QUESTION: Does faulty proprioceptive input disrupt the internal model of the body that the brain uses to control movement? DESIGN: Randomised, within-participant experimental study. PARTICIPANTS: Twenty-two (13 F) health...QUESTION: Does faulty proprioceptive input disrupt the internal model of the body that the brain uses to control movement? DESIGN: Randomised, within-participant experimental study. PARTICIPANTS: Twenty-two (13 F) healthy adults. INTERVENTION: Participants performed a motor imagery task that involved making left/right judgements of pictured right and left hands in 16 different postures under five conditions involving stimuli being applied to the experimental (L) hand. The five conditions were: vibration (of the wrist extensor tendons to elicit the illusion of wrist flexion), sham (vibration of the ulna styloid), active flexion, passive flexion, and control (no stimulus). OUTCOME MEASURES: Accuracy and response time of the control (R) hand in making left/right judgements of the pictures. RESULTS: Response time during vibration was longer for those who reported the illusion of wrist flexion (n = 18) than for those who did not (p < 0.01) whereas accuracy was unaffected (p = 0.71). In those who reported the illusion, accuracy was unaffected by condition, hand or picture (p > 0.21). Response time during vibration was 910 ms longer (95% CI 730 to 1090) for pictures of the experimental (L) hand (mean 2731 ms, 95% CI 2543 to 2918) than it was for pictures of the control (R) hand (mean 1822 ms, 95% CI 1634 to 2009), and approximately 580 ms longer (95% CI 380 to 785) for pictures of either hand during any other condition (p < 0.025). CONCLUSION: Faulty proprioceptive input disrupted this motor imagery task, which suggests it can disrupt the model of the limb that the brain uses for movement.
QUESTION: What is the effect of the Mapleson C circuit compared with the Laerdal circuit in removing secretions and improving ventilation and gas exchange during manual hyperinflation? DESIGN: Prospective, randomised, cr...QUESTION: What is the effect of the Mapleson C circuit compared with the Laerdal circuit in removing secretions and improving ventilation and gas exchange during manual hyperinflation? DESIGN: Prospective, randomised, cross-over trial. PARTICIPANTS: Twenty patients from a tertiary-level intensive care unit who were being mechanically ventilated. INTERVENTION: Manual hyperinflation in side-lying with both the Mapleson C or Laerdal circuit on the one day, one circuit in the morning and one in the afternoon, with a washout period of at least three hours between them. OUTCOME MEASURES: Secretion clearance was measured as sputum weight, ventilation was measured as respiratory compliance and tidal volume, while gas exchange was measured as oxygenation and CO2 removal. RESULTS: The Mapleson C circuit cleared 0.89 g (95% CI 0.80 to 1.15) more secretions than the Laerdal circuit (p < 0.02). There was no difference between the Mapleson C and the Laerdal circuits on respiratory compliance (p = 0.81), tidal volume (p = 0.45), oxygenation (p = 0.28), or CO2 removal (p = 0.17). CONCLUSION: Although more secretions were cleared using the Mapleson C compared with the Laerdal circuit in this study, this had no consequence in terms of oxygenation and compliance only trended to improve. As the study was underpowered the clinical significance of these findings is not clear.
QUESTION: Which models of undergraduate/entry-level clinical education are being used internationally in allied health disciplines? What is the effect and, from the perspective of stakeholders, what are the advantages, d...QUESTION: Which models of undergraduate/entry-level clinical education are being used internationally in allied health disciplines? What is the effect and, from the perspective of stakeholders, what are the advantages, disadvantages, and recommendations for successful implementation of different models of undergraduate/entry-level clinical education? DESIGN: Systematic review with data from quantitative and qualitative studies synthesised in a narrative format. PARTICIPANTS: Undergraduates/entry-level students from five allied health disciplines undergoing clinical education. INTERVENTION: Six broad models of clinical education: one-educator-to-one-student (1:1); one-educator-to-multiple-students (1:2); multiple-educators-to-one-student (2:1); multiple-educators-to-multiple-students (2:2); non-discipline-specific-educator and student-as-educator. OUTCOME MEASURES: Models were examined for productivity; student assessment; and advantages, disadvantages, and recommendations for implementation. RESULTS: The review found few experimental studies, and a large amount of descriptive research and opinion pieces. The rigour of quantitative evidence was low, however qualitative was higher. Evidence supporting one model over another was largely deficient with few comparative studies available for analysis. Each model proffered strengths and weaknesses, which were unique to the model. CONCLUSION: There is currently no 'gold standard' model of clinical education. The perception that one model is superior to any other is based on anecdotes and historical precedents, rather than on meaningful, robust, comparative studies.
QUESTION: Is therapeutic exercise of benefit? DESIGN: A summary of systematic reviews on therapeutic exercise published from 2002 to September 2005. PARTICIPANTS: People with neurological, musculoskeletal, cardiopulmonar...QUESTION: Is therapeutic exercise of benefit? DESIGN: A summary of systematic reviews on therapeutic exercise published from 2002 to September 2005. PARTICIPANTS: People with neurological, musculoskeletal, cardiopulmonary, and other conditions who would be expected to consult a physiotherapist. INTERVENTION: Therapeutic exercise was defined as the prescription of a physical activity program that involves the client undertaking voluntary muscle contraction and/or body movement with the aim of relieving symptoms, improving function or improving, retaining or slowing deterioration of health. OUTCOME MEASURES: Effect of therapeutic exercise in terms of impairment, activity limitations, or participation restriction. RESULTS: The search yielded 38 systematic reviews of reasonable or good quality. The results provided high level evidence that therapeutic exercise was beneficial for patients across broad areas of physiotherapy practice, including people with conditions such as multiple sclerosis, osteoarthritis of the knee, chronic low back pain, coronary heart disease, chronic heart failure, and chronic obstructive pulmonary disease. Therapeutic exercise was more likely to be effective if it was relatively intense and there were indications that more targeted and individualised exercise programs might be more beneficial than standardised programs. There were few adverse events reported. However, in many areas of practice there was no evidence that one type of exercise was more beneficial than another. CONCLUSION: Therapeutic exercise was beneficial for patients across broad areas of physiotherapy practice. Further high quality research is required to determine the effectiveness of therapeutic exercise in emerging areas of practice.
QUESTION: What is the compliance with guidelines for acute ankle sprain for physiotherapists? DESIGN: Survey of random sample of physiotherapists. PARTICIPANTS: 400 physiotherapists working in extramural health care in t...QUESTION: What is the compliance with guidelines for acute ankle sprain for physiotherapists? DESIGN: Survey of random sample of physiotherapists. PARTICIPANTS: 400 physiotherapists working in extramural health care in the Netherlands. OUTCOME MEASURES: Questions covered attitude towards guidelines in general, familiarity with the guidelines for acute ankle sprain,compliance with the guidelines, advantages and disadvantages of the guidelines, and factors relating to compliance with the guidelines. RESULTS: The majority of the physiotherapists were familiar with the content of the guidelines to some degree and 66%applied it to more than half of their patients with acute ankle sprain. The recommendations to determine both the prognosis and the necessity of treatment by using the function score were the least followed. Some physiotherapists thought the function score was not completely clear, which may have been a barrier for implementation. Factors relating positively to compliance were a positive attitude towards guidelines in general, and having colleagues who implemented the guidelines for acute ankle sprain. CONCLUSION: Although compliance with the guidelines for acute ankle sprain was fair/moderate, compliance may be enhanced by improving clarity of the function score, including it in the short version and improving the attitude of physiotherapists towards guidelines in general.
QUESTION: What is the lifetime and current prevalence of thumb problems in Australian physiotherapists and what are the factors associated with thumb problems? DESIGN: Survey of a random cross-section of physiotherapists...QUESTION: What is the lifetime and current prevalence of thumb problems in Australian physiotherapists and what are the factors associated with thumb problems? DESIGN: Survey of a random cross-section of physiotherapists. PARTICIPANTS: 1562(approximately 10% of the total) registered Australian physiotherapists. OUTCOME MEASURES: General questions covered demographic information, area of practice, hours worked per week, and years worked as a physiotherapist. Specific questions about thumb problems covered thumb affected, symptoms, onset of symptoms, treatment sought, relevance of work-related factors, and joint hypermobility. RESULTS: 1102 (71%) questionnaires were returned and 961 (68%) completed. The lifetime prevalence of thumb problems was 65% and the current prevalence was 41%. Factors that were significantly associated with thumb problems included: working in orthopaedic outpatients (OR 3.2, 95% CI 1.8 to 5.8); using manual therapy (OR 2.3 to 3.4, 95% CI 1.7 to 5.1), trigger point therapy (OR 2.3, 95% CI 1.7 to 3.0) and massage (OR 2.1, 95% CI 1.6 to 2.8); having thumb joint hypermobility (OR 2.2 to 2.6, 95% CI 1.4 to 4.5); or an inability to stabilise the joints of the thumb whilst performing physiotherapy techniques (OR 4.2, 95% CI 2.9 to 5.9). Of those respondents who reported thumb problems, 19% had changed their area of practice and 4% had left the profession as a result of their thumb problems. CONCLUSION: The prevalence of thumb problems in Australian physiotherapists appears to be high and can be of sufficient severity to impact on careers.
QUESTION: Does change in impairments within and between the first two manual therapy treatments predict change in activity limitations by the end of treatment in patients with subacute neck symptoms? DESIGN: Longitudinal...QUESTION: Does change in impairments within and between the first two manual therapy treatments predict change in activity limitations by the end of treatment in patients with subacute neck symptoms? DESIGN: Longitudinal, observational study. PARTICIPANTS: 29 people with neck pain for more than two weeks who subsequently received >or= three treatments. OUTCOME MEASURES: Impairments measured were active neck ROM in six directions (total ROM), most limited direction of ROM (limited ROM), pain intensity, and pain location. Activity limitations were measured using the Neck Disability Index and the Patient Specific Functional Scale. Patients' perceptions of change were measured using the Global Perceived Effect Scale. Impairments and patients' perceptions were measured before and after the first two treatments and before the final treatment whereas activity limitations were measured only before the first and last treatments. RESULTS: All measures improved by the end of treatment.Between-treatment change in limited ROM predicted change in limited ROM (rs2 = 0.53 and 0.57) and total ROM (rs2 = 0.26) by the end of treatment. Within- and between-treatment change in pain location predicted change in pain location (rs2 = 0.24, 0.27,0.28, and 0.57) by the end of treatment. No significant relationships were found between change in any impairments in the first two treatments and change in activity limitations by the end of treatment. CONCLUSIONS: Change in impairments predicts change in the same impairment by the end of treatment, but not in other impairments or activity limitations. It is recommended that there assessments used to guide and refine treatment be individualised and related to the specific goals for that patient.
QUESTION: Why do some patients who have received a behavioural graded activity program successfully integrate the activities into their daily lives and others do not? DESIGN: Qualitative study. PARTICIPANTS: 12 patients...QUESTION: Why do some patients who have received a behavioural graded activity program successfully integrate the activities into their daily lives and others do not? DESIGN: Qualitative study. PARTICIPANTS: 12 patients were selected according to the model of deliberate sampling for heterogeneity, based on their success with the intervention as assessed on the Patient Global Assessment. INTERVENTION: Behavioural graded activity. OUTCOME MEASURES: Data from 12 interviews were coded and analysed using the methods developed in grounded theory. The interviews covered three main themes: aspects related to the content of behavioural graded activity, aspects related to experience with the physiotherapist, and aspects related to characteristics of the participant. RESULTS: Interview responses suggest that two factors influence long-term adherence to exercise and activity.First, initial long-term goals rather than short-term goals seem to relate to greater adherence to performing activities in the long term. Second, active involvement by participants in the intervention process seems to relate to greater adherence to performing activities in the long term. CONCLUSION: Although involvement of patients in the intervention process is already part of behavioural graded activity, it would be beneficial to emphasise the importance of active involvement by patients right from the start of the intervention. Furthermore, to increase the success of behavioural graded activity, physiotherapists should gain a clear understanding of the patient's initial motives in undergoing intervention.
QUESTION: What is the relationship between vibration of the chest wall and the resulting chest wall force, chest wall circumference,intrapleural pressure, and expiratory flow rate? Is the change in intrapleural pressure...QUESTION: What is the relationship between vibration of the chest wall and the resulting chest wall force, chest wall circumference,intrapleural pressure, and expiratory flow rate? Is the change in intrapleural pressure during vibration the sum of the intrapleural pressure due to recoil of the lung, chest wall compression, and chest wall oscillation? DESIGN: Randomised, within-subject,experimental study. PARTICIPANTS: Seven experienced cardiopulmonary physiotherapists and three healthy adults. INTERVENTION: Vibration (compression + oscillation), compression alone, and oscillation alone were applied manually to the chest walls of healthy participants during passive exertion and compared with passive expiration alone. OUTCOME MEASURES: Chest wall force, chest wall circumference, intrapleural pressure, and expiratory flow rate. RESULTS: During vibration, coherence was high(r2 > 0.97) between external chest wall force, chest wall circumference, intrapleural pressure, and expiratory flow. The mean change in intrapleural pressure during vibration was 9.55 cmH2O (SD 1.66), during chest compression alone was 8.06 cmH2O(SD 1.65), during oscillation alone was 7.93 cmH2O (SD 1.57), and during passive expiration alone was 6.82 cmH2O (SD 1.51). During vibration, compression contributed 13% of the change in intrapleural pressure, oscillation contributed 12%, and lung recoil contributed the remaining 75%. CONCLUSIONS: During vibration the chest behaves as a highly linear system. Changes in intrapleural pressure occurring during vibration appear to be the sum of changes in pressure due to lung recoil and the compressive and oscillatory components of the technique, which suggests that all three components are required to optimise expiratory flow.
QUESTION: What are the effects of manual therapy on pain, range of motion, and activity in patients with anterior knee pain? DESIGN: Randomised controlled trial. PARTICIPANTS: Thirty-eight ambulatory care patients (one d...QUESTION: What are the effects of manual therapy on pain, range of motion, and activity in patients with anterior knee pain? DESIGN: Randomised controlled trial. PARTICIPANTS: Thirty-eight ambulatory care patients (one dropout) with anterior knee pain. INTERVENTION: The experimental intervention consisted of six sessions of manual therapy, while the control intervention was to remain on the waiting list for two weeks. OUTCOME MEASURES: Pain was measured using the Patellofemoral Pain Severity Questionnaire. Active knee flexion and extension was measured from photographs. Activity was measured by having the participants step up and down a 15 cm step, leading with the painful leg as many times as they could in a 60 second period. Measurements were taken before and after intervention by a blinded assessor. RESULTS: The experimental group decreased their pain by -8 mm (95% CI to 1 p =0.08) and pain on stairs by-10, (95% CI -22 to 2 p = 0.10) compared with the control group. They increased their active knee flexion by 10 deg (95% CI TO 16, p = 0.004) and and the number of steps in 60 seconds by 5 (95% CI 2 TO 8, p = 0.001) compared with the control group. CONCLUSION: Manual therapy is effective improving knee flexion and stair climbing i patients with anterior knee pain. There is a trend towards a small improvement in pain.
QUESTION: What is the effectiveness of 12 weeks of nightly stretch in reducing thumb web-space contracture in people with neurological conditions? DESIGN: Assessor-blinded, randomised controlled trial. PARTICIPANTS: Fort...QUESTION: What is the effectiveness of 12 weeks of nightly stretch in reducing thumb web-space contracture in people with neurological conditions? DESIGN: Assessor-blinded, randomised controlled trial. PARTICIPANTS: Forty-four (one dropout)community-dwelling patients with a neurological condition (14 stroke, 7 traumatic brain injury, 23 spinal cord injury) who had uni or bilateral thumb web-space contractures (60 thumbs). INTERVENTION: The experimental thumbs were splinted into a stretched,abducted position each night for 12 weeks. The control thumbs were not splinted. OUTCOME MEASURES: Thumb web-space was measured as the carpometacarpal angle during the application of a 0.9 Nm abduction torque before and after intervention. RESULTS: The mean increase in thumb web-space after 12 weeks was 1 deg (95% CI, -1 to 2). CONCLUSION: Intensive stretch administered regularly over three months does not reduce thumb web-space contractures in neurological conditions.
QUESTION: Is strength training after stroke effective (ie, does it increase strength), is it harmful (ie, does it increase spasticity), and is it worthwhile (ie, does it improve activity)? DESIGN: Systematic review with...QUESTION: Is strength training after stroke effective (ie, does it increase strength), is it harmful (ie, does it increase spasticity), and is it worthwhile (ie, does it improve activity)? DESIGN: Systematic review with meta-analysis of randomised trials. PARTICIPANTS: Stroke participants were categorised as (i) acute, very weak, (ii) acute, weak, (iii) chronic, very weak, or (iv) chronic, weak. INTERVENTION: Strengthening interventions were defined as interventions that involved attempts at repetitive, effortful muscle contractions and included biofeedback, electrical stimulation, muscle re-education, progressive resistance exercise, and mental practice. OUTCOME MEASURES: Strength was measured as continuous measures of force or torque or ordinal measures such as manual muscle tests. Spasticity was measured using the modified Ashworth Scale, a custom made scale, or the Pendulum Test. Activity was measured directly, eg, 10-m Walk Test, or the Box and Block Test, or with scales that measured dependence such as the Barthel Index. RESULTS: 21 trials were identified and 15 had data that could be included in a meta-analysis. Effect sizes were calculated as standardised mean differences since various muscles were studied and different outcome measures were used. Across all stroke participants, strengthening interventions had a small positive effect on both strength (SMD 0.33, 95% CI 0.13 to 0.54) and activity (SMD 0.32, 95% CI 0.11 to 0.53). There was very little effect on spasticity (SMD -0.13, 95% CI -0.75 to 0.50). CONCLUSION: Strengthening interventions increase strength, improve activity, and do not increase spasticity. These findings suggest that strengthening programs should be part of rehabilitation after stroke.