Blennerhassett et al: Risk factors for shoulder pain after stroke of staff, carers, and patients in how to care for the arm of Australian Physiotherapy Association 7th International are also warranted (Nicks et al 2007, Turner-Stokes and Congress. Sydney, p 80. Jackson 2002), given the vulnerability of a weak shoulder and the events described that may have contributed to the Blennerhassett JM, Lythgo N, Muir C, Galea M (2009) development of shoulder pain. Dynamic 3-dimensional shoulder motion in people with stroke. Proceedings of Australian Physiotherapy Association The sample was representative of stroke patients who Conference week, National Neurology Group. Sydney. undertake rehabilitation in a public setting. The histories Australian Journal of Physiotherapy 55(4): eSupplement, p 5. were randomly selected, and comprised a broad cross- section of patients, including those with moderate to severe 9Whh @>\" I^[f^[hZ H8\" DehZ^ebc B\" Bodd[ : '/.+ cognitive and communication deficits who are often under- Investigation of a new Motor Assessment Scale for stroke represented in the literature (Macrae and Douglas 2008). patients. Physical Therapy 65: 175–180. Our findings may therefore be generalised to similar cohorts with due considerations to the study’s limitations. Carr JH, Shepherd RB (1998) The upper motor neuron The study was a retrospective audit that relied on clinical syndrome. In Carr JH, Shepherd RB (Eds) Neurological documentation. However, compliance with documentation Rehabilitation: Optimizing motor performance. Edinburgh: was found to be good, and the assessments were conducted Butterworth Heinemann, pp 185–204. in a standardised manner by trained therapists. It was likely that the broad approach taken to audit each history captured Chae J, Mascarenhas D, Yu D, Kirsteins A, Elovic E, Flanagan the majority of complaints of shoulder pain. For instance, S, Harvey R, Zorowitz R, Fang Z (2007) Poststroke shoulder the notes covered the 24-hour period and were written by pain: its relationship to motor impairment, activity limitation, staff who worked closely with each patient doing tasks and quality of life. Archives of Physical Medicine and requiring shoulder function. Nevertheless, the audit did Rehabilitation 88: 298–301. not collate important aspects such as severity and nature of shoulder pain, nor did it attempt to evaluate management Dontalelli R (2004) Functional anatomy and mechanics. In processes or treatment outcome. The observational study Dontalelli R (Ed) Physical therapy of the shoulder. St Louis, supports that post-stroke shoulder pain is common, and Missouri: Churchill Livingstone, pp 11–28. more likely to occur in patients who have stiff and weak shoulders. Q Dromerick AW, Edwards D, Kumar A (2008) Hemiplegic shoulder pain syndrome: frequency and characteristics Ethics: The study was approved by the Human Research during inpatient stroke rehabilitation. Archives of Physical and Ethics Committee at Austin Health (No H2008/03389). Medicine and Rehabilitation 89: 1589–1593. Acknowledgements: We are grateful to Associate Professor Lingdgren I, Jonsson A, Norrving B, Lindgren A (2007) Leonid Churilov from the National Stroke Research Institute Shoulder pain after stroke: a prospective population–based for statistical advice and guidance; to physiotherapists study. Stroke 38: 343–348. and occupational therapists from the neurology units at Austin Health-Royal Talbot Rehabilitation Centre, and to Lo S, Chen S, Lin H, Jim Y, Meng N, Kao M (2003) Arthrographic undergraduate physiotherapists undertaking a professional and clinical findings in patients with hemiplegic shoulder development elective from the University of Melbourne pain. Archives of Physical Medicine and Rehabilitation 84: who assisted with data collection and management for the 1786–1791. project; and the Health Information Management staff for supporting this project. Ludewig P, Reynolds J (2009) The association of scapular kinematics and glenohumeral joint pathologies. Journal of Correspondence: Dr Jannette Blennerhassett, Physiotherapy Orthopaedic and Sports Physical Therapy 39:90–104. Department, Austin Health: Royal Talbot Rehabilitation Centre, 1 arra Blvd. Kew, Victoria 3101, Australia. Email. Macrae M, Douglas J (2008) Communication Outcome 12 Email: Jannette.Blennerhassett austin.org.au Months Following Left Hemisphere Stroke in the Elderly. Brain Impairment 9: 170–178. References Nicks RJ, DeGruyter MA, Walkenhorst-Maccanti H, Bernhardt Bender L, McKenna K (2001) Hemiplegic shoulder pain: J (2007) Changing practice for acute hemiplegic shoulder defining the problem and its management. Disability and care: a best practice model. International Journal of Therapy Rehabilitation 23: 698–705. and Rehabilitation 14: 266–273. Bernhardt J, Griffin A (2002) A best practice guide for Price C (2002) Shoulder pain after stroke: a research challenge. management of the hemiplegic upper limb. Proceedings Age and Ageing 3: 36–38. Ratnasabapathy Y, Broad J, Baskett J, Pledger M, Marshall J, Bonita R (2003) Shoulder pain in people with a stroke: a population–based study. Clinical Rehabilitation 17: 304–311. Snels I, van der Lee J, Lankhorst G, Beckerman H, Bouer L (2002) Treating patients with hemiplegic shoulder pain. American Journal of Physical Medicine and Rehabilitation 81: 150–160. Tabachnick B, Fiddell LS (2001) Using Multivariate Statistics. Allyn and Bacon, Boston Turner-Stokes L, Jackson D (2002) Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway. Clinical Rehabilitation 16: 276– 298. Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010 199
Appraisal Correspondence Rethink the effect of resistance training on six-minute walk distance? The utilisation of resistance training in patients with chronic the respective control and experimental groups similar heart failure is an area of great interest and potential. In at baseline and the assessor measuring outcomes was not their recent systematic review, Hwang et al (2010) provide blinded to group allocation in one of the studies. However, a clear argument supporting the hypothesis that resistance Hwang et al state that therefore some firm evidence’ exists training could improve peripheral muscle strength and for improvements in six-minute walk distance following ultimately functional capacity in people with chronic resistance exercise training. heart failure. Their review reports the meta-analysis of randomised controlled trials; however, both the title and There is also a suggestion that participants included in the primary conclusion should be considered with caution. review were particularly sick patients with heart failure and yet they are able to perform resistance training at intensive The authors are to be commended on the presentation of levels. Further, this suggestion is clouded by the apparent their methodology and for rating the quality of included discrepancies in how chronic heart failure was defined in trials using the PEDro scale (Maher et al 2003). However, both the manuscript and at least some of the studies (ie, all systematic reviews are limited by the quality of the studies they include and this is particularly relevant here. 40% or 45%). It is well documented that poorly conducted randomised controlled trials may yield misleading results. Results In summary, the findings reported by Hwang et al (2010) suggest a clinically important and statistically significant are of interest and are hypothesis-generating rather than 30–50% exaggeration of treatment efficacy when results of confirmatory. Readers should be cautious not to over- studies of low methodological quality are pooled (Moher et interpret the title of the paper and the lead conclusion. As al 1999). While Hwang et al report the quality of included is the case with all systematic reviews, the findings are trials using PEDro scores, they appear not to have taken the limited by the quality of the included trials. In this case, the next step and interpreted the meta-analysis in the context of included trials are not of particularly high quality or large these quality ratings. Although heterogeneity is mentioned, size and hence the results should be considered within the its consideration in having combined the studies should be context of the heterogeneity and quality of trials. We agree detailed, as should the quality of the studies excluded from that further large-scale controlled trials with high quality analysis. Thus, readers should be circumspect about their designs are needed. interpretation of results reported by Hwang et al. Julie Redfern Specifically, the title and conclusion of the paper selectively The George Institute for International Health, and highlight one of multiple primary outcome measures, that being the only significant finding of the review. A more Faculty of Medicine, The University of Sydney plausible conclusion would be that resistance training may improve six-minute walk distance and at best their findings Tom Briffa are hypothesis-generating. In fact, the title of the paper is University of Western Australia focussed on the meta-analysis of only two studies and one of these only scored 5 out of a possible 10 for quality, which References raises some concern. These same two studies of six-minute walk distance after resistance training included a combined Hwang CL, et al (2010) Journal of Physiotherapy 56: 87–96. total of only 24 patients in their experimental groups. Neither study used concealed group allocation, nor were Maher CG, et al (2003) Physical Therapy 83: 713–712. Moher D, et al (1998) Lancet 352: 609–613. Moher D, et al (1999) Health Technology Assessment 3: 1–98. 206 Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010
Appraisal Clinical Practice Guidelines Juvenile idiopathic arthritis Clinical guideline for the diagnosis and management of juvenile idiopathic arthritis Latest update: August 2009. Date of next update: 2014. Description: This is a 43-page document that presents Patient group: Patients aged under 16 years presenting recommendations to assist with the early diagnosis and with arthritic symptoms and those diagnosed with multidisciplinary management of JIA in the primary care Juvenile idiopathic arthritis (JIA). Intended audience: setting. The guideline focuses on evidence underpinning Health professionals (general practitioners and allied four main areas: the diagnosis of JIA, treatment and health including physiotherapy) in the primary health care management of JIA in the early stage, during acute episodes, setting. Additional versions: Nil. Expert working group: and the long term management of JIA. It covers issues such Two working groups were involved: the Royal Australian as early and accurate diagnosis, care and referral pathways, College of General Practitioners (RACGP) Juvenile use of medications, non-pharmacological management Idiopathic Arthritis Working Group consisted of 8 health including evidence for land and water exercise, patient care professionals (representing medicine, nursing, public self-management education, and psychosocial support health, and physiotherapy) and a consumer representative. requirements. Two detailed algorithms are presented on The Australian Paediatric Rheumatology Working Group pages 8 and 9, covering the diagnosis and early management consisted of 7 medical fellows. Funded by: RACGP of JIA, and the management of JIA. A summary of the and the Australian Department of Health and Ageing. 21 recommendations is presented on pages 10–11, with Consultation with: Draft versions of the guidelines were more detailed explanation of the recommendation level available on the RACGP website for public consultation, and specific evidence contained in pages 12–24. Three and over 200 stakeholder groups were targeted specifically. pages of resources are provided on pages 35–37 including Approved by: National Health and Medical Research publications, electronic sources (websites), and a history and Council of Australia, RACGP. Location: http://www.racgp. clinical examination checklist to assist with examination org.au/guidelines/juvenileidiopathicarthritis and differential diagnosis. Sandra Brauer The University of Queensland The COPD-X plan \"VTUSBMJBOBOE/FX;FBMBOEHVJEFMJOFTGPSUIFNBOBHFNFOUPGDISPOJDPCTUSVDUJWF pulmonary disease Latest update: May 2010. Date of next update: 2014. Description: The .pdf version is a 71-page document that Patient group: Individuals with chronic obstructive presents recommendations and the underlying evidence pulmonary disease (COPD). Intended audience: Health to assist with the diagnosis and management of patients professionals who manage patients with COPD. Additional with COPD. The key recommendations are summarised versions: This is the first update to the guidelines. The on page 10 in the COPD- plan: Confirm diagnosis, original guidelines were published in the Medical Journal Optimise function, Prevent deterioration, Develop a self- of Australia in 2003. (http://www.mja.com.au/public/ management plan, and manage eXacerbations. Information issues/178 06 170303/tho10508 all.html). Expert working is presented on the aetiology and natural history of COPD, group: The guidelines were developed by the Australian the role of history, physical examination, and spirometry Lung Foundation and the Thoracic Society of Australia in diagnosis, methods to assess severity, and indicators and New ealand. The guidelines evaluation committee for referral to specialist respiratory care. The evidence consisted of 8 Australian health professionals representing for the efficacy of medication and non-pharmacological medicine, public health, and physiotherapy. A larger group approaches to optimise function is discussed, including of 27 experts from Australia and New ealand including exercise, education and self management, pulmonary physiotherapists also contributed. Funded by: Australian rehabilitation, chest physiotherapy, psychosocial support, Lung Foundation. Consultation with: Draft versions of and nutrition. Likely co-morbidities and their management the guidelines were available on the RACGP website for are presented, and surgical options and palliative care public consultation and over 200 stakeholder groups were are discussed. Evidence and approaches for the reduction specifically targeted. Approved by: The Royal Australian of risk factors such as smoking cessation, medication, College of Physicians, The Royal College of Nursing vaccination, and oxygen therapy are presented. The section Australia, the Australian Physiotherapy Association, on self management promotes a multidisciplinary team Australian Asthma and Respiratory Educators Association, approach. Evidence underpinning the management of and the Asthma Foundation. Location: The website (http:// acute exacerbations is presented. This includes guidelines www.copdx.org.au/home) contains the guidelines spread to confirm the exacerbation and categorise its severity, over pages on the site, as well as a .pdf version. pharmacological and non-pharmacological interventions, indicators for hospitalisation or ventilation, and discharge planning. Appendices provide information on inhaler devices, and long-term oxygen therapy. Sandra Brauer The University of Queensland Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010 205
Appraisal Clinimetrics The Depression Anxiety Stress Scale (DASS) Description 3.0 is considered severe, and z-scores ®3 are considered to be extremely severe depression/anxiety/stress. Although it The DASS is a 42-item self-administered questionnaire has been suggested that a composite measure of negative designed to measure the magnitude of three negative mood can be obtained by taking a mean of the 3 subscales, emotional states: depression, anxiety, and stress. The DASS- interpretation of this score is problematic as normative data Depression focuses on reports of low mood, motivation, or cut-off scores are not currently available. and self-esteem, DASS-anxiety on physiological arousal, perceived panic, and fear, and DASS-stress on tension and Clinimetrics: Internal consistency for each of the subscales irritability. of the 42-item and the 21-item versions of the questionnaire are typically high (eg Cronbach’s α of 0.96 to 0.97 for DASS- Instructions to client and scoring: A respondent indicates Depression, 0.84 to 0.92 for DASS-Anxiety, and 0.90 to 0.95 on a 4-point scale the extent to which each of 42 statements for DASS-Stress (Lovibond 1995, Brown et al 1997, Antony applied over the past week. A printed overlay is used to et al 1998, Clara 2001, Page 2007). There is good evidence obtain total scores for each subscale. Higher scores on each that the scales are stable over time (Brown et al 1997) and subscale indicate increasing severity of depression, anxiety, responsive to treatment directed at mood problems (Ng or stress. Completion takes 10 to 20 minutes. A shorter, 2007). Evidence has been found for construct (Lovibond 21-item version of the DASS (DASS-21), which takes 5 to 1995) and convergent (Crawford and Henry 2003) validity 10 minutes to complete, is also available. Subscale scores for the anxiety and depression subscales of both the long from the shorter questionnaire are converted to the DASS and short versions of the DASS. The clinimetric properties normative data by multiplying the total scores by 2. of the questionnaire have been examined in general and clinical populations Including chronic pain (Taylor 2005), Individual patient scores on the DASS subscales can be post myocardial infarction (Lovibond 1995), psychiatric in- interpreted by converting them to z-scores and comparing patients (Ng 2007) and out-patients (Lovibond 1995). to the normative values contained within the DASS manual. A z-score 0.5 is considered to be within the normal range, obtained from large, relatively heterogenous samples. On a z-score of 0.5 to 1.0 is mild, 1.0 to 2.0 is moderate, 2.0 to this basis, an individual severity rating reflects how far scores are positioned from these population means; the Commentary further away the score is from the population mean, the more severe the symptoms. If DASS scores suggest that a Patients who present for physiotherapy care may also have patient has significant symptoms of depression, anxiety, or low or disturbed mood, particularly clinically relevant stress, then referral to a qualified colleague with experience symptoms of depression and anxiety. Co-morbid mood in managing mood disturbance is required. disturbance is likely to influence patients’ symptoms (including reporting of symptoms), complicate management, For more information on the DASS the developers have and slow recovery from the primary presenting condition. provided a comprehensive FA section on their web Accurate evaluation of mood is therefore an essential page, along with an overview and link to download the element of a comprehensive physiotherapy assessment. The questionnaire. application of a valid questionnaire is likely to assist with evaluating mood disturbance and will reduce the likelihood Luke Parkitny, James McAuley of the clinician failing to recognise these problems Neuroscience Research Australia (NeuRA), Randwick, (Haggman 2004). Australia A variety of questionnaires assess mood disturbance but many contain somatic items (eg sleep problems, loss of References appetite), which are likely to reflect the patient’s presenting condition rather than any mood disturbance. The DASS Antony MM et al (1998) Psychol Assess 10: 176–181. was developed with somatic items excluded to address this problem specifically. It is therefore likely to provide Brown TA, et al (1997) Behav Res Ther 35: 79–89. clinicians with an accurate assessment of their patient’s symptoms of depression, anxiety and stress. Clara I et al (2001) J Psychopathol Behav Asses 23: 61–67. The DASS has excellent clinimetric properties and few Crawford JR, Henry JD (2003) Brit J Clin Psych 42: 111–131. limitations, however clinicians should be aware that certain patient groups (eg children, the developmentally Haggman S et al (2004) Phys Ther 84: 1157–1166. delayed, or those who are taking certain medications) may have difficulty understanding the questionnaire items or Lovibond PF, Lovibond SH (1995) Manual for the Depression responding to them in an unbiased manner. For non-English Anxiety Stress Scales 2nd ed. Sydney, Psychology speaking patients over 25 translations of the DASS are Foundation. available. Ng F et al (2007) Acta Neuropsychiatr 19: 304–310. Finally, we caution against using the DASS scores to independently diagnose discrete mood disorders such as Page AC, et al (2007) Brit J Clin Psych 46: 283–297. depression. The DASS is not intended to replace a complete psychological assessment. It is important to remember that Taylor et al (2005) Clin J Pain 21: 91–100. DASS severity ratings are based on mean population scores Website mmm($fio$kdim$[Zk$Wk%]hekfi%ZWii 204 Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010
Editorial The importance of health literacy in physiotherapy practice Andrew M Briggs and Joanne E Jordan Curtin University, Western Australia Physiotherapy practice is changing rapidly, with greater others encompass broader attributes such as conceptual leadership opportunities and recognition of physiotherapy and cultural knowledge, and social skills. Increasingly, across healthcare sectors. For example, physiotherapists health literacy is recognised as a complex multidimensional increasingly hold leadership roles in management of concept that involves interaction between patient abilities chronic disease and other inter-professional teams, engage and broader social, environmental, and healthcare factors in extended scope of practice duties, perform triage roles (Jordan 2010a). in tertiary centre clinics and emergency departments, have the opportunity to progress to clinical specialisation, and Why is health literacy important in healthcare? lead prestigious research programs. Such professional advances bring greater responsibilities in providing health Low health literacy has been linked to poor health information. Indeed, continued recognition as important behaviours and outcomes, independent of other socio- and highly skilled health professionals demands that we demographic factors (DeWalt et al 2004). It is therefore deliver reliable and accurate health information to our recognised as an important public health issue both in patients and stakeholders so that they can make informed Australia and internationally. For example, a recent report decisions about their healthcare. concluded that low health literacy skills increased national annual healthcare expenditures by –US73 billion (USA Critical elements of a patient-centred healthcare National Academy on an Aging Society 1999). approach Several reviews have highlighted the relationship between Effective information exchange is particularly important in low health literacy and poorer health behaviours and physiotherapy practice since this constitutes a fundamental outcomes (Box 1) (DeWalt et al 2004, Paasche-Orlow et al component of most patient-practitioner encounters (Liddle 2005). Baker et al (1998) examined the association between et al 2009), particularly in the context of self-management. low health literacy and the likelihood of admission to In order to do this effectively, we must consider how this hospital in a prospective cohort study of patients presenting information is made available and the manner in which it is to an urban emergency department. Patients with low health delivered, and ultimately understood. As the requirement for literacy were more likely than patients with adequate health self-management in healthcare is increasingly emphasised, literacy to be hospitalised. Low health literacy has also been especially in the management of chronic conditions, patients associated with less utilisation of preventive healthcare are asked to assume greater responsibility in: services. For example, in a study of people aged 65 years and older, those with low health literacy were more likely to handling diverse information resources such as report never having received an influenza or pneumococcal educational materials, prescriptions and medical vaccination (Scott et al 2002). Low health literacy has forms; also been associated with poor adherence to prescribed medication (Chew et al 2004) and poorer chronic condition navigating different healthcare settings; self-management skills (Schillinger et al 2002). In a hospital-based study of patients with type 2 diabetes, those communicating with a range of health professionals with low health literacy were twice as likely to have poor who will have different experiences and approaches glycosylated haemoglobin (HbA1c) control, after adjusting in how they deliver therapeutic instructions or advice; for potential confounders (Schillinger et al 2002). and #PY. Health behaviours and outcomes associated with making informed decisions about their healthcare suboptimal health literacy. including adhering to prescribed therapeutic regimens and implementing lifestyle changes to optimise health. To undertake these tasks effectively, patients require a basic Reduced health-related knowledge set of skills which enable them to seek, understand, and Poor self-management skills utilise health information, a concept referred to as health Poor communication between healthcare literacy (USA Department of Health and Human Services 2000). This editorial outlines the importance and relevance professionals and patients of health literacy to physiotherapy practice and potential ways to optimise the exchange of information during the Non-adherence to medication physiotherapist-patient encounter. Lower self-reported health status Reduced use of preventive healthcare services What is health literacy? Increased risk of hospitalisation Increased healthcare costs Myriad definitions of healthy literacy exist, leading to debate as to what health literacy represents and how it should be Collectively, these studies indicate that health information is measured. However, across definitions there is a consistent a critical factor in shaping individual health behaviours and theme that patients require a distinct set of abilities to seek, understand, and use health information. Some definitions focus on literacy and numeracy skills, while Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010 149
Editorial outcomes; they provide strong evidence that the inability information being delivered to them. An individual’s ability to seek, understand, and use health information directly to seek, understand, and utilise health information is greatly influences an individual’s health management. They also influenced by broad social, environmental and healthcare highlight the importance of the role health professionals play factors (Briggs et al 2010, Jordan 2010a). Although clinicians in ensuring effective delivery and uptake of information, definitely play an important role in enhancing a patient’s particularly when the information is directed towards a health literacy, they need to realise and accept the part patient-centred management approach to a long-term health played by these other factors in modifying the outcome, and condition. For example, in a recent study examining health work within these constraints. Evidence about interventions literacy among patients with chronic low back pain, we to improve the health behaviours and outcomes of patients identified that although physiotherapists were considered with suboptimal health literacy is slowly emerging (DeWalt to be principal providers and specialists’ in information 2007). To date there have been three main approaches: related to low back pain, their use of biomedical terminology and limited range of methods used to deliver information 1. Improving the readability and comprehension of were identified as key barriers to patients’ understanding written health materials. (Briggs et al 2010). Other studies also highlight that patients’ understanding of biomedical terminology is limited (Lerner 2. Utilising multi-media forms or different techniques to et al 2000), especially with respect to anatomic terms enhance patient-health professional communication. (Weinman et al 2009), which clearly has implications for physiotherapy practice. Further, we identified that barriers 3. Training and education of health professionals to to patients utilising back pain information provided by assist them to effectively manage individuals with clinicians included competing lifestyle commitments, suboptimal health literacy. socioeconomic circumstances, and prescribed treatment not being consistent with their attitudes or beliefs. These Notably, these approaches are consistent with barriers to understanding and utilising health information recommendations in the Models of Care developed for represent important considerations for physiotherapists various health conditions in Western Australia (http://www. in clinical practice who anticipate that patients will both healthnetworks.health.wa.gov.au/modelsofcare/). Clinical understand and utilise information provided. studies evaluating different training and communication strategies demonstrate promising results – increasing Are clinicians health literate? health professionals’ awareness and ability to enhance patient health literacy. For example, a communication Given the increasing relevance of health literacy to primary method shown to be highly effective is the teach back’ care practice and patient health behaviours and outcomes, method. This involves the health professional, after initially it may be timely for health practitioners to consider (i) their providing verbal information, asking the patient to reiterate own health literacy, particularly in the context of evidence- the information in their own words. This strategy provides based care and utilisation of clinical guidelines, and (ii) an opportunity to clarify understanding and confirm recall ways to optimise their ability to assist patients to understand of the patient (DeWalt 2007). A study conducted in a and utilise health information. diabetes clinic reported that when the teach back’ strategy was used in consultations, patients were eight times more Recent evidence suggests that many practitioners fail likely to have better controlled HbA1c levels compared to to apply evidence-based care consistently or to utilise patients whose health professional had not used the strategy clinical guidelines. This has been demonstrated recently (Schillinger et al 2003). Health communication training in the context of low back pain (Williams et al 2010) and has also been shown to be effective in managing patients reinforced by surveys highlighting that many clinicians still with low health literacy. In a randomised trial of health rely on a biomedical model of low back pain aetiology and communication training delivered to general practitioners advocate activity avoidance (Bishop et al 2008), discordant (GPs), those patients under the care of GPs in the with current evidence-based guidelines. This issue intervention group were more likely to undergo colorectal highlights potential barriers encountered by clinicians in cancer screening than patients treated by GPs who had not seeking, understanding, and utilising health information in received the training (Ferreira 2005). clinical practice, specifically best evidence and guidelines. Indeed, barriers to the implementation and uptake of Whilst training and education strategies exist, it is clinical guidelines remain a research priority in health. In important that health professionals are provided with addition to the use of clinical guidelines to inform practice, adequate resources and opportunities to assist patients provision of accurate and appropriate information to health with suboptimal health literacy. It is an area that will need consumers is a critical element in shaping a patient’s health to be explored further by policy makers and healthcare behaviour and attitudes. There is evidence that practitioner organisations, particularly given current national health beliefs about low back pain influence patient beliefs (Linton initiatives (see below). Another consideration may be et al 2002), and therefore the understanding and utilisation to implement health literacy screening within clinical of health information. In a recent study, patients with settings to identify patients with inadequate abilities to chronic low back pain and high disability tended to cite seek, understand, and utilise health information. Whilst pathoanatomic reasons for their pain more consistently a range of health literacy measurement tools exist (see than those with chronic low back pain and low disability Jordan et al 2010b), they predominantly measure reading (Briggs et al 2010). This raises the question, are patients comprehension abilities, which do not represent the breadth receiving the correct information about chronic low back of components implied in existing definitions of health pain aetiology from their health professionals? literacy. Further empirical evidence demonstrating the validity and reliability of existing measures is also required In addition to providing accurate and evidence-based before considering feasibility at a clinical level (Jordan information, it is also imperative that health professionals 2010b). ensure patients understand and utilise the relevant 150 Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010
Conclusion Editorial Not surprisingly, health literacy is starting to be addressed Chew LD, et al (2004) Am J Surg 188: 250–253. at both health policy and program levels in Australia. Both DeWalt DA (2007) N C Med J 68: 327–330. the Health and Hospitals Reform Commission Report DeWalt DA, et al (2004) J Gen Intern Med 19: 1228–1239. and the National Primary Health Care Strategy outline Ferreira M, et al (2005) J Clin Oncol 23: 1548–1554. key initiatives relating to health literacy. These include Jordan JE, et al (2010a) Patient Educ Couns 79: 36–42. health professionals supporting patients to improve their Jordan JE, et al (2010b) J Clin Epi (in press). health literacy skills to navigate the health system, engage Lerner EB, et al (2000) Am J Emerg Med 18: 764–766. in preventive activities, enhance self-management, and Liddle SD, et al (2009) Man Ther 14: 189–196. change risky lifestyle behaviours. Similar policy and Linton SJ, et al (2002) J Occup Rehab 12: 223–232. program initiatives are also in development by state Paasche-Orlow MK, et al (2005) J Gen Intern Med 20: 175–184. governments. For physiotherapists, who are recognised Schillinger D, et al (2002) JAMA 288: 475–482. primary care clinicians and spend considerable time with Schillinger D, et al (2003) Arch Intern Med 163: 83–90. patients delivering health information, particularly in the Scott TL, et al (2002) Med Care 40: 395–404. context of chronic condition management and post-surgical USA Department of Health and Human Services (2000) rehabilitation, these policy initiatives imply that clinicians will increasingly need to be familiar with health literacy Healthy People 2010: Understanding and improving health. concepts, measurement, and interventions to assist patients US Government Printing Office. Washington, DC. in seeking, understanding and utilising health information. USA National Academy on an Aging Society (1999) Low health literacy skills increase annual health care expenditures References by $73 billion. The Center for Health Care Strategies and National Academy on an Aging Society. Washington, DC. Baker DW, et al (1998) J Gen Intern Med 13: 791–798. Weinman J, et al (2009) BMC Family Practice 10: 43. Williams CM, et al (2010) Arch Intern Med 170: 271–277. Bishop A, et al (2008) Pain 135: 187–195. Briggs AM, et al (2010) Pain 150: 275–283. Erratum In Vol 55 No 3 there was an error in the results reported in predicted by revision hip arthroplasty. The regression the paper by Stevens et al (2009). The error occurred in the coefficient for being in the revision group was –1153.7 (95% final page make up. The last two paragraphs of Column 1 CI –2241.1 to –66.3). The regression coefficient for being in p. 188 should be corrected as follows (corrected text in bold the revision group of –912.8 (95% CI –1989.1 to 163.6) was type): no longer significant when age, gender, and Charnley group were added to the prediction equation, suggesting that these Linear regression analysis was also performed to determine additional predictors did confound the relation between whether total amount of physical activity was predicted by group and total intensity of physical activity (Box 3). revision hip arthroplasty. The regression coefficient for Revision group, age, gender, and Charnley group accounted being in the revision group was –394.3 (95% CI –701.1 to for 9% of the variance in total intensity of physical activity.’ –87.5). The regression coefficient for being in the revision group of –121.2 (95% CI –408.0 to –165.7) was no longer AJP apologises to the authors and to our readers. significant when age, gender, and Charnley group were added to the prediction equation, suggesting that these Reference additional predictors did confound the relation between group and total amount of physical activity (Box 2). Stevens M, Hoekstra T, Wagenmakers R, Bulstra SK, van Revision group, age, gender, and Charnley group accounted den Akker-Scheek I (2009) People who undergo revision for 18% of the variance in total amount of physical activity. arthroplasty report more limitations but no decrease in physical activity compared with primary total hip arthroplasty: Finally, linear regression analysis was performed to an observational study. Australian Journal of Physiotherapy determine whether total intensity of physical activity was 55: 185–189. Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010 151
Appraisal Correspondence Trial quality was transparent We are pleased to respond to the letter written by Dr resistance training on six-minute walk distance was based Redfern and Dr Briffa. First, we used the PEDro scale to on the results of two studies (as we stated in the Discussion). rate the quality of included trials in our meta-analysis. The score of included trials in our systemic review was at least We thank Dr Redfern and Dr Briffa and agree that 4, half of them were 6 or 7, and the average was 5.8 (SD some studies could improve their study design by using 1.2). The average PEDro score of trials of physiotherapy concealed group allocation and by blinding investigators interventions published in the same years as the included to group allocation while measuring outcomes. However, trials (ie, 1997–2008) was 5.0 (SD 1.5) (scores downloaded the comment on the diagnosis of chronic heart failure from PEDro on 17/7/2010). Therefore we do not feel that the was somewhat misleading. As we know, heart failure is a trials were of particularly low quality. We agree that readers clinical syndrome characterised by signs and symptoms should consider the quality of the included trials and we of exertional dyspnoea due to structural and/or functional presented the scores in Table 2 for this purpose. We also heart diseases with a range of left ventricular ejection agree that trial quality could have been higher and that there fraction (LVEF) (Libby et al 2008). Some discrepancies in is definitely a need for high-quality large scale randomised LVEF could be possible. trials focusing on the effect of resistance training in patients with chronic heart failure. Chueh-Lung Hwang, Chen-Lin Chien and Ying-Tai Wu As stated in our Data Analysis, heterogeneity was examined first and the meta-analysis of each outcome was conducted National Taiwan University, Taipei, Taiwan with the appropriate model. We put the major significant finding in the title and conclusion but also pointed out the References limitations. We agree with Dr Redfern and Dr Briffa that readers should be reminded that the benefit we found of Hwang CL, et al (2010) Journal of Physiotherapy 56: 87–96. Libby P et al (2008) In: Braunwald’s Heart Disease, 8th edition. Philadelphia: Saunders Elsevier Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010 207
Appraisal Critically Appraised Papers Twelve months of resistance training can improve the cognitive functioning of older women living in the community Synopsis of exercises for stretching, range of motion, pelvic floor and balance, and relaxation techniques. Outcome measures: Summary of: Liu-Ambrose T, Nagamatsu LS, Graf P, The primary outcome was change in the executive cognitive Beattie BL, Ashe MC, Handy TC (2010) Resistance training function of selective attention and conflict resolution as and executive functions: a 12-month randomized controlled measured by the Stroop test at 6 and 12 months. The Stroop trial. Arch Intern Med 170: 170–178. Prepared by Nicholas test assesses the time taken to name words of colours typed Taylor, CAP Co-ordinator. in incongruent ink colours. Secondary outcome measures were cognitive functions of set shifting and working memory, Question: Does resistance training improve cognitive whole-brain volume, and functional measures of gait speed function in older women living in the community? Design: and muscular performance. Results: 135 participants (87%) Randomised controlled trial with concealed allocation and completed the study and were included in the analysis. At blinded outcome assessment. Setting: A local fitness centre 6 months there was no between-group difference but at 12 and research centre in Canada. Participants: Women aged months, task performance in the Stroop test had improved 65 to 75 years living independently in the community and by –2.9 s in the 2RT group compared to BAT (95% CI –12.2 with a Mini-Mental state examination score of at least to –0.8) and –4.3 s in the 1RT compared to BAT (95% CI 24 were included. Having a medical condition for which –13.8 to –2.5) representing improvement of 11% and 13% exercise was contraindicated, participating in resistance in 2RT and 1RT groups, respectively, and deterioration of training in the last 6 months, and having depression were 0.5% in the BAT group. Peak quadriceps muscle power exclusion criteria. Randomisation of 155 participants increased by 13% in the 2RT group, but decreased by 8% allocated 52 to once-weekly resistance training (1RT), 54 in 1RT and 16% in the BAT group. There was a small but to twice-weekly resistance training (2RT), and 49 to twice- significant reduction in whole brain volume in 1RT and 2RT weekly balance and tone exercises (BAT). Interventions: compared with BAT. The groups did not differ significantly All groups received 60-minute exercise classes for 52 on the remaining secondary outcomes. Conclusion: Twelve weeks supervised by fitness instructors. The 1RT and 2RT months of once or twice-weekly resistance training can groups participated in a progressive high intensity protocol improve the cognitive functioning of older women living in using a weights machine and free weights for resistance the community. with a training regimen of 2 sets of 6 to 8 repetitions for arm and leg exercises. The BAT group’s program consisted volume was reduced in both resistance training groups in comparison to the control group – opposite to what one Commentary would have expected. Similar controversial brain volume findings have been reported previously and one hypothesis This randomised controlled trial (RCT) contributes to the is that it might have to do with the intervention helping to growing body of literature showing that physical activity dissolve specific cerebral pathology (eg, amyloid plaques). can improve cognitive function in cognitively healthy If β-amyloid were measured it could have helped to explore older adults (Angevaren et al 2008). Liu-Ambrose and this hypothesis further. This RCT encourages us not only to colleagues demonstrated that only one 60-minute session recommend physical activity for the ageing brain, but also of supervised progressive resistance training per week to investigate further what type, frequency, and intensity of for 12 months improved participants’ selective attention physical activity might be optimal. and conflict resolution in comparison to a twice weekly balance and tone training control group. This improvement Nicola T Lautenschlager was greater in the once weekly resistance training group The University of Melbourne, Australia than in the twice weekly group. However, the authors did not offer any explanations for this dose effect. The References authors conclude that the positive cognitive effect may be selective for executive functions since other secondary Angevaren M et al (2008) Cochrane Database Syst Rev.3: cognitive outcomes did not improve, however the battery CD005381. of cognitive tests used was small. Furthermore the authors reported that the improvement in executive functions was Soumaré A et al (2009) J Gerontol A Biol Sci Med Sci 64: 1058– significantly associated with increased gait speed. This 1065. important finding adds further weight to the relevance of gait speed for cognitive function and survival (Soumar et Hardy SE et al (2007) J Am Geriatr Soc 55: 1727–1734. al 2009, Hardy et al 2007). A puzzling result is that brain 200 Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010
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