal cancer patients during chemotherapy, and Assessment of the characteristics of the studies found significant improvements in the supervised exercise group on fatigue, physical activity,]FDI$T_[7 physical functioning, social functioning, Quality hand-grip strength, cardiorespiratory fitness, and pain subscales of The methodological quality of the studies including their risk of quality of life. Similarly, in a sample of 113 breast cancer patients, Schneider et al18 reported that moderate-intensity individualised bias was assessed using the Physiotherapy Evidence Database exercise improved cardiopulmonary function and fatigue during and (PEDro) scale.26 The PEDro scale rates the methodological quality after treatment. This apparent value of supervision and the lack of of randomised trials out of 10. A trained assessor determined the subgroup analysis of supervised physical activity interventions in score for each included study (JFM-E). Scores were based on all isolation from unsupervised interventions in previous reviews information available from both the published version and from necessitated a systematic review to determine the effectiveness communication with the authors. A score of 5 out of 10 was set as of supervised physical activity. The current systematic review the minimum score for inclusion in the review. therefore aimed to answer two questions: Participants 1. Does supervised physical activity improve cancer-related This systematic review included studies involving people fatigue and physical and functional wellbeing among people with current or previous cancer? diagnosed with any type of cancer, without restriction to a particular stage of diagnosis or treatment. Participants may have 2. What are the effects of specific modalities of supervised physical received active treatment regardless of therapeutic approach (eg, activity on these outcomes among people with current or chemotherapy, radiotherapy). previous cancer? Intervention Methods The experimental intervention was supervised physical activity. This systematic review was conducted according to the PF]I$DT_31[ hysical activity was considered as any body movement causing an Cochrane Handbook for Systematic Reviews of Interventions,22 increase in energy expenditure, and involving a planned or analysed using Review Manager Software version 5.2,23 and structured movement of the body performed in a systematic reported according to the PRISMA statement.24 manner in terms of frequency, intensity, and duration and is designed to maintain or enhance health-related outcomes.27 TF]ID$T_41[ he Identification and selection of studies control intervention was sham or conventional care. Physical activity interventions s]FID$T_51[ uch as aerobic, resistance and/or stretching Four electronic databases were searched (PubMed, CENTRAL, training were included. All interventions had to be supervised by EMBASE and OVID) to September 2013. The search strategy health professionals; therefore, home-based physical activity, incorporated the recommendations for a highly sensitive search telephone monitoring and cognitive approaches were excluded strategy for the retrieval of clinical trials on PubMed.25 The final from the analysis. Yoga and Tai Chi interventions were not included search strategy followed the format: (randomized controlled trial OR due to excessive variation in their mode, frequency, duration and controlled clinical trial OR randomized OR trial OR ‘‘clinical trials as intensity. S]FID$T_61[ ubgroup analysis was performed to explore the specific topic’’) AND (cancer OR neoplasm* OR tumour* OR tumor* OR carcino* effect of supervised physical activity modalities (ie, aerobic, OR leukaemi* OR leukemi*) AND (physical activity OR exercise OR resistance and stretching training). The pooled statistical analysis aerobic OR resistance OR strength OR flexibility OR stretching) AND and effect size was calculated for each physical activity training (fatigue). See Appendix 1 o]FDI$T_8[ n the eAddenda for further details of modality. search strategy. Outcome measures Two authors (JFM-E and RR-V) independently reviewed all of The primary outcome measure was cancer-related fatigue the retrieved studies against the ]9FDIT$_[inclusion criteria (Box 1). The title measured using the Functional Assessment of Cancer Therapy Box 1. Inclusion TFD]cI$_[4 riteria. (FACT)-Fatigue Scale, European FIOD$[T_3] rganisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ- Design C30), Piper Fatigue Scale (PFS), Schwartz Cancer Fatigue Scale Randomised controlled trial (SCFS) and the Multidimensional Fatigue Inventory (MFI). The Participants secondary outcomes were physical and functional wellbeing Patients with any type of cancer, without restriction to a measured with the EORTC QLQ-C30 and FACT, and adverse events. particular stage of diagnosis or treatment Data analysis Intervention Supervised physical activity interventions (aerobic, Relevant data were extracted independently from the eligible trials by two reviewers (JFM-E and RR-V) using a standard form, resistance or stretching) and the third author (EG-J) arbitrated in cases of disagreement. The Outcome measures reviewers extracted information about the methods (ie, design, Cancer-related fatigue (primary outcome) participants and intervention) and the outcome data for the Physical wellbeing experimental and control groups. A random-effects model was Functional wellbeing used when there was substantial heterogeneity (I2 > 50%). Comparisons Continuous outcomes were reported as standardised mean Supervised physical activity versus conventional care
re_1)uD$FIG]gi([T Research 5 Titles and abstracts screened from electronic cancer type (six trials, 55%),29,30,34–37 followed by prostate cancer search (n = 18, 471) (two trials, 18%),33,38 and lymphoma (one trial, 9%).31 Two trials (18%) included diverse types of cancer.28,32 Papers excluded after screening Interventions titles/abstracts (n = 18, 383) The interventions had a mean duration of 17 weeks (SD 12) Potentially relevant papers retrieved for full with an average of three sessions (SD 1) per week. The mean text evaluation (n = 88) session duration was 45 minutes (SD 29). The interventions included aerobic exercise (ie, walking and stationary cycling) in Papers excluded after full text all trials, resistance training in six trials (55%) and stretching/ evaluation (n = 76) flexibility exercises in four trials (36%). Training intensity varied considerably among studies, ranging from 50 to 90% maximum ineligible intervention (n = 39) heart rate. All studies reported pre-exercise screening before high- no supervision (n = 17) intensity physical training. Table 2 summarises the characteristics no measure of fatigue (n = 9) of the included studies. high risk of bias (n = 11) no control group (n = 1) Outcome measures The primary outcome – cancer-related fatigue – was measured Trials included in systematic review (n = 11) Trials included in meta-analysis (n = 11) using the FACT-Fatigue Scale in 55% of the included trials, the EORTC QLQ-C30 in 36% of trials, the PFS in 9% and the SCFS in 9%. Figure 1. Flow of studies through the review. Effect of intervention differences (SMD) with 95% CI, with statistical significance set at a p-value < 0.05. Primary outcome Data from all of the included trials were used in the meta- Results analysis of the primary outcome.28–38 The pooled SMD was –1.69 Flow of trials through the review (95% CI –2.99 to –0.39), indicating a moderate reduction in fatigue from supervised physical activity (Figure 2, see Figure 3 on the Eleven randomised controlled trials involving 1530 participants eAddenda for a detailed forest plot). Due to considerable statistical were included (Figure 1).28–38 The majority of studies were heterogeneity _F7]1T(ID[$ p < 0.001, I2 = 81[_D$IF]9T 9%), this result was calculated using conducted in Canada (n = 4, 36%), Australia (n = 2, 18%) and UK a random-effects modelD]FI_,$19[T which was mostly due to a single outlying (n = 2, 18%). trial.36 Characteristics of the included studies Secondary outcomes Physical wellbeing was reported in seven studies.28,30,32–35,37 Quality The assessment of risk of bias showed a mean PEDro score of 6.5 The pooled effect was not statistically significant (SMD = 0.27 in favour of exercise, 95% CI –0.19 to 0.74), with considerable (SD 1.1), indicating consistent methodological quality and a low statistical heterogeneity (p < 0.001, I2 = 88%). Functional wellbeing risk of most biases except blinding (Table 1). was reported in six studies.28,32,32–35 The pooled effect was not statistically significant (SMD = 0.47 in favour of exercise, 95% CI Participants 0.00 to 0.95), again with considerable statistical heterogeneity The mean age of participants in the included studies ranged (p < 0.001, I2 = 87%). from 47 to 66 years. Most participants were female (n = 1192, 78%). Three studies (27%) reported adverse events related to super- All participants were receiving treatment at the time of the study vised physical activity interventions. Courneya et al30 reported five interventions and the most frequent treatment procedure was adverse events in the exercise group (l]FI$DT0_[2 ymphoedema, gynaecologic chemotherapy (n = 1028). The average time since cancer diagnosis complaints and influenza) and two in the control group (foot fracture was 8 months (SD 11). Breast cancer was the most investigated and bronchitis). Courneya et al31 reported one case each of back, hip and knee pain in the exercise group only. Segal et al38 reported adverse events related to exercise: chest pain during resistance training (cardiologic investigations were negative), a syncopal episode before a treadmill exercise test in the aerobic group (no cause was identified), and a myocardial infarction 15 minutes after an exercise session in the aerobic group (full recovery). Table 1 PEDro Scale scores for the included trials (n = 11). Study Random Concealed Groups Participant Therapist Assessor < 15% Intention-to-treat Between-group Point estimate Total allocation allocation similar at blinding blinding Blinding dropouts analysis difference and variability (0 to 10) Adamsen28 baseline reported Campbell29 Y Y N N N Y Y reported 7 Courneya30 Y N Y N N N Y N Y 5 Courneya31 Y Y Y N N Y Y Y Y Y 8 Dimeo32 Y Y Y N N N Y Y Y Y 7 Galva˜o33 Y Y Y N N N Y N Y Y 6 Milne34 Y Y Y N N N Y Y Y Y 7 Mutrie35 Y Y Y N N N Y Y Y Y 7 Saarto36 Y Y Y N N Y Y Y Y Y 8 Segal37 Y N Y N N N Y N Y Y 5 Segal38 Y N Y N N N N Y Y Y 5 Y Y Y N N N Y Y Y Y 7 Y Y Y Y N = No, Y = Yes, PEDro = Physiotherapy Evidence Database.
6 Meneses-Echa´vez et al: Supervised physical exercise for cancer-related fatigue Table 2 Characteristics of the included trials (n = 11). Study Cancer type Participants Interventiona Outcome measures Adamsen28 I[$]FDT1C_ ancer treatment EORTC QLQ-C30, MOS SF-36, Campbell29 Mixed types of cancer n = 235 (171 female) Exp: aerobic, resistance and stretching; 120 min x Leisure Time Physical Activity Courneya30 Chemotherapy Exp: n = 118, age (yr) = 47 (SD 11) 5/wk x 6 wk; intensity 85 to 95% Questionnaire, 1RM Courneya31 Con: n = 117, age (yr) = 47 (SD 11) Con: conventional care FACT-G, FACT-B, SWLS, PFS, Breast: early stage (I-II) SPAQ, 12-minute walk test Dimeo32 Chemotherapy, n = 22 (22 female) Exp: aerobic and resistance; 20 min x 2/wk x FACT- G, FACT-B, FACT-F Galva˜o33 radiotherapy Exp: n = 12, age (yr) = 48 (SD 10) 12 wk; intensity 60 to 75% Milne34 Breast: early stage Con: n = 10, age (yr) = 47 (SD 5) Con: conventional care FACT-G, FACT-F Mutrie35 Chemotherapy, Saarto36 radiotherapy n = 52 (52 female) Exp: aerobic; 35 min x 3/wk x 15 wk; intensity EORTC QLQ-C30 Lymphoma: stages I-IV; Exp: n = 24, age (yr) = 59 (SD 5) 70 to 75% Segal37 Hodgkin’s (18%) and Con: n = 28, age (yr) = 58 (SD 6) Con: conventional care EORTC QLQ-C30, MOS SF-36, non-Hodgkin’s (82%) DEXA, 1 RM Segal38 Chemotherapy n = 122 (72 male) Exp: aerobic; 45 min x 3/wk x 12 wk; intensity Exp: n = 60, age (yr) = 53 60 to 75% FACT-B, SCFS, PARQ, Aerobic Mixed: tumour stages I-IV (range 18 to 77) Con: conventional care Power Index Chemotherapy, Con: n = 62, age (yr) = 54 radiotherapy (range 18 to 80) Exp: aerobic; 30 min x 5/wk x 3 wk; intensity FACT-G, FACT-B, FACT-F, BDI, 80% PANAS, SPAQ Leisure time, BMI, Prostate: localised (93%), n = 69 (49 male) Con: progressive relaxation training; 45 min 12-min walk test nodal metastases (7%) Exp: n = 34, age (yr) = 55 (SD 10) x 3/wk x 3 wk EORTC QLQ-C30, FACIT-F, RBDI, Chemotherapy, Con: n = 35, age (yr) = 60 (SD 10) WHQ radiotherapy Exp: aerobic, resistance, stretching; 20 min x 2/wk Breast: early stage n = 57 (57 male) x 12 wk; intensity 60 to 80% FACT-G, FACT-B, MOS SF-36 Chemotherapy, Exp: n = 29, age (yr) = 54 (SD 9) Con: conventional care radiotherapy Con: n = 28, age (yr) = 52 (SD 12) FACT-G, FACT-P, FACT-F, Exp: aerobic, resistance, stretching; 30 min x 3/wk VO2max, 1RM, DEXA scan Breast: early stage n = 58 (58 female) x 12 wk; intensity 75% (percent body fat) Chemotherapy, Exp: n = 29, age (yr) = 55 (SD 8) Con: delayed the same exercise program until radiotherapy Con: n = 29, age (yr) = 55 (SD 8) week 13 Breast: early stage Chemotherapy, n = 174 (174 female) Exp: aerobic, resistance; 45 min x 2/wk x 12 wk; radiotherapy Exp: n = 82, age (yr) = 51 (SD 10) intensity 50 to 75% Con: n = 92, age (yr) = 52 (SD 9) Con: conventional care Breast: early stage Chemotherapy n = 500 (500 female) Exp: aerobic; 60 min x 1/wk x 48 wk; intensity Exp: n = 263, age (yr) = 52 86 to 92% Prostate: stages I-IV (range 36 to 68) Con: encouragement to maintain their previous Radiotherapy Con: n = 237, age (yr) = 52 level of physical activity and exercise habits (range 35 to 68) Exp: aerobic; session duration not stated; 3/wk x n = 123 (123 female) 26 wk; intensity 50 to 60% Exp: n = 42, age (yr) = 51 (SD 9) Con1: conventional care Con1: n = 41, age (yr) = 50 (SD 9) Con2: self-directed progressive walking; 5/wk x Con2: n = 40, age (yr) = 51 (SD 9) 26 wk; intensity 50 to 60% n = 121 (121 male) Exp1: aerobic, resistance, stretching; 45 min x 3/ Exp1: n = 40, age (yr) = 66 (SD 7) wk x 24 wk; intensity 70 to 75% Exp2: n = 40, age (yr) = 66 (SD 8) Exp2: supervised resistance exercise; 2 x 8–12 Con: n = 41, age (yr) = 65 (SD 8) reps of 10 exercises; 3/wk x 24 wk; 60 to 70% of estimated 1RM Con: conventional care BDA = Beck Depression Inventory; BMI = Body mass index; DEXA = Dual-energy X-ray aF[]ID2$T_ bsorptiometry; EORTC QLQ-C30 = European O]FIT[_D$3 rganisation for Research and Treatment of Cancer Quality of Life Questionnaire; FACT = Functional Assessment of Cancer Therapy, FACT-B = FACT – Breast; FACT-F = FACT – Fatigue; FACT-G = FACT – General; FACT- P = FACT – Prostate; FACIT = Functional Assessment of Chronic Illness Therapy; FACIT-F = FACIT questionnaire for fatigue; MFSI-SF = Multidimensional Fatigue Inventory; MOS SF-36 = Medical Outcomes Study Short Form; PANAS = Positive And Negative Affect Scale; PARQ = Physical Activity Readiness Questionnaire; PFS = Piper Fatigue Scale; RBDI = Finnish modified version of Beck’s 13-item depression scale; SCFS = Schwartz Cancer Fatigue Scale; SPAQ = Scottish Physical Activity Questionnaire; SWLS = Satisfaction with Life Scale; VO2max = maximal oxygen uptake; WHQ = Women’s Health Questionnaire; 1RM = one repetition maximum. a Supervised physical activity interventions usually consisted of a warm-up period, aerobic training (walking, cycle ergometers and circuits), muscle strength training, stretching exercises and a cool-down and relaxation period. The prescribed exercise intensities are reported as a percentage of maximal predicted oxygen uptake, unless otherwise stated. Outcomes beyond the intervention period Subgroup analyses At the 6-month follow-up, Courneya et al31 reported that the Aerobic favourable effect of aerobic exercise training on physical function- Aerobic exercise was the only component of the physical ing was no longer statistically significant (mean difference 5.5 points, 95% CI –1.5 to 12.4). Similarly, overall quality of life activity intervention in five trials.30–32,36,37 The effect of supervised (including fatigue) was no longer statistically significant (mean aerobic exercise on cancer-related fatigue was non-significant difference 7.6 points, 95% CI –0.1 to 15.4); however, regular (SMD = –2.99, 95% CI –6.49 to 0.51) with considerable statistical exercise was significantly more common among the experimental heterogeneity (p < 0.001, I2 = 100%) (Figure 4, see Figure 5 on the group (p = 0.017). Conversely, Mutrie et al35 stated that most FD2$]oTI[_1 f the eAddenda for a detailed forest plot). benefits of exercise observed at 12 weeks continued to the 6- month follow-up. In addition, a beneficial effect of exercise on the Resistance primary outcome of breast-cancer-specific quality of life was Only one trial had a group that undertook supervised resistance observed, even though it had not been significant at the end of the intervention. training only.38 The authors analysed the effect of supervised resistance exercise on cancer-related fatigue using a mixed-model
]GIF$[(igure_2)TD ResearcDGTI)8[(F$_eir]guh 7 Study SMD (95% CI) Study SMD (95% CI) Adamsen28 Random Adamsen28 Random Campbell29 Galvão33 Courneya30 Milne34 Courneya31 Segal38 Dimeo32 Pooled Galvão33 Milne34 -4 -2 0 2 4 Mutrie35 Favours training Favours control Saarto36 Segal37 Figure 8. Standardised mean difference (SMD) of the effect of combined aerobic, Segal38 resistance and stretching exercise with supervision on cancer-related fatigue. Pooled Aerobic, resistance and stretching -4 -2 0 2 4 The physical activity intervention involved aerobic and resis- Favours training Favours control tance training and stretching in four studies.28,33,34,38 This Figure 2. Standardised mean difference (SMD) of the effect of supervised physical supervised exercise regimen reduced cancer-related fatigue activity on cancer-related fatigue. significantly (SMD = –0.67, 95% CI –1.17 to –0.17) with consider- able statistical heterogeneity (p = 0.001, I2 = 81%) (Figure 8, see ]GIF$T)4_erugi([D Figure 9 on the eAddenda for a detailed forest plot). Study SMD (95% CI) Discussion Courneya30 Random Courneya31 The present review identified a substantial amount of Dimeo32 information about the effects of supervised exercise on cancer- Saarto36 related fatigue. These data were from trials that were rated above Segal37 average on the PEDro Scale for trials in physiotherapy.39 These Pooled ratings were evaluated by one author, but they can be confirmed against the ratings on the PEDro website; therefore, there is -10 -5 0 5 10 confidence in the quality of the trials and in the included data. Favours training Favours control The overall meta-analysis showed that supervised physical activity has a favourable effect on cancer-related fatigue when Figure 4. Standardised mean difference (SMD) of the effect of supervised aerobic compared with conventional care. The final analysis of the results exercise on cancer-related fatigue. revealed that supervised physical activity interventions are effective in the management of cancer-related fatigue for all types repeated measures analysis, which showed a benefit of 4.8 points of cancer (SMD = –1.69, 95% CI –2.99 to –0.39). The considerable on the FACT-Fatigue, which was statistically significant (95% CI statistical heterogeneity in this meta-analysis (Figure 2) is due to 1.9 to 7.7). the outlying result of Saarto et al.36 This trial had the largest sample size (n = 500) and the longest intervention program (48 weeks). Aerobic and resistance Similar beneficial effects have been reported in meta-analyses of the effect of physical activity on depression,40 fatigue9,17 and The physical activity intervention involved both aerobic and quality of life41 among cancer survivors. The results of the present resistance training in two studies.29,35 The effect of supervised study are in line with those published by Fong et al42 where physical activity, with or without supervision, was positively aerobic and resistance exercise on cancer-related fatigue was associated with body composition, physical functioning and psychological outcomes, including fatigue. Nevertheless, there statistically significant (SMD = –0.41, 95% CI –0.70 to –0.13) with still is insufficient information available to define the physiological no statistical heterogeneity (p = 0.47, I2 = 0%) (Figure 6, see mechanism for any potential benefit of exercise in reducing fatigue during cancer therapy or decreasing cancer risk.43–48 ]GIF$DT)6_er[(iguFigure 7 on the eAddenda for a detailed forest plot). In contrast to other systematic reviews in this area, the trials Study SMD (95% CI) included in the present review all analysed participants during an Campbell29 Random active treatment stage – the most frequent treatment was Mutrie35 chemotherapy (n = 1028). Oechsle et al,49 in a recent prospective Pooled randomised pilot trial, found that supervised exercise improved fatigue among 48 participants receiving myeloablative chemo- -4 -2 0 2 4 therapy. The exercise was ergometer training and strength Favours training Favours control exercises for 20 minutes each, five times a week during hospita- lisation for chemotherapy. This trial is consistent with the finding Figure 6. Standardised mean difference (SMD) of the effect of combined aerobic and of the present systematic review: that supervised physical activity resistance exercise with supervision on cancer-related fatigue. improves fatigue during cancer treatment, especially in people receiving chemotherapy; however, further trials are warranted to strengthen this evidence. O]FI$DT_2[ ur subgroup analysis showed that supervised aerobic exercise did not provide significant benefits to cancer-related fatigue (SMD = –2.99, 95% CI –6.49 to 0.51). This finding is inconsistent
8 Meneses-Echa´vez et al: Supervised physical exercise for cancer-related fatigue with recent evidence suggesting that physical activity reduces 8FI_]D$2CT[ orrespondence: Jose´ Meneses-Escha´ vez, Facultad de Cultura fatigue in breast cancer survivors,50 although that study analysed Fı´sica, Deporte y Recreacio´ n, Universidad Santo Toma´ s, Carrera data from unsupervised interventions. Interestingly, oF]ID$T_32[ ur subgroup analysis revealed that combined aerobic and resistance training 9 No 51-23, Colombia. Email: [email protected]. leads to a significant reduction in fatigue in cancer survivors (SMD = –0.41, 95% CI –0.70 to –0.13). Only one study examined the References effects of resistance training alone, although this was also benefi- cial.38 The effects of resistance exercise have not been addressed by 1. Siegel R, Naishadham D, Jemal A. Cancer statistics. Cancer J Clin. 2013;63:11–30. the American Cancer Society3 but have been examined recently in 2. 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Journal of Physiotherapy 61 (2015) 44 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers Tai Chi improves balance and prevents falls in people with Parkinson’s disease Synopsis Summary of: Gao Q, Leung A, Yang Y, Wei Q, Guan M, Jia C, He C. Go (TUG) test were assessed. Over the subsequent 6 months, falls Effects of Tai Chi on balance and fall prevention in Parkinson’s were assessed via a falls diary and monthly phone calls. Results: disease: a randomized controlled trial. Clin Rehabil 2014;28: Seventy-six participants completed the study. BBS scores im- 748–753. proved significantly more in the Tai Chi group, by 3.8 points (95% CI 2.3 to 5.3). The UPDRS scores didn’t differ significantly. Change in Question: Does Tai Chi improve balance and functional TUG time was significantly better in the Tai Chi group, by mobility, and prevent falls in people with Parkinson’s disease? 1.4 seconds (95% CI 0.9 to 2.0). Tai Chi reduced the relative risk of Design: Randomised, controlled trial with blinded outcome falls significantly, to 0.44 (95% CI 0.22 to 0.89). Conclusion: Three assessment. Setting: A hospital and local community in China. months of Tai Chi improved balance and decreased the incidence of Participants: Adults aged over 40 years with idiopathic Parkin- falls in people with Parkinson’s disease. son’s disease who were independently mobile and had fallen during the past year. Randomisation allocated 40 participants to [95% CIs calculated by the Editor using data from the published the Tai Chi group and 40 to the control group. Interventions: Both paper. Note that the TUG result is statistically significant, but it was groups received usual medical treatment. The intervention group not significant in the published paper. This may have been due to participated in Yang style Tai Chi, which emphasises diagonal slight differences in the equations that were used.] weight shifts, awareness of body position and breathing. An experienced instructor guided the participants through three Mark Elkins 60-minute sessions per week for 12 weeks. The control group Editor, Journal of Physiotherapy undertook no Tai Chi exercise. Outcome measures: At the end of the intervention period, the Berg Balance Scale (BBS), the Unified http://dx.doi.org/10.1016/j.jphys.2014.11.010 Parkinson’s Disease Rating Scale (UPDRS) III and the Timed Up and Commentary population have also been demonstrated.4 However, the effect of Tai Chi on falls is arguably clinically worthwhile; for every four The major finding of this trial was that 3 months of Tai Chi people (95% CI 2 to 18) who undertake Tai Chi, one person avoids a improved balance and decreased the incidence of falls in people fall who otherwise would have fallen. with Parkinson’s disease. A recent systematic review about the effects of Tai Chi in Parkinson’s disease1 found similar results; These mainly complementary benefits suggest that people with however, the pooled estimate of the effect on functional mobility Parkinson’s disease may benefit from a combination of Tai Chi and was lower than that reported by Gao et al. Therefore, this trial is a other physiotherapy interventions. Studies that address adherence useful addition to this field of study. and satisfaction with Tai Chi could help with the clinical decision- making. Unfortunately, the authors did not describe in detail the traditional Chinese mind-body exercises that they used, thus Aline Scianni making it difficult to replicate in clinical practice. To apply such Department of Physiotherapy, Universidade Federal de Minas Gerais, exercises in a clinical setting would require an experienced instructor, which may be expensive or unfeasible in some countries. Belo Horizonte, Brazil Tai Chi appears to have complementary benefits to some other References physiotherapy interventions for Parkinson’s disease.2 In a recent systematic review,2 the effect of treadmill training on balance was 1. Ni X, et al. PLoS ONE. 2014;9(6):e99377. twice that reported for Tai Chi by Gao et al, where the mean 2. Tomlinson CL, et al. Cochrane Datab Syst Rev. 2013;9:CD002817. estimate and 95% CI did not exceed 10% of the Berg Balance Scale 3. Downs S, et al. J Physiother. 2014;60:85–89. range from 0 (high falls risk) to 56 (low falls risk).3 The effect of Tai 4. Lima LO, et al. J Physiother. 2013;59:7–13. Chi on the Timed Up and Go test reported by Gao et al was similarly small and of borderline statistical significance. The effects of http://dx.doi.org/10.1016/j.jphys.2014.11.008 exercise or general physiotherapy on the Unified Parkinson’s Disease Rating Scale are significant,2 which is again in contrast to Tai Chi in the Gao study. The beneficial effects of resistance training on strength, mobility and functional performance in this 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 46 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinimetrics The Berg Balance Scale Summary The Berg Balance Scale was developed in 1989 to measure than 20 suggest that the tool might have similar absolute reliability balance in the elderly.1 The scale consists of 14 items, scored from at the low and high ends.2 A clinician would therefore need to see a 0 to 4, which are added to make a total score between 0 and 56; a change of three points or more at the very high and very low ends higher score indicates better balance. The items vary in difficulty – from sitting in a chair to standing on one leg. The Berg Balance of the scale to be confident that there was a real change, but would Scale takes approximately 10 to 15 minutes to complete. It requires need to find a change of at least seven points in the middle scores. a chair, a stopwatch, a ruler and a step. Although the Berg Balance Scale was originally developed to measure balance in the elderly, it Higher scores on the Berg Balance Scale have been found to be is now commonly used to measure balance in people with varying strongly related to a higher probability of discharge from hospital conditions and disabilities. to home, rather than to nursing home.3 Lower Berg Balance Scale scores in older people have been found to predict the onset of Reliability and validity: The Berg Balance Scale has a high inability to perform important activities of daily living.4 Most, 5–11 relative reliability with inter-rater reliability estimated at 0.97 though not all, 12,13 prospective studies investigating the (95% CI 0.96 to 0.98) and intra-rater reliability estimated at 0.98 (95% CI 0.97 to 0.99). The absolute reliability of the Berg Balance relationship between the Berg Balance Scale and falls support its Scale varies across the scale, with minimal detectable change with validity for predicting falls. 95% confidence varying between 2.8/56 and 6.6/56. The absolute reliability is stronger at the high end and weaker towards the Normal values: People aged 69 years without any health middle of the scale. Limited data from subjects with scores of less conditions likely to affect mobility can be expected to have a Berg Balance Scale score of 56/56. This normal value declines with increasing age, at a rate of 0.75 points per year. Thus, a person aged 75 would be expected to have a Berg Balance Scale score of 51.14 Commentary References The Berg Balance Scale is a reliable, valid and widely-used tool 1. Berg K, et al. Physiother Can. 1989;41(6):304–311. that can be administered easily with minimal equipment in 10 to 2. Downs S, et al. J Physiother. 2013;59(2):93–99. 15 minutes. It can be used in people with varying conditions and 3. Downs S, et al. Aust J Rural Health. 2012;20(5):275–280. disabilities. Unlike other tests of balance and mobility, which require 4. Wennie Huang WN, et al. J Am Geriatr Soci. 2010;58(5):844–852. people to be able to walk or stand independently, the Berg Balance 5. Ersoy Y, et al. Gerontol. 2009;55(6):660–665. Scale can be used for people who are unable to move from a chair. 6. Hall. et al. Australas J Ageing. 2001;20(2):73–78. 7. Li F, et al. Med Sci Sports Exerc. 2004;36(12):2046–2052. Limitations: The Berg Balance Scale has a ceiling effect when 8. Mackintosh SF, et al. Arch Phys Med Rehabil. 2006;87(12):1583–1589. used in people younger than 75 who do not have a specific health 9. Maurer MS, et al. J Gerontol A Biol Sci Med Sci. 2005;60(9):1157–1162. condition likely to affect balance even if they have an increased risk 10. Muir SW, et al. Phys Ther. 2008;88(4):449–459. of falling. Therefore, it may not be a good screening tool for these 11. Teasell R, et al. Arch Phys Med Rehabil. 2002;83(3):329–333. individuals. In addition, the Berg Balance Scale measures neither 12. Boulgarides LK, et al. Phys Ther. 2003;83(4):328–339. the quality of gait nor the speed of walking and, therefore, may be 13. Cakar E, et al. Brain Inj. 2010;24(3):426–427. less useful than other tools where motor control is a bigger 14. Downs S, et al. J Physiother. 2014;60(2):85–89. contributor to poor balance than muscle weakness. Stephen Downs Transitional Aged Care, Bellingen River District Hospital, Bellingen, Australia http://dx.doi.org/10.1016/j.jphys.2014.10.002 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Journal of Physiotherapy 61 (2015) 42 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Trial Protocol The PACT trial: PAtient Centered Telerehabilitation Effectiveness of software-supported and traditional mirror therapy in patients with phantom limb pain following lower limb amputation: protocol of a multicentre randomised controlled trial Andreas Stefan Rothgangel a,b, Susy Braun b,c,d, Ralf Joachim Schulz e, Matthias Kraemer f, Luc de Witte c,d, Anna Beurskens b,g, Rob Johannes Smeets a,h a Department of Rehabilitation, Research School CAPHRI, Maastricht University; b Research Centre Autonomy and Participation of People with a Chronic Illness, Faculty of Health, Zuyd University of Applied Sciences; c Research Centre Technology in Care, Faculty of Health, Zuyd University of Applied Sciences, Heerlen; d Department Health Research Services, Research School CAPHRI, Maastricht University; e Department of Geriatrics, Cologne University; f Centre of Neurological Rehabilitation, St. Marien Hospital Cologne, Germany; g Department of Family Medicine, Research School CAPHRI, Maastricht University, Maastricht; h Adelante Centre of Expertise in Rehabilitation, Hoensbroek, The Netherlands Abstract Introduction: Non-pharmacological interventions such as mirror pain-related limitations in daily activities, global perceived effect, pain- therapy are gaining increased recognition in the treatment of phantom specific self-efficacy, and quality of life. Discussion: Several questions limb pain; however, the evidence in people with phantom limb pain is still concerning the study design that emerged during the preparation of this weak. In addition, compliance to self-delivered exercises is generally low. trial will be discussed. This will include how these questions were addressed The aim of this randomised controlled study is to investigate the and arguments for the choices that were made. effectiveness of mirror therapy supported by telerehabilitation on the intensity, duration and frequency of phantom limb pain and limitations in Trial registration: U.S. National Institutes of Health Clinical Trials Registry. daily activities compared to traditional mirror therapy and care as usual in Registration number: NCT02076490. Was this trial prospectively registered: people following lower limb amputation. Method: A three-arm multi-centre Yes. Date: 28.02.2014. Funded by: Ministry of Health, State of North Rhine- randomised controlled trial will be performed. Participants will be randomly Westphalia, Germany and the European Union through the NRW Ziel2 Program assigned to care as usual, traditional mirror therapy or mirror therapy as a part of the European Fund for Regional Development. Funder approval supported by telerehabilitation. During the first 4 weeks, at least number: 005-GW02-035. Anticipated completion: July 2015. Correspon- 10 individual sessions will take place in every group. After the first 4 weeks, dence: Andreas Rothgangel, Department of Rehabilitation Medicine, Research participants will be encouraged to perform self-delivered exercises over a School for Public Health and Primary Care CAPHRI, Maastricht University, period of 6 weeks. Outcomes will be assessed at 4 and 10 weeks after Maastricht, The Netherlands. Email: [email protected] baseline and at 6 months follow-up. The primary outcome measure is the average intensity of phantom limb pain during the last week. Secondary Full protocol: Available on the eAddenda at doi:10.1016/ j.jphys.2014.08.006 outcome measures include the different dimensions of phantom limb pain, http://dx.doi.org/10.1016/j.jphys.2014.08.006 ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved. Commentary successful this would represent a major advance in the management of this complex and difficult-to-manage condition. The researchers also plan to Phantom pain is common following limb amputation. Although data are conduct a cost-effectiveness and cost-utility analysis of the intervention. limited prognosis is regarded to be poor and there are few effective This will provide high quality information to guide policy makers and health treatment options.1 Mirror therapy has been investigated in 2 small trials care providers/consumers. and its effects on reducing pain intensity are promising. A significant concern with mirror therapy and related interventions such as graded motor This is a well-designed and high quality trial. Although neither the imagery for complex regional pain syndrome (CRPS) is that they often patients nor the therapist delivering the intervention will be blinded to require considerable therapist and patient time to achieve therapeutic allocation, efforts have been taken to minimise most other known sources of benefits. bias. This will lead to a high confidence in the findings. This three-arm randomised controlled study will investigate the James McAuley effectiveness of telerehabilitation-supported mirror therapy for phantom Neuroscience Research Australia (NeuRA) Sydney, Australia limb pain. The effectiveness of mirror therapy will be determined by comparing telerehabilitation supported mirror therapy to mirror therapy Reference and care as usual. The primary outcome is pain intensity. Secondary outcomes include duration and frequency of phantom limb pain and 1. Alviar MJM, et al. Cochrane Database Syst Rev. 2011;12:CD006380. http://dx.doi.org/ activities of daily living. These patient-centered outcomes are appropriate 10.1002/14651858.CD006380.pub2. for this patient group and reflect the patient’s main concerns. http://dx.doi.org/10.1016/j.jphys.2014.10.001 The study is powered to detect a two-point difference on an 11-point numerical rating scale of pain intensity. This is an ambitious between-group difference as pain interventions rarely achieve effects of this magnitude. If 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association.
Journal of Physiotherapy 61 (2015) 16–20 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Research The use of a modified, oscillating positive expiratory pressure device reduced fever and length of hospital stay in patients after thoracic and upper abdominal surgery: a randomised trial Xiang-yu Zhang a, Qixing Wang a, Shouqin Zhang a, Weilin Tan b, Zheng Wang c, Jue Li d a Department of Critical Care Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine; b Shanghai Jiangong Hospital; c Department of Thoracic Surgery, Shanghai Putuo District Center Hospital; d Tongji University School of Medicine, Shanghai, China KEYWORDS ABSTRACT Mucus-clearance device Question: Does the use of an oscillating positive expiratory pressure (PEP) device reduce postoperative Postoperative pulmonary complications pulmonary complications in thoracic and upper abdominal surgical patients? Design: A multi-centre, Length of stay parallel-group, randomised controlled trial with intention-to-treat analysis, blinding of some outcomes, and concealed allocation. Participants: A total of 203 adults after thoracic or upper abdominal surgery with general anaesthesia. Intervention: Participants in the experimental group used an oscillating PEP device, thrice daily for 5 postoperative days. Both the experimental and control groups received standard medical postoperative management and early mobilisation. Outcome measures: Fever, days of antibiotic therapy, length of hospital stay, white blood cell count, and possible adverse events were recorded for 28 days or until hospital discharge. Results: The 99 participants in the experimental group and 104 in the control group were well matched at baseline and there was no loss to follow-up. Fever affected a significantly lower percentage of the experimental group (22%) than the control group (42%), with a RR of 0.56 (95% CI 0.36 to 0.87, NNT 6). Similarly, length of hospital stay was significantly shorter in the experimental group, at 10.7 days (SD 8.1), than in the control group, at 13.3 days (SD 11.1); the mean difference was 2.6 days (95% CI 0.4 to 4.8). The groups did not differ significantly in the need for antibiotic therapy, white blood cell count or total expense of treatment. Conclusion: In adults undergoing thoracic and upper abdominal surgery, postoperative use of an oscillating PEP device resulted in fewer cases of fever and shorter hospital stay. However, antibiotic therapy and total hospital expenses were not significantly reduced by this intervention. Trial registration: NCT00816881. [Zhang X-y, Wang Q, Zhang S, Tan W, Wang Z, Li J (2015) The use of a modified, oscillating positive expiratory pressure device reduced fever and length of hospital stay in patients after thoracic and upper abdominal surgery: a randomised trial. Journal of Physiotherapy 61: 16–20] ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Introduction postoperative respiratory interventions, some hospitals use a traditional technique where the patients regularly blow up a Following both thoracic and upper abdominal surgical proce- balloon after the operation until mobilisation is re-established. dures, postoperative pulmonary complications (PPCs) are fre- This technique is a form of respiratory exercise that is typically quently observed and are still a major contributor to the overall used for individuals at high risk of PPCs. risk of surgery.1 A recent Australian study reported that PPCs affect 13% of patients undergoing upper abdominal laparotomy.2 Risk Oscillating positive expiratory pressure (PEP) devices have been factors for PPCs are: duration of anaesthesia, surgical category, shown to assist mucus clearance in a number of respiratory current smoking, respiratory comorbidity, and predicted maximal diseases, including: cystic fibrosis,6–9 chronic obstructive pulmo- oxygen uptake.3 Preoperative physiotherapy interventions,4 par- nary disease,10,11 asthma,12 diffuse panbronchiolitis13 and bron- ticularly inspiratory muscle training,5 decrease the risk of PPCs. chiectasis.14,15 In some of these studies, there is also some evidence Postoperatively, early mobilisation is recommended to minimise that use of the oscillating PEP device may help to improve lung PPCs.2 expansion, although the mechanism is unclear. Thoracic and upper abdominal surgical patients at risk of PPCs may benefit from an Many pre-operative and post-operative physiotherapy inter- intervention that facilitates the clearance of retained secretions ventions are not yet available or accepted in most hospitals in with a possible additional effect on lung expansion. China. Postoperatively, early mobilisation is used. Currently in China, no other standardised physiotherapy and respiratory care is The hypothesis of the present study was that regular use of a provided during the postoperative period. With regard to hand-held oscillating PEP device might improve respiratory management in patients after thoracic or upper abdominal http://dx.doi.org/10.1016/j.jphys.2014.11.013 1836-9553/ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
Researc$FIGDT)1_[(igure]h 17 surgery. Therefore, the research question for the present study was: In patients who have undergone thoracic or upper abdominal surgery, what is the effect of regular postoperative use of an oscillating PEP device on fever, white cell count, length of hospital stay, mortality, treatment costs and the need for antibiotics? Method Figure 1. The oscillating PEP device was modified by the addition of a flexible adaptor inserted between the oscillating valve and the mouthpiece. This was done Design so that the participants could use it at the required angle while in any body position and without any uncomfortable sensation of dental vibration. A randomised trial with intention-to-treat analysis, blinding of assessors for some outcomes, and concealed allocation was thoracic vibration during exhalation through the device. The undertaken. Preoperatively, patients were informed about the procedure was repeated for five to ten breaths over a 5-minute study protocol and their willingness to participate was deter- period, three times a day, for the first 5 postoperative days. The mined. Those who remained willing and eligible to participate following schedule was recommended: after waking up in the postoperatively were enrolled and randomised by one of the study morning, after an afternoon nap, and before going to bed in the investigators. On the first postoperative day, eligible patients were evening. Participants were instructed to avoid having a full randomly allocated to an experimental or control group, with each stomach for the breathing sessions. Participants were encouraged allocation removed from a sealed, consecutively numbered, to cough up sputum during the breathing sessions. opaque envelope by a research assistant. Outcomes were measured up to 28 days postoperatively or until discharge from Routine medical management and early mobilisation were hospital. provided to the participants in both groups, as appropriate and according to each patient’s postoperative condition. No other Before the study was registered and commenced, the principal routine physiotherapy, such as standardised thoracic expansion investigators from each centre reached consensus on the study exercises,16 was administered to both groups, as this is not protocol. Study inspectors, who were organised and instructed by routinely available in the participating hospitals. Therefore, the the principal investigator from Shanghai Tenth People’s Hospital, control group had no other physiotherapy, unless a physician conducted site visits and made phone calls to ensure study quality. specifically ordered it after the development of a PPC. Participants, therapists and centres Due to the unavailability of a convincing sham, the control group did not undertake sham training; therefore, the participants Adults aged 18 to 80 years were eligible to participate if they were unblinded. were undergoing thoracic or upper abdominal surgery with tracheal intubation under general anaesthesia and were extubated Outcome measures within 24 hours postoperatively. Exclusion criteria were: inability to use the oscillating PEP device (eg, due to decreased conscious- The primary outcomes were fever, antibiotic therapy and length ness or intellectual disability); advanced cancer; diffuse interstitial of hospital stay. Fever was defined as a body temperature ! 38 deg lung disease; systolic blood pressure ! 180 mmHg; diastolic blood Celsius. Antibiotic therapy was quantified as the number of days on pressure ! 110 mmHg; and severe cardiac, hepatic, renal, intravenous antibiotics. Length of hospital stay was calculated as circulatory or endocrine dysfunction. the number of days from admission to discharge; it was calculated as a continuous outcome, as well as being analysed after being The investigators who administered the oscillating PEP devices dichotomised into those extending beyond 28 days or not. and taught participants to use them were physicians or respiratory therapists. These investigators received consistent instructions in The secondary outcomes were white cell count, abnormal chest the use of the devices via the study protocol. radiograph, mortality, treatment costs and the need for mechanical ventilation. The white cell count was measured on the fifth Three hospitals recruited participants for the present study. The postoperative day, and was calculated by laboratory staff who co-ordinating centre was the Shanghai Tenth People’s Hospital, were unaware of the participants’ group allocation. Radiologists, Tongji University School of Medicine. The other centres were the who were unaware of the participants’ group allocation, decided Shanghai Jiangong Hospital and the Shanghai Putuo District Centre whether there were any abnormalities on the participants’ chest Hospital. radiographs. Mortality and treatments costs were determined from hospital records. At discharge from hospital, participants who Interventions had used the oscillating PEP device were questioned about any adverse events associated with the device. Participants who were randomised to the experimental group were instructed to use an oscillating PEP device.a The device is Data analysis required to be held in a particular position with respect to gravity. Given that the participants may have been limited in the positions All participants completed the study as allocated, so analysis that they could adopt in the early postoperative period, the device was consistent with the intention-to-treat principle. Group data was modified by the addition of some wide-bore connector tubing used as a flexible adaptor, which was inserted between the oscillating valve and the mouthpiece, as shown in Figure 1. This allowed the participants to use the device at the required angle whilst in any body position and avoided any uncomfortable sensation of dental vibration. Participants were instructed to take a deep breath and then to exhale through the device actively but not forcefully. The participants were also instructed to adjust the position of the device relative to gravity in order to yield the strongest feeling of
18 Zhang et al: Oscillating PEP after thoracic and abdominal surgery were summarised as means and SD. For continuous outcome Effect of intervention measures, between-group comparisons used the independent- samples t-test and were reported as mean differences with 95% CI. The first primary outcome – the incidence of fever – was For dichotomous outcomes, between-group comparisons used the significantly reduced by the intervention. Specifically, the inci- chi-square test and were reported as relative risks with 95% CI. dence of fever was 39% in the control group and 22% in the Significant results were also converted to ‘number needed to treat’. experimental group. This means that the experimental group had a All statistical tests were two-tailed, with an alpha level of risk of fever that was 0.56 of the risk in the control group. This < 0.05 considered to be statistically significant. ‘relative risk’ estimate of 0.56 was statistically significant (95% CI 0.36 to 0.87), as presented in Table 2. It also suggests that, on Results average, for every six patients who undertook the oscillating PEP intervention, one remained afebrile who would otherwise have Compliance with the study protocol experienced a fever during their first 28 postoperative days. However, this estimate of six patients, as the number needed to One 16 year old was enrolled, despite being below the intended treat to prevent one case of fever, has some imprecision associated age range for participants. All participants provided data for the with it. The true ‘number needed to treat’ could be as low as 3 or as planned outcome measures, except that a white blood cell count high as 22 patients. was unavailable for three experimental group participants and four control group participants. The length of hospital stay was analysed in two ways: as a continuous outcome and as a dichotomous outcome. When Flow of participants, therapists and centres through the study analysed as a continuous outcome, length of stay was significantly reduced from 13.3 days (SD 8.7) in the control group to 10.7 days Between January 2009 and February 2010, 233 adult patients (SD 7.1) in the experimental group, with a mean difference of –2.6 undergoing thoracic and upper abdominal surgery in the three (95% CI –4.8 to –0.4), as shown in Table 3. The risk of prolonged hospitals located in Shanghai, China were screened for eligibility. hospitalisation (ie, > 28 days) was 9% in the control group and 6% in Of these, 30 were excluded: 22 did not meet the eligibility criteria, the experimental group, with a RR of 0.58 (95% CI 0.20 to 1.68), as six declined to participate, and informed consent was not obtained shown in Table 2. from the remaining two participants. Therefore, 203 patients were randomised – all of whom completed the study and provided data The other primary outcomes were not significantly improved for analysis, as shown in Figure 2. by the oscillating PEP intervention. The risk of requiring antibiotics was 95% in the control group and 93% in the experimental group, The baseline characteristics of the two groups were similar, as with a RR of 0.99 (95% CI 0.92 to 1.05), as shown in Table 2. The presented in Table 1. number of days spent receiving antibiotic therapy was also not significantly affected by the intervention, with a mean difference of 1.61 days less in the experimental group (95% CI –0.13 to 3.36), as presented in Table 3. ]GIF$DT)2_erugi([ Figure 2. Flow of participants through the study.
Research 19 Table 1 Table 2 Characteristics of participants at baseline. Prevalence of adverse dichotomous outcomes in the two groups and RR (95% CI). Characteristic Experimental Control Outcome Exp Con RR (95% CI) group group (n = 99) (n = 104) Gender (male), n (%) (n = 99) (n = 104) 0.56 (0.36 to 0.87) Age (yr), mean (SD) Fever, n (%) 22 (22) 41 (39) 0.58 (0.20 to 1.68) Body mass index (kg/m2), mean (SD) 61 (62) 63 (61) Hospital stay more 5 (5) 9 (9) 0.99 (0.92 to 1.05) Comorbidities, n (%) 56 (10) 58 (12) than 28 days, n (%) 0.90 (0.64 to 1.27) 23.5 (3.3) 23.3 (4.2) Antibiotic therapy, 93 (93) 99 (95) chronic cardiovascular disease n (%) chronic respiratory disease 19 (19) 18 (17) Abnormal of chest 37 (37) 43 (42) other 1 (1) 2 (2) radiograph, n (%) Emergency operation, n (%) 9 (9) Thoracic operation, n (%) 12 (12) Exp = experimental group, Con = control group. Upper abdominal operations, n (%) 26 (26) 26 (25) laparotomy, n (%) 50 (51) 54 (52) In the present study, some statistically significant results were laparoscopy, n (%) 49 (49) 50 (48) observed. It is important to put these into context. The statistically Total operative time (hr), mean (SD) 24 (24) 25 (24) significant reduction in the risk of fever was also clinically Max body temperature on Day 1 25 (25) 25 (24) substantial, because the best estimate was that for every six (deg C), mean (SD) 2.01 (1.42) 2.15 (1.48) patients who used the oscillating PEP, one would avoid fever who White blood cell count on Day 1 37.4 (0.5) 37.5 (0.5) would otherwise have experienced it. However, this estimate (Â109/L), mean (SD) carried some imprecision, with this estimate of six as the ‘number 9.25 (4.18) 10.33 (4.24) needed to treat’ having a 95% CI from 3 to 22. If 22 patients had to use the oscillating PEP to prevent one case of fever, this would not None of the secondary outcomes was significantly affected by be as clinically worthwhile. Also, fever may not have been an the oscillating PEP intervention. The white cell count on Day 5 was indicator of a very severe PPC, because this result was not similar in the two groups, with a mean difference of 0.09 x 109/L. accompanied by significant reductions in antibiotic use or The incidence of an abnormal chest radiograph was 42% in the radiological abnormalities. The other statistically significant result control group and 37% in the experimental group, with a RR of 0.90 (ie, a 2.6 day reduction in length of hospital stay) was clinically (95% CI 0.64 to 1.27). Treatment costs were 3800 RMB cheaper in relevant to the centres in Shanghai. However, it is acknowledged the experimental group, but this was not statistically significant that other centres have shorter lengths of hospital stay, so the (95% CI –8400 to 900), as shown in Table 3. During the course of the potential to reduce them by 2.6 days with oscillating PEP may be study, there were no deaths, and no other adverse events or limited. reactions were reported. Individual participant data are available in Table 4 on the eAddenda. The present results should also be considered in the context of other studies in this area. A previous single-centre study with a Discussion relatively small sample size indicated that incentive spirometry in addition to regular physiotherapy did not further reduce pulmo- General anaesthesia with tracheal intubation has adverse nary complications or hospital stay in postoperative lung and effects on the respiratory system. These effects begin with oesophagus surgery patients.23 Silva and colleagues reported that anaesthetic induction and extend into the postoperative period. the addition of deep breathing exercises to physiotherapy-directed General anaesthesia reduces functional residual capacity, with an early mobilisation did not further reduce PPCs, compared with immediate and universal development of atelectasis in the mobilisation alone.24 Mackay and colleagues reported that the dependent regions of the lung.17 Secretion retention may also addition of deep breathing and coughing exercises to a physio- occur and, when it does, it may contribute to the development of therapist-directed program of early mobilisation in high-risk, open postoperative pulmonary complications. The vibrations generated abdominal surgery patients did not significantly reduce the by expiratory flow in the oscillating PEP device are intended to incidence of clinically significant PPCs.25 However, both of these loosen and help the removal of retained airway secretions.18,19 The studies had smaller sample sizes and were single-centre studies. oscillating PEP device used in the present study must be set at a Another study reported no reduction in PPCs from respiratory fixed angle relative to gravity, which is most readily achieved in a physiotherapy in elective pulmonary resection via open thoracot- sitting position.20 The modified device in the present study omy surgical patients, when compared to standard medical/ allowed the participants to use the device effectively in any body nursing care.26 Although the interventions in these studies had position and eliminated any uncomfortable vibration of the teeth. similar aims (eg, improving ventilation and reducing secretion Its transparent design helped the user to find the best position for retention) to the intervention in the present study, the results of maximum vibration and comfort.21 As in previous studies,22 the these studies are different from the present results. However, a device was well tolerated and accepted by the study participants. recent study with a larger sample size found that incentive Adverse events or adverse reactions to the device were not spirometry might be a favourable intervention for patients with a reported spontaneously during the study, nor when participants high risk of developing a PPC – in particular, those with chronic were specifically questioned about this at discharge from hospital. Table 3 Comparison of days of antibiotic therapy, white blood cell count, length of hospital stay, total expense of treatment and days of fever between groups. Characteristics Exp Con Exp – Con (n = 99) (n = 104) Mean difference Length of hospital stay (d) Antibiotic therapy (d) Mean (SD) Mean (SD) (95% CI) White cell count on Day 5 (Â109/L) Total expense of treatment (RMB Â 10 000) 10.7 (7.1) 13.3 (8.7) –2.6 (–4.8 to –0.4) Exp = experimental group, Con = control group. 7.23 (5.93) 8.85 (6.62) 1.61 (–0.13 to 3.36) a n = 96, 7.66 (2.50) a 7.76 (2.87) b 0.09 (–0.67 to 0.86) b n = 100. 2.07 (1.67) 2.44 (1.68) –0.38 (–0.84 to 0.09)
20 Zhang et al: Oscillating PEP after thoracic and abdominal surgery respiratory disease or a history of smoking.27 Scholes and 5. Mans CM, Reeve JC, Elkins MR. Postoperative outcomes following preoperative colleagues3 and Agostini and colleagues28 reported risk factors inspiratory muscle training in patients undergoing cardiothoracic or upper ab- that predicted PPCs, including: duration of anaesthesia, surgical dominal surgery: a systematic review and meta analysis. Clin Rehabil. 2014. http:// category, current smoking, respiratory comorbidity, predicted dx.doi.org/10.1177/0269215514545350. maximal oxygen uptake and a body mass index over 30 kg/m2. This high-risk population may benefit from physiotherapy intervention 6. Gondor M, Nixon PA, Mutich R, Rebovich P, Orenstein DM. Comparison of Flutter to minimise PPCs. device and chest physical therapy in the treatment of cystic fibrosis pulmonary exacerbation. Pediatr Pulmonol. 1999;28:255–260. Currently, in most of the hospitals in China, there is no regular standardised respiratory or physiotherapy care for postoperative 7. Konstan MW, Stern RC, Doershuk CF. Efficacy of the Flutter device for airway mucus patients. The consensus statement29 regarding pulmonary compli- clearance in patients with cystic fibrosis. J Pediatr. 1994;124:689–693. cations after thoracic surgery, which was published in 2009 by the Chinese Association of Thoracic Surgery, did not report the incidence 8. Homnick DN, Anderson K, Marks JH. Comparison of the Flutter device to standard of PPC in China and did not recommend physiotherapy for chest physiotherapy in hospitalized patients with cystic fibrosis. A pilot study. prevention. Given the favourable results from the present study, Chest. 1998;114:993–997. the favourable results in high-risk patients discussed above,25 and evidence that physiotherapist-directed postoperative exercise 9. McIlwaine PM, Wong LTK, Peacock D, Desmard M, Mentec H. Long-term compar- decreases pain and improves shoulder function over usual care ative trial of positive expiratory pressure versus positive expiratory pressure for patients following open thoracotomy, physiotherapists may have (flutter) physiotherapy in the treatment of cystic fibrosis. J Pediatr. 2001;138: the opportunity to gain referrals for patients in this area.16 845–850. From this randomised controlled study, it can be concluded that 10. Wolkove N, Kamel H, Rotaple M, Baltzan Jr MA. Use of a mucus clearance device in developing areas where physiotherapy is not standard, the use enhances the bronchodilator response in patients with stable COPD. Chest. of a modified oscillating PEP device results in fewer cases of fever 2002;121(3):702–707. and reduced length of hospital stay in thoracic and upper abdominal postoperative adult patients. 11. Mador MJ, Deniz O, Aggarwal A, Shaffer M, Kufel TJ, Spengler CM. Effect of respiratory muscle endurance training in patients with COPD undergoing pulmo- Footnotes:aFlutter1 VRP1, Tyco Healthcare, Germany. nary rehabilitation. Chest. 2005;128(3):1216–1224. eAddenda: Table 4 can be found online at doi:10.1016/ j.jphys.2014.11.013. 12. Girard JP, Terki N. The flutter VRP1: a new personal pocket therapeutic device used Ethics approval: The Shanghai Tenth People’s Hospital Ethics as an adjunct to drug therapy in the management of bronchial asthma. J Investig Committees approved this study. All participants gave written Allergol Clin Immunol. 1994;4:23–27. informed consent before data collection began. Competing interests: None declared. 13. Burioka N, Sugimoto Y, Suyama H, Hori S, Chikumi H, Sasaki T. Clinical efficacy of Sources of support: This study was supported by Shanghai the Flutter device for airway mucus clearance in patients with diffuse panbronch- Hospital Development Center; grant number SHDC12007211. iolitis. Respirol. 1998;3:183–186. Acknowledgments: We thank the study participants. We thank Mingsong Wang, Yiling Wang and Liangxu Wang (Shanghai Tenth 14. Thompson CS, Harrison S, Ashley J, Hori S, Chikumi H, Sasaki T. Randomised People’s Hospital), Wenqiang Jin and Lu Han (Shanghai Jiangong crossover study of the Flutter device and the active cycle of breathing technique Hospital), and Zhiqiang Guo (Shanghai Putuo District Center in non-cystic fibrosis bronchiectasis. Thorax. 2002;57(5):446–448. Hospital) for their assistance with identifying eligible patients. We also thank Jue Li, Liling Zou, Jianfeng Xiu (Tongji University School 15. Ambrosino N, Callgari G, Galloni C, Brega S, Pinna G. Clinical evaluation of of Medicine) for their help with statistical analysis. oscillating positive expiratory pressure for enhancing expectoration in diseases Correspondence: Xiangyu Zhang, Department of Critical Care other than cystic fibrosis. Monaldi Arch Chest Dis. 1995;50:269–275. Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China. Email: [email protected] 16. Reeve J, Stiller K, Nicol K, McPherson KM, Birch P, Gordon IR, et al. A postoperative Contributions: All authors contributed equally to this study. shoulder exercise program improves function and decreases pain following open thoracotomy: a randomised trial. J Physiother. 2010;56:245–252. References 17. Canet J, Mazo V. Postoperative pulmonary complications. Minerva Anestesiol. 1. Shander A, Fleisher LA, Barie PS, Bigatello LM, Sladen RN, Watson CB. Clinical and 2010;76:138–143. economic burden of postoperative pulmonary complications: Patient safety sum- mit on definition, risk-reducing interventions, and preventive strategies. Crit Care 18. Newbold ME, Tullis E, Corey M, Ross B, Brooks D. The flutter device versus the PEP Med. 2011;39(9):2163–2172. mask in the treatment of adults with cystic fibrosis. Physiotherapy Canada. 2005;57:199–207. 2. Haines KJ, Skinner EH, Berney S. Austin Health POST Study Investigators. Associa- tion of postoperative pulmonary complications with delayed mobilisation follow- 19. Alves LA, Pitta F, Brunetto AF. Performance analysis of the Flutter VRP1 under ing major abdominal surgery: an observational cohort study. Physiotherapy. different flows and angles. Respir Care. 2008;53(3):311–333. 2013;99(2):119–125. 20. Wolkove N, Baltzan Jr MA, Kamel H, Rotaple M. A randomized trial to evaluate the 3. Scholes RL, Browning L, Sztendur EM, Denehy L. Duration of anaesthesia, type of sustained efficacy of a mucus clearance device in ambulatory patients with chronic surgery, respiratory co-morbidity, predicted VO2max and smoking predict post- obstructive pulmonary disease. Can Respir J. 2004;11(8):567–572. operative pulmonary complications after upper abdominal surgery: an observa- tional study. Aust J Physiother. 2009;55:191–198. 21. Wang QX, Zhang XY, Li Q. 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Journal of Physiotherapy 61 (2015) 43 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Critically Appraised Papers The use of positive expiratory pressure therapy does not appear to be effective in people hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) Synopsis Summary of: Osadnik CR, McDonald CF, Miller BR, Hill CJ, Tarrant B, self-reported symptom severity, measured using the Breathlessness, Cough Steward R, et al. The effect of positive expiratory pressure (PEP) therapy on and Sputum Scale at hospital discharge, 8 weeks, and 6 months following symptoms, quality of life and incidence of re-exacerbation in patients with discharge. Other outcomes included: functional limitation due to dyspnoea, acute exacerbations of chronic obstructive pulmonary disease: a multi- health-related quality of life, the need for ventilatory assistance, length of centre, randomised controlled trial. Thorax 2014;69:137-143. hospital stay and the number of acute exacerbations over the first 6 months following discharge. Results: A total of 88 participants completed the study. Question: In people who are hospitalised with an acute exacerbation of There were no between-group differences in the Breathlessness, Cough and chronic obstructive pulmonary disease (AECOPD), does the addition of Sputum Scale at hospital discharge (0.2 units, 95% CI –0.9 to 1.4), or at any positive expiratory pressure (PEP) therapy to usual medical care improve other time point. Those in the intervention group had less functional symptoms and reduce the incidence of future exacerbations? Design: Multi- limitation due to dyspnoea 8 weeks following discharge (between-group centre, randomised, controlled trial with concealed allocation and blinding of difference –0.4 units, 95% CI –0.5 to –0.3), but this was not maintained at outcome assessors. Setting: Two public tertiary hospitals in Melbourne, 6 months following discharge. There were no between-group differences in Australia. Participants: Adults who were hospitalised with AECOPD were the other outcomes at any time point. Conclusion: In people who are included if they had a history of chronic sputum production and were within hospitalised with AECOPD and are characterised by chronic sputum 48 hours of admission. Exclusion criteria were: a history of a chronic lung production, PEP therapy may produce a short-term reduction in functional condition more significant than their COPD, established airway clearance limitation due to dyspnoea, but not affect symptoms, health-related quality of routines, the need for an artificial airway, or a contraindication to PEP therapy. life, the need for ventilatory assistance, length of hospital stay or the future Randomisation allocated 46 people each to the intervention and control incidence of acute exacerbations. groups. Interventions: Participants in both groups received usual medical care in accordance with COPD-X guidelines and a standard exercise-training Kylie Hill program. Those in the intervention group performed additional PEP therapy School of Physiotherapy and Exercise Science, Curtin University via a facemask, in an upright position, three times a day (one session was supervised). During each session, the participants took 8 to 10 tidal volume http://dx.doi.org/10.1016/j.jphys.2014.11.009 breaths and used a slightly active expiration to achieve an expiratory pressure of 10 to 20 cmH2O, followed by one huff at low-lung volume, one huff from mid-lung volume and two strong coughs. This sequence was repeated five times each session. Outcome measures: The primary outcome was ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved. [3_TD$IF]4Commentary those who have significant bronchiectasis and, during an exacerbation, this group is likely to benefit from airway clearance techniques. Despite the limited evidence supporting their routine use,1 Australian physiotherapists use a variety of airway clearance techniques to treat These findings indicate that airway clearance techniques, in particular patients during acute exacerbations of chronic obstructive pulmonary PEP, should not be included as part of routine physiotherapy care for people disease (AECOPD).2 This lack of evidence calls for further clinical trials, as who are hospitalised with AECOPD. Given the benefits of exercise training in performing airway clearance techniques is time consuming and costly, if this clinical population,3 an alternative for people who experience difficulty purchasing devices. in clearing airway secretions may be huffing intermittently during exercise, which itself increases tidal volume and expiratory flow. The multi-centre, randomised, controlled trial by Osadnik et al investigated the effects of positive expiratory pressure (PEP) therapy during Jamie Wood AECOPD. This technique was chosen based on the theory that resistance DF_][ID1$T epartment of Physiotherapy, Sir Charles Gairdner Hospital, during expiration prevents dynamic airway collapse, moves the equal pressure point peripherally, and may reduce dynamic hyperinflation and Perth, Western Australia dyspnoea. References Choosing outcome measures for an airway clearance technique study can be difficult. The primary outcome measure used in this trial was the 1. Ides K, et al. COPD. 2011;8:196–205. Breathlessness, Cough and Sputum Scale, which is clinically relevant as these 2. Osadnik C, et al. Physiotherapy. 2013;99:101–106. symptoms impact on the daily life of those with COPD. Using expectorated 3. Puhan MA, et al. Cochrane Database Syst Rev. 2011;5:CD005305. sputum as an outcome measure has flaws and therefore was not included. The effect of PEP on health-related quality of life and healthcare utilisation was http://dx.doi.org/10.1016/j.jphys.2014.11.011 also investigated. This high-quality and adequately powered trial found that the addition of PEP to usual care conferred no short-term or long-term benefits to the person or healthcare service. It is worth noting that this trial excluded 1836-9553/Crown Copyright ß 2014 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. All rights reserved.
Journal of Physiotherapy 61 (2015) 47 Journal of PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys Appraisal Clinimetrics Timed Up and Go test in musculoskeletal conditions Summary with a low standard error of measurement (SEM), 0.84 seconds, in people with hip OA.3 It has moderate test-retest reliability (ICC2,1 Description: The Timed Up and Go test (TUG)1 is a short and 0.75, 95% CI 0.51 to 0.98), a SEM of 1.07 seconds (95% CI 0.86 to simple performance-based test that was originally developed for frail, elderly people, but is now also recommended for musculo- 1.41) and a minimally detectable change (MDC90) of 2.5 seconds, in skeletal conditions, such as hip and knee osteoarthritis (OA) and people with end-stage hip and knee OA when tested over a long lower back pain (LBP). interval (median 178 days).4 Larger MDC95 have been found for people with knee OA (36.7%) and hip OA (45%).5 In people with LBP, The TUG has most commonly been used as an outcome measure following therapy or surgery, but has also been used to predict falls the test has high day-to-day stability, ICC1,1 0.98, and a low SEM of and function. The Osteoarthritis Research Society International 0.99 seconds. has endorsed it as an outcome measure for people with hip and/or knee OA. Validity, responsiveness and interpretability: In people with The TUG is a transition test that assesses strength, agility and hip OA, a TUG > 10 seconds was predictive of being at risk of dynamic balance during multiple activities including sit-to-stand, falling (OR 3.1, 95% CI 1.0 to 9.9).6 A TUG 10.1 seconds was walking short distances and changing direction whilst walking. The predictive of reduced physical function performance at 6 months TUG measures (in seconds) the time taken to stand up from a following knee replacement.7 The test was responsive in detecting standard arm chair (approximate seat height of 46 cm, arm height of 65 cm), walk a distance of 3 m, turn around, walk back to the chair initial deterioration (standard response mean [SRM] –1.08, 95% CI and sit down. Regular footwear is worn, a walking aid can be used if required, but no physical assistance is provided. A practice trial is –1.38 to 0.92) and then subsequent improvement (SRM 1.04, 95% recommended and the better of the two trials is scored. A test description, along with scoring instructions and normal age values CI 0.84 to 1.61) in the early postoperative period following hip or are freely available on the Internet (eg, www.oarsi.org/research/ knee joint replacement.4 Lower responsiveness was found physical-performance-measures). Most healthy people up to the age of 80 are able to perform the TUG in 10 seconds or less.2 following physiotherapy in people with knee OA (SRM 0.35, median change score 1 second)8 and hip OA (area under the curve Reliability and measurement error: The TUG has high inter- 0.69, 95% CI 0.48 to 0.90, mean change score 0.8 seconds).3 rater reliability (ICC2,1 0.87, 95% CI 0.63, 0.91), which is associated Following nine physiotherapist-guided exercise sessions, a Commentary minimal, clinically important improvement (MCII) of 0.8 to 1.4 seconds was reported for people with hip OA (mean age 66.5, SD 9.4 years).3 The TUG test is quick, easy to administer without special Knowledge of MCII is limited in musculoskeletal conditions and training and can be used in most environmental contexts. requires further investigation for different interventions and Although a cut-off score of 10 seconds appears to be predictive contexts. In everyday clinical practice, it is recommended that of risk of falling in older people with hip OA, it does not the TUG is used in conjunction with other performance-based tests discriminate well between fallers and non-fallers. Further, a rather than a stand-alone outcome measure or diagnostic test. recent meta-analysis in community dwelling older adults9 showed that the TUG was more useful for ruling in falls (specificity Acknowledgement: This work was funded by the National 0.74, 95% CI 0.52 to 0.88) than ruling out falls (sensitivity 0.31, 95% Health and Medical Research Council (Program Grant #631717). CI 0.13 to 0.57). Therefore, the TUG appears to act as a better ‘confirming test’ than a ‘screening test’ and should not be used in Fiona Dobson isolation when screening for falls. Department of Physiotherapy, The University of Melbourne, Australia As the TUG incorporates different subcomponents that repre- sent different functioning constructs, the total timed score limits References interpretation about the proportional contribution of these subcomponents on activity limitation. Floor effects may limit 1. Podsiadlo D, et al. J Am Geriatr Soc. 1991;39:142–148. the use of the TUG directly following joint replacement surgery, 2. Shumway-Cook A, et al. Phys Ther. 2000;80:896–903. and ceiling effects may limit its use in younger patients with 3. Wright AA, et al. J Orthop Sports Phys Ther. 2011;41:319–327. musculoskeletal conditions. In people with musculoskeletal 4. Kennedy DM, et al. BMC Musculoskelet Disord. 2005;6:3. conditions, the TUG has a capacity to detect real change above 5. Naylor JM, et al. BMC Musculoskelet Disord. 2014;15:235. measurement error. In hip and knee OA, it is responsive following 6. Arnold CM, et al. BMC Geriatr. 2007;7:17. joint replacement surgery and, to a lesser degree, rehabilitation. 7. Bade MJ, et al. J Orthop Res. 2012;30:1805–1810. 8. French HP, et al. Physiotherapy. 2011;97:302–308. 9. Barry E, et al. BMC Geriatr. 2014;14:14. http://dx.doi.org/10.1016/j.jphys.2014.11.003 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
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